VOL: 98, ISSUE: 25, PAGE NO: 62
Mark Collier, BA, RNT, RCNT, ONC, RN, is lead nurse, tissue viability, United Lincolnshire Hospitals NHS Trust, Pilgrim Hospital, Boston, LincolnshireTissue viability affects all age groups, involves all health care settings and is the focus of many government initiatives and reports (Department of Health 2000; 2001). This is not surprising in the present economic health climate, especially as the true costs for the management of acute and chronic wounds have never been quantified. Pressure ulcers have been reported to cost the NHS between £60-£420m a year (Franks, 2001), while the costs of leg ulcers have been estimated at between £300 and £600m (Dale et al, 1983; Bosanquet, 1993).
Tissue viability affects all age groups, involves all health care settings and is the focus of many government initiatives and reports (Department of Health 2000; 2001). This is not surprising in the present economic health climate, especially as the true costs for the management of acute and chronic wounds have never been quantified. Pressure ulcers have been reported to cost the NHS between £60-£420m a year (Franks, 2001), while the costs of leg ulcers have been estimated at between £300 and £600m (Dale et al, 1983; Bosanquet, 1993).
Wounds and their management in the UK use vast amounts of resources. In addition to the direct costs, such as equipment, dressings and staff (including increasing numbers of tissue viability nurse specialists), there are 'hidden' costs, such as pharmaceuticals and litigation. Wounds also have social costs, including time off work and reduced quality of life (Franks, 2001; Franks and Collier, 2001). Despite this, while travelling around the UK, I often hear nurses (thankfully the minority) using the excuse of limited resources to excuse any perceived deficiency in the care they deliver.
Of course, professionals should always strive to improve the human and financial resources available to provide appropriate evidence-based health care (Hicks, 1997) to our patients. However, perhaps we should occasionally reflect on the experiences of others and, if we have the chance to visit another health care system, compare and contrast the availability of resources and the quality of care achieved with our own.
I have been fortunate to have the opportunity to experience different health care systems in Europe, the Americas and Australasia - and most recently in south west Azerbaijan, formerly under Russian control. In May 2001 I was invited, along with Hilary Oliver, a continence specialist nurse, to visit a rehabilitation centre in Stepanekert, Nagorno-Karabakh (NK).
We were invited by Christian Solidarity Worldwide (CSW) to fact-find, advise and educate about our respective specialties. The trip was supported by the RCN and coincided with a visit by Baroness Caroline Cox, who has supported the rehabilitation centre for the past decade. The centre cares for a number of patients following injuries sustained during the war against Azerbaijan in 1992.
Having previously been an 'autonomous' state, NK gained its independence with the collapse of the Soviet Union. However, it has been the subject of long-running disputes between Azerbaijan and Armenia, and its independence has only been preserved through a massive loss of life in an almost constant state of war - the height of which was between 1988 and 1992. The ongoing struggle to maintain independence consumes over a quarter of the total economy.
We were met at Yerevan Airport in the capital of Armenia (it is not possible to enter NK via Azerbaijan) by the director of the rehabilitation centre and driven through beautiful but rugged mountainous territory. This journey, which took over eight hours, was completed in a 12-year-old Lada that would not have passed its MOT in the UK, and on a road that in parts was 'missing', although it was now starting to be repaired - nine years after it was damaged.
On arrival at the centre we took the opportunity to find out what activities were undertaken and discover the range of patient facilities available. The director, a physiotherapist and the only male professional, coordinated activities, assisted by an occupational therapist, six nurses and several volunteers who take on the kitchen, maintenance and odd-job roles.
In total over 150 patients received care in the centre, almost all as out-patients. There were just three in-patient beds with 'new' horsehair mattresses on them, although it was hoped to increase this number in the forthcoming months (there was a long queue of patients waiting to come in for in-patient treatments).
The centre had a power supply, although this could be erratic at times. Television was only available for a couple of hours each evening. It also had a physiotherapy room and a room containing the shell of an hydrotherapy pool, an occupational therapy room, a teaching room and a kitchen, plus the director's office. Most of the equipment was in working condition but very old. A steam steriliser was used to clean the few surgical instruments available, as well as the wound-dressing materials and various containers, including urinals.
Initially Hilary took the educational lead, meeting the six female nurses, introducing and discussing a number of continence issues that included:
- Reasons why people needed to be catheterised;
- The advantages and disadvantages of urethral and suprapubic catheterisation;
- The principles of choosing the appropriate charriere size and balloon size of catheter;
- The different catheter materials available and the optimum length of time they should remain in situ;
- How to recognise urinary infections and how to minimise the risk;
- The importance of hand-washing and basic hygiene;
- The use of catheter accessories - for instance, straps, leg bags and valves;
- The need for bladder washouts.
It was difficult to assess the nurses' level of understanding due to the language difficulties - all dialogue was translated by the centre director. However, it did become clear in later informal discussions that the nurses found it difficult to select appropriate catheters for individual patients for two reasons. The centre had a limited choice of catheters (many old, varied types and inappropriate catheters had been donated from abroad), while cultural differences meant that the only woman for whom it was acceptable to see a man's genital area was his wife. This led to many practical, physical and mental conflicts for the staff.
The following day I took the educational lead with the same six nurses, discussing the following aspects of tissue viability.
- The importance of moving and handling patients, and of planning the frequency of this an individual basis;
- The use of the 30 degree tilt and the rationale underpinning it (Shea, 1975);
- The need to acquire pressure-reducing support surfaces (both mattresses and cushions), and the importance of incorporating these into the preventative programme.
- The importance of hand-washing before any patient contact (generally gloves were relied on, and we did not see hand-washing being practised in the community setting, although it must be acknowledged that this would have been difficult in most of the homes we visited);
- The practical use of the 'moist wound healing' principle;
- The use of medicaments directly on healing tissues. Most patients had an antibiotic or antimicrobial cream put into the wound bed, although nobody knew the ingredients of the creams or other 'cleansing' solutions used except the sterile saline contained in glass vials;
- Issues relating to the maintenance and/or improvement of the skin surrounding pressure ulcers. It was clear that the nurses did not understand the difference between the concepts of excoriation and maceration (Collier, 2002).
The majority of patient consultations Hilary and I undertook were in the patients' own homes in the areas around Stepanekert. The case studies in boxes 1-3 are typical of our clinical encounters and demonstrate the difficulties experienced by professionals trying to provide health care in NK.
While the three patient histories demonstrate the problems faced by both patients and professionals, more general aspects of the situation in NK also contributed to these difficulties. For example, there was little evidence to suggest that care planning was undertaken on an individual basis.
There were no pressure-reducing mattresses available in the whole of the country for use in a community setting. Food was mainly available only from within the country and was very expensive. By way of illustration, Hilary and I were taken out for a pizza one evening, after which we were told that our meal had cost the equivalent of a month's wages locally.
The country has very few imports and a very poor economic structure. Much of the infrastructure throughout NK needs rebuilding, including roads, basic services and sanitation, houses and government buildings such as schools. The nurses had difficulty understanding the principles of both moist wound healing and closed drainage systems. Nurse education is based on the Russian model, which essentially encompasses a strict medical model and does not include evidence from any research published outside Russia. Foreign donations of equipment were not always appropriate to the needs of the patients at the centre.
Despite the limited resources available to the health care system in terms of education, equipment, facilities, nutrition and staff, all the patients were extremely appreciative of what was being done for them. It could be argued that the staff were doing a tremendous job in preventing any deterioration in the patients with pressure ulcers, let alone in endeavouring to facilitate an improvement in their conditions.
This visit had a profound effect on me and Hilary, to the extent that we hope to return to the centre in the near future, but this time with a more realistic educational plan focusing on the basics of care rather than the specifics of a particular specialty. The visit certainly changed my perception of 'limited resources' and my definition and understanding of the word 'poor'.
Although ideally all health care professionals would have an opportunity during to visit and experience another health care system, the resources are not available to support this. However, should this mean they can only base their practice on what they experience within their current clinical environments? The answer to this should, of course, be no.
It could be argued that all qualified professionals have a responsibility to undertake postregistration education that encourages them to reflect on their own professional experiences (CRICP, 1997). They should also compare their practice with that of others - either on the same course or as a result of a visit to another, different health care setting. In the meantime, we should not operate to the lowest common denominator, but perhaps be more realistic about available resources and occasionally remember how fortunate we are in the UK.
We must be more proactive in asking the right questions of our colleagues and employers, seek ways in which to improve our practice and be prepared to invest just a little of our own resources - even if in the short term this means only that we read relevant journals regularly. Only then will we be able to claim that we are seeking to be the patient's advocate in offering truly evidence-based practice and have a realistic view of the resources available with which to provide that care.
- This article is an expanded version of one published in the Journal of Community Nursing - Collier, M. (2002) Limited resources in wound management: a reality for some. Journal of Community Nursing; 16: 3, 38-42.