nurse-patient consultations in leg ulcer care do patients ... · pdf filenurse-patient...

Health Services Research Unit

HS RU

Nurse-patient consultations

in leg ulcer care – do patients

disclose their concerns?

Dr. Julie Green. PhD, M.Sc., B.Sc. (Hons), PGCert, RGN., B.Ed.

Lecturer & Award lead for Community

Nursing Practice (District Nursing).

Keele University.

[email protected]

mailto:[email protected]


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Nellie.

Nellie (82) has a 60 year history of

intermittent bilateral chronic

venous leg ulcers (CVLU).

Current episode of ulceration for

over 4 years with twice weekly

dressings by the District Nurse.

Nellie is now housebound,

immobile and dependent on carers.


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Aims & objectives.

• To outline patient centredness.

• To put the research question into context.

• To provide a synopsis of the research project as a whole.

• To provide a summary of phases 1 and 2 and an overview of the findings.


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Patient-centred care. • Patient centred care (PCC) is a relationship between the

patient and their health care practitioner which focusses on the well-being of the patient, where their experiences are central. Shared decision-making is key, with decisions made jointly between practitioner and patient (1-4).

• The key factors of patient-centredness identified by patients include (2,3,6-10): – The practitioner knowing about the patient’s progress.

– Responsiveness to patient needs.

– Encouraging patient participation in planning care.

– Providing information on condition and treatment plan.

– Treating the patient with respect.


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Patient-centred care (PCC).

• Despite these benefits, practitioners frequently fail to

elicit patient concerns or negotiate treatment options

during consultations. (6, 7)

– 54% of patient problems and 45% of patient concerns were

either not elicited by the doctor or disclosed by the patient. (8)

– The physician and patient failed to agree on the presenting

problem during 50% of consultations. (10)

– Nurses fail to communicate effectively and mainly approach

patients when undertaking administrative or functional

activities. (12)


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Chronic Venous Leg Ulcers. • Occur frequently.

– 1.5 - 3 per 1000 of the population suffer from venous ulceration. (18)

• Are expensive.

– Costs for care are estimated to be in excess of £200 million per year. (19)

• Recur.

– Annual recurrence rate of between 33-42% - a statistic that has remained unchanged for over 20 years. (20, 21)

• Impact on quality of life.

– Life is complicated by many issues and this negatively impacts on quality of life. (22, 23; 24)


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Phase 1 & 2 study aims.

1) To establish the factors that leg ulcer sufferers feel

have an impact on their day-to-day lives (Phase 1).

2) To determine the extent to which these factors are

addressed during patients’ current consultations with

their nursing team (Phase 2).


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Phase 1.

• Unstructured interviews

undertaken with patient

participants from two local

District Nursing Teams.

• CVLU for in excess of 6

weeks was required.

• Interviews patient-led,

audio recorded, transcribed

verbatim and continued

until saturation.

• Thematic analysis was

undertaken. (25)

• Four main themes – the

ulcer, symptoms, wound

management and effects

on daily life - each

containing a number of

subthemes.


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Phase 1 findings.

• Restrictions

• Mobility

• Hygiene

• Clothes and shoes

• Sleep

• Relationships

• The nurse.

• Location of treatment.

• The treatment applied and understanding.

• Concordance.

• Pain

• Exudate and odour

• Emotional effects of ulceration.

• Family history

• Comorbidities

• The cause, position and duration of ulceration.

The Ulcer Symptoms

Effects on daily life

Wound Management


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Phase 2.

• An observation checklist

was developed based on

phase 1 findings.

• Consultations for the

same participants were

observed.

• Each participant

underwent four

observations, providing

20 observation

opportunities in total.

• The checklist was completed

during each observation and

field notes promptly

recorded.

• Data analysis determined

the extent that phase 1

themes were raised and

addressed during patients’

consultations.


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Consultation

checklist.

• The checklist

contained 28

theme.

• Each theme

was rated

between 0 – 5.


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Phase 2 results. • The checklist was completed during each phase 2

consultation; providing 20 observations and a total of 560

item assessment opportunities.

• Analysis revealed the following ratings for checklist items

overall:

• Where study participants highlighted a theme as being of

significance during their phase 1 interview, these were

specifically monitored during their phase 2 consultations.

These statistics are presented in the following slides.

Score 0 Score 1 Score 2 Score 3 Score 4 Score 5

293 26 5 138 23 75

52% 5% 1% 25% 4% 13%


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The ulcer.

• Without exception, the participants were keen to describe

their ‘story’ which included their:

– family history;

– ‘all my mother’s sisters had it and me mother...runs in my family it does with us....’

(Mary, 72).

– co-morbidities and

– the cause, location and duration of ulceration.

– ‘God, they’ve been doing it....this Christmas it’ll be just over about 14 years...it’s just

been millimetres...millimetres all the time just going in…..very, very slow…..’(Steve, 39).

All patient talked of their experiences of ulceration which

provided an overview of their leg ulcer ‘journey’.


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Symptoms. • Pain was consistently reported and dominated the

interviews. – ‘.....it was getting more painful, it was like one time it was like burning pain, then it was

more like a stabbing pain, then.....now it’s like real sore....like someone is just rubbing,

rubbing, rubbing, all the time....Oh, the pain......it’s just unbearable.’ (Steve, 39).

• There was a reluctance to take analgesia and, when taken, it

was often deemed to be ineffective. – ‘I don’t take them unless I have to....I’d rather not take painkillers though....’ (Sam, 86).

• Where pain was raised as significant during the phase 1

interview, phase 2 observations revealed:


55 9 1 36 9 21

42% 7% 1% 27% 7% 16%


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Symptoms. • Exudate was described as a challenge to daily life.

• For many odour caused embarrassment and stress, this

often led to a restricting of contact with others. – ‘oh, and when you first have them......I wondered what the smell was....ohhhh, it’s

terrible the smell....it all comes out, a lot of rubbish........when you went anywhere.....you

didn’t get too close to people.....because I can smell it terrible.....and you can smell it in

your bed....you know...’ (Ellen, 80).

• Where exudate and odour were raised as significant

during the phase 1 interview, phase 2 observations

revealed:


9 1 1 5 1 11

32% 4% 4% 18% 4% 39%


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Symptoms. • Emotional effects due to ulceration included feeling

depressed, having a poor self-image and a range of fears. – ‘it’s just depressing really, if you think about it....I am on antidepressants ......I just have

to put up with it.....it’s either that or kill myself.....’ (Steve, 39).

– ‘I tell you......you have to shake yourself....you have to shake your feathers and when you

go out you have to put your outside face on......you know, you just have to.....’ (Margaret,

72).

• Where the emotional effects of ulceration were raised as

significant during the phase 1 interview, phase 2

observations revealed:


16 2 1 8 0 1

57% 7% 4% 29% 0% 4%


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Wound management. • Wound management included the role of the nurse, the

treatment regime, patient understanding and concordance

issues. – ‘..with the consistency of a team...much better. They did once send another from another

surgery out of........it wasn’t the same....when you’re seeing someone only once....it isn’t

the same....nothing wrong with her...did the job just the same....fine...but I wasn’t used to

her...’ (Tom, 76).

– ‘....but I’ve had loads of different dressings on before that....I’ve had a lot of different

things ....silver.......honey…..’ (Sam, 86).

• Where wound management themes were raised as

significant during the phase 1 interview, phase 2

observations revealed:


3 0 1 9 4 18

9% 0% 3% 28% 13% 47%


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Effects on daily life. • CVLUs impacted on every aspect of daily living: restricting

mobility; creating problems whilst working; difficulties

maintaining personal hygiene and restricted choices with

clothes and shoes; disturbed sleep and changing

relationships. – ‘Social life? ‘Errrr.....I haven’t got one........I just don’t bother cause I know I’ve got to get myself

better...but relationship wise.......no chance...I couldn’t...once these have healed then, obviously

yes...but it’s just, you know, with these on me legs all the time......there was one girl and I

tried...she said ‘what’s all that on your legs?’ and I tried make out that I’d been in a fire and I’d

burned myself but....with the smelling and that...it didn’t last...and I’ve just sort of put it off....’

(Steve, 39).

• Where the effects on daily life were raised as significant during

the phase 1 interview, phase 2 observations revealed:


32 8 1 33 3 7

38% 10% 1% 39% 4% 8%


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Conclusion. • Research exposes concerns for CVLU sufferers that go beyond

their actual wound care (26; 24) ; however, a review of consultations demonstrates that important themes are often not raised or are inadequately addressed during current consultations.

• Research demonstrates that communication in the consultation can be improved by either enhancing the ability of the practitioner to facilitate communication or by activating the patient to communicate their needs. (15)

• The development and pilot of a new patient-centred consultation template for people with leg ulcers, will encourage the exploration of important themes during consultations. The feasibility of this will be evaluated in phase 3.


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With thanks to my supervisory team for their support:

Professor Robert McKinley

Professor Rebecca Jester

Doctor Alison Pooler

I also gratefully acknowledge my funding from the

former West Midlands Strategic Health Authority.


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18. Graham, I., Harrison, M., Nelson, E., Lorimer, K. & Fisher, A. (2003). Prevalence of lower limb ulceration: a systematic review of prevalence studies. Advances in Skin and Wound Care. 16; 305-316.

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20. Heit, J., Rooke, T., Silverstein, M., Mohr, D., Lohse, C., Petterson, T., O’Fallon, M. and Melton, J. (2001) Trends in the incidence of venous stasis syndrome and venous ulcer: A 25-year population-based study. Journal of Vascular Surgery 33, 5, 1022-1027.

21. Ehrenberg, A. & Birgersson, C. (2003). Nursing documentation of leg ulcers: Adherence to clinical guidelines in a Swedish primary health care district. Scandinavian Journal of Caring Sciences. 17; 278-284.

22. Jones, J. and Nelson,E. (2005). Skin grafting for venous leg ulcers Cochrane Database Systematic Review. (1):CD001737.

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24. Palfreyman, S. (2008). Assessing the impact of venous ulceration on quality of life. Nursing Times. 104 (41), 34-37.

25. Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology. 3: 2, 77 — 101

26. Hopkins, A. (2004) Disrupted lives: investigating coping strategies for non-healing leg ulcers. British Journal of Nursing. 13, 9, 556–563.

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