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Patient involvement in the management of leg ulcers.

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VOL: 101, ISSUE: 24, PAGE NO: 52

Caroline Dowsett, MSc, DipN, DN, RN, is nurse consultant tissue viability, Newham Primary Care Trust, London

The NHS Improvement Plan (Department of Health, 2004) is the government's strategy for modernising the health service. It places great emphasis on the following:

The NHS Improvement Plan (Department of Health, 2004) is the government's strategy for modernising the health service. It places great emphasis on the following:

- Putting patients and service-users first by providing more personalised care;

- Taking an holistic approach to patients' health and well-being, and not simply focusing on illness;

- Devolving decision-making to local organisations further than has hitherto been the case.

To achieve these targets in leg ulcer management, we need to challenge traditional ways of working and recognise both service and practitioner limitations.

Despite the recommendations in The NHS Improvement Plan (DoH, 2004), the government does not see leg ulcer management as a key priority, a policy that presents funding difficulties for practitioners.

Prevention/health promotion
Time and effort spent on healing venous leg ulcers will be wasted unless a prevention programme is in place. Graduated compression hosiery is regarded as a prerequisite for preventing venous leg ulceration (Edwards and Moffatt, 1996) and patients should be advised they will need to wear it for the rest of their lives (O'Hare, 1997) to minimise recurrence. Current guidelines support intervention and advocate regular follow-up (RCN, 1998; Nelson et al, 2002)

Concordance with treatment regimens can be facilitated by sharing knowledge and clinical skills with patients and carers (Edwards and Moffatt, 1996) through supervision and by ensuring the correct fit of hosiery.

Assessment and management
Assessment should follow national guidelines (RCN, 1998). A recommended care pathway (European Wound Management Association, 2003; Dowsett, 2004) should be instigated or a referral made to other services as appropriate. Therapy should be based on clinical need and the patient's preferences (Moffatt, 2004).

A detailed risk assessment should be undertaken to ensure safety at different levels:

- For the patient: to prevent, for example, loss of limb owing to inappropriate compression;

- For the practitioner: to be aware that the repetitive nature of applying compression bandages can cause back problems;

- For the organisation: to avoid the risk of litigation; for example, in cases where a patient may not have received appropriate therapy (Health and Safety Executive, 1999).

Specific issues, such as the use of evidence-based practice or postural problems caused by bandaging, should be addressed by tissue viability/leg ulcer specialists and included in training programmes. It is also important that a process for reporting clinical incidents is in place.

Patient choice
Developing the correct regimen requires involvement from patients in terms of offering choices that meet their clinical, quality-of-life and psychosocial needs. Ensuring that this happens will invariably require flexibility in service operating times.

A key component of evidence-based health care is patient choice, which is facilitated by helping patients to increase their knowledge and understand the available options and evidence (Muir-Gray, 1997). For example, if they are aware of the potential consequences of adapting a therapy, such as one associated with reduced compression, they will be able to appreciate that this will result in slower healing rates.

Fig 1 outlines some treatment choices for patients.

Learning from the patient can help to inform service improvements (Price and Harding, 1996), for even when leg ulcer services are well established things can go wrong. For example, the use of an inappropriate therapy, lost results and inconsistent approaches to wound management can have significant consequences for both the patient and the services concerned. Reflection can help answer the following question: what went wrong for the patient and how can we ensure it does not happen again?

Good communication is essential, especially as patients often do not understand the underlying causes of their leg ulceration. Such deficits in understanding can result in delayed wound healing (Edwards et al, 2002).

Improved communication will give patients a greater sense of control, while withdrawing information can lead to 'difficult' behaviours (English and Morse, 1998).

Evaluating services and individual patient care programmes is a necessary part of getting the regimen right. It is also a means of facilitating service improvements.

It is important regularly to audit wound-healing rates, access to services and patient satisfaction with treatment as part of this process.

A full version of this article was published in Journal of Wound Care: Dowsett, C. (2004) Patient involvement must be a key aspect of choosing an appropriate regimen for leg ulcer management. Journal of Wound Care; 13: 10, 443-444.

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