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Conservative sharp debridement: the professional and legal issues

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Jenny Ashworth, RN, PGDip (Wound healing and tissue repair); Marc Chivers, BA (Hons), MSc, RN, PGCE.

Jenny-Clinical Nurse Specialist, Tissue Viability; Marc-Lecturer in Healthcare, The Royal West Sussex NHS Trust, St Richard’s Hospital, Chichester, West Sussex

Debridement describes the removal of dead or devitalised tissue, particulate matter and foreign bodies from a wound bed and is generally accepted as a necessary precursor to the formation of new tissue (Vowden and Vowden, 1999; Bale, 1997).
In addition to the inhibition of wound healing, the presence of devitalised tissue may also promote infection (Bale, 1997). Whiteside and Moorehead (1994) concur with this view: they argue that devitalised tissue acts as a culture medium that promotes bacterial growth. They therefore argue that removing tissue that is heavily contaminated with dirt and bacteria protects the patient from invasive organisms.
Bale (1997) takes this argument further, suggesting that wound debridement is essential in order to prevent bacterial colonisation progressing to clinical infection. Debridement has been variously described as ‘essential to promote wound healing’ (Edwards, 2000), ‘the first goal in the management of chronic wounds’ (Poston, 1996), and ‘the most important component of managing chronic wounds’ (Rodheaver, 1999). Several methods of debridement exist, including mechanical, autolytic, biological, enzymatic, chemical, sharp and surgical debridement (Box 1). Vowden and Vowden (1999) state that ‘Surgical debridement implies extensive and aggressive removal of tissue… it is probably best performed by a skilled surgeon. Sharp or conservative debridement involves the removal of loose avascular tissue.’
In recent years there has been much debate over the appropriateness and efficacy of the various methods of wound debridement available to nurses in the management of chronic wounds. Vowden and Vowden (1999) suggest that holistic, inclusive patient assessment be used before deciding on the preferred modality of debridement. This, they claim, is crucial in maximising patient comfort and acceptability of the treatment method selected, which in turn leads to compliance and greater success in removing necrotic material.
Poston’s (1996) arguments concur with Vowden and Vowden’s, suggesting that conservative sharp debridement has a place in treating certain wound types in conjunction with other modes of wound management. All these authors highlight the potential legal pitfalls of undertaking this practice and emphasise the importance of competence in not only the practical skill involved in removing devitalised tissue but also in the anatomical knowledge needed of the underlying structures.
Professional and legal issues
Nurses regularly undertake this mode of treatment because ‘excision of necrotic tissue by sharp debridement is undoubtedly the most rapid method available’ (Vowden and Vowden, 1999). Despite this, until now, there has been limited formal education available to prepare nurses to undertake this role. In the authors’ view this anomaly has led to variation in practice, role insecurity and uncertainty in relation to the nurse’s legal position in the event of complications.
Nurses are accountable in their practice to the UKCC, as well as their employer, who is vicariously liable for the negligent actions of employees (UKCC, 1992a; Tingle and Cribb, 1998; Dimond, 2002). The professional standards of nursing practice are clearly laid out in the Code of Professional Conduct and are supported with the overarching statement ‘you are personally accountable for your practice’ (UKCC, 1992a).
The UKCC’s Code of Professional Conduct is complemented by its document the Scope of Professional Practice (UKCC, 1992b), which recognises the dynamic nature of nursing and supports the development and advancement of nursing roles. Advanced nursing roles can be undertaken only where the nurse is competent and is satisfied that the new role is in the patient’s best interest. Equally, undertaking an advanced role must not impinge or fragment existing aspects of professional practice.
Issues of competence in relation to the Scope of Professional Practice and the Department of Health’s clinical governance agenda clearly emphasise the importance of ensuring that patients are offered best-evidenced, high-quality services in which the practitioners are competent and skilled (UKCC, 1992b; DoH, 1998). However, finding practitioners skilled in debridement who are willing to act as mentors may prove problematic (Vowden and Vowden, 1999).
What the practitioner engaging in an advanced nursing role must remember is that, should anything go wrong, his or her competence will be judged against that of the person who normally undertakes this role - in this case a surgeon (Duff et al, 1996; Tingle and Cribb, 1998; Dimond, 2002). This is emphasised by Dimond (2002), who explains that, legally, the competence standard will be judged in accordance with the practice accepted as proper by a body of responsible professional people skilled in that procedure.
This principle is founded in case law (Bolam versus Friern Hospital Management Committee 1957) and is known as the Bolam test. In order to win a case of negligence the plaintiff must be able to prove that the defendant owed a duty of care, that the defendant breached that duty of care either by an act or an omission and, as a consequence of that breach, the plaintiff suffered harm (Tingle and Cribb, 1998; Dimond, 2002).
The need for nurses who are skilled in conservative sharp debridement has been acknowledged by the trust in which the authors work. Within the trust this issue of the appropriateness of conservative sharp debridement and the level of competence to practise has been discussed and is being addressed through the trust’s policy on the Scope of Professional Practice. The policy requires nurses undertaking roles that are beyond their normal nursing duties to undertake a study day on accountability to risk management as well as appropriate education and training in the identified and trust-agreed advanced role. Competence in this role is assessed and then peer-reviewed on an annual basis. This policy is primarily designed to protect patients and falls under the broad quality umbrella of clinical governance (DoH, 1998).
The issue of clinical governance in relation to conservative sharp debridement has been made easier by the recent development of national guidelines by the Association of Tissue Viability Nurses (South) (Fairburn, 2002). These were in draft form at the time of writing this article but are now ratified (Tables 1a and 1b). The trust has adapted these draft national guidelines to meet agreed local need and these will be used to inform practice.
It has to be remembered that guidelines and protocols set the parameters of practice and are used to aid the clinical decision-making process (Duff et al, 1996). Dimond (2002) suggests that guidelines and protocols should generally be followed, although she recognises that there may be instances where deviation from them is necessary. In these instances practitioners must always ensure that they use their own informed, reasonable clinical judgement when making treatment decisions and document their reasons for deviating from protocol (Tingle and Cribb, 1998; Duff et al, 1996; Dimond, 2002).
Obtaining informed consent is a fundamental principle before undertaking any nursing or medical procedure and it has to be remembered that the patient is able to withdraw consent at any time (Dimond, 2002). Failure to obtain informed consent before proceeding with conservative sharp debridement, for instance, may result in an action being brought for trespass to the person as well as an action in negligence for a breach of the duty of care to inform the patient (Dimond, 2002).
Whether formal written consent should be obtained is open to debate, but Dimond (2002) suggests that this is the preferred method if there is any significant risk attached to the procedure. This procedure is invasive and, in the authors’ opinion, written consent is the most appropriate method of obtaining a patient’s consent to proceed. Again, as with any other procedure, the treatment or care provided must be accurately and objectively documented in the patient’s notes and the entry must be dated, timed and signed (UKCC, 1998).
Addressing these issues in practice
Within the Royal West Sussex NHS Trust, only five named tissue viability link nurses who have achieved a pass in an accredited specialist course and passed the practice assessment will be permitted to undertake conservative sharp debridement.
The trust is fortunate in that a specialist course - the Masterclass in Methods of Wound Debridement - exists locally. As far as the authors are aware, this is the only accredited education programme in wound debridement available in the UK. It is run by the Chichester Centre of Health Care Studies - a unique organisation which comprises three separate local health-care providers, representing primary, secondary and hospice care, which have joined together as tripartite education providers and develop and franchise courses accredited through a recognised higher education institution, namely the University of Portsmouth.
This course has been run for the past two years at a national level and has attracted tissue viability and district nurses from all over the country. In light of the new national conservative sharp debridement guidelines (NATVN(S), 2002) the authors intend to run this course locally to include the five identified link nurses within the trust. Other local trusts have demonstrated an interest in this course and places will be sold to external applicants to offset the substantial cost of running this education programme.
The Masterclass in Methods of Wound Debridement runs over three days and is divided into one theory and two practical days. The theory day examines the theory and evidence for debridement and identifies the key professional and legal issues associated with it. The students then spend a day with a licensed anatomist, who provides further detail on the relevant anatomy and physiology, using cadavaric prosections as teaching aids.
This theory is then underpinned by a practical day with a consultant surgeon who teaches the basic surgical techniques required for this procedure. Three months after the last taught day, students from the trust must submit an evaluative case study on debridement. If students pass this assessment, they are awarded 10 level 3 (degree) Credit Accumulation and Transfer Scheme Credits. Students from outside the trust will have the option of submitting the assignment, although it is our expectation that they will submit in order to gain academic credit.
The practice assessment of the link nurses within the author’s trust will be undertaken by the tissue viability clinical nurse specialist with the support of a consultant vascular surgeon. From the trust’s perspective, and in line with clinical governance, the support of a consultant surgeon is vital to ensure that an inter-professional approach to learning and patient care is fostered (DoH, 1998; 2001).
The trust believes this approach will ensure that practice is founded on best evidence and that this expanded service will provide a valuable treatment adjunct to patients with chronic wounds. In the past 12 months there have been 10 conservative sharp debridements performed on patients with venous leg ulcers and sacral pressure injuries within the trust. These have been carried out by the clinical nurse specialist in tissue viability.
The trust recognises that the amount of conservative sharp debridement intervention is currently small - and this is partly a consequence of the lack of skilled practitioners. It must be emphasised that conservative sharp debridement will not replace other modalities of treatment but will provide selected nurses with an extra tool in their wound-management toolkit. There will be close auditing and monitoring of this expanded service.
The evidence supporting one method of wound debridement over another is inconclusive (Vowden and Vowden, 1999; Bale, 1997; Poston, 1996; Edwards, 2000; NICE, 2001). Holistic patient assessment has to be the determining factor in the treatment decision process and this has to be matched against employer policies and guidelines and the skill and competence of the practitioner undertaking the procedure (UKCC, 1992a; 1992b; DoH, 1998). Failure of the practitioner to do this is a breach of the duty of care to the patient. Where the patient suffers harm through either an act or an omission, then the practitioner is negligent (Dimond, 2002).
Therefore, the authors strongly recommend that before practitioners decide to offer conservative sharp debridement to their patients, they seek support from their employer and ensure that a rigorous structure is imposed under their employer’s clinical governance framework.
Formal assessed education, as well as assessment of competence in practice, is vital. If conservative sharp debridement is properly structured and supported, it will provide a valuable treatment adjunct at a minimal risk to patients who are suffering from slow-to-heal wounds.
The authors would like to acknowledge Mark O’Brien, Clinical Nurse Specialist, Tissue Viability (Education), The East London Wound Healing Centre, for his work in helping to develop the Masterclass in Methods of Wound Debridement.
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