Ann Van Hecke

A review of why patients with leg ulcers do not adhere to treatment

AIMnTo provide an overview of what is known thus far about reasons for and determinants of non-adherent behaviour.nnnBACKGROUNDnCompression, leg exercises and leg elevation are regarded as essential components in leg ulcer treatment and in the prevention of ulcer recurrence. Non-adherence to leg ulcer regimen is a major problem. Reasons for non-adherence are not fully understood.nnnDESIGNnSystematic review.nnnMETHODnMedline, CINAHL and the Cochrane database were explored from 1995 - December 2007. Reference lists of retrieved articles were searched. Studies were eligible if they included patients with venous or mixed leg ulcers, reported reasons or determinants of non-adherence and were published in English, Dutch, French or German. Thirty-one studies were included.nnnRESULTSnNon-adherence is a multidimensional problem. Pain, discomfort and lack of valid lifestyle advice by healthcare professionals were primary reasons for non-adherence from patients perspective.nnnCONCLUSIONSnHealthcare professionals mainly focus on patient-related factors such as poor motivation, lack of knowledge and understanding and unwillingness. The beliefs that compression was unnecessary, uncomfortable, worthwhile and prevented recurrence significantly determined (non-)adherence. RELEVANCE TO NURSING AND NURSING SCIENCE: Interventions to promote adherence will require a multifaceted approach and a holistic comprehensive assessment. Therapeutic non-judgemental relationships are essential to enhance patient adherence. Effective pain management is recommended and social support by family or significant others could be encouraged. Healthcare professionals should give clear, unambiguous and tailored information. Research can best focus on the factors and processes affecting patient adherence to leg ulcer treatment. Comprehensive adherence-enhancing strategies could be developed and their effectiveness should be tested.

The association between malnutrition and oral health status in elderly in long-term care facilities: A systematic review

OBJECTIVESnMalnutrition is a common problem in the elderly. It is not clear if oral health is associated to malnutrition in this population. The aim of this systematic review is to determine whether an association exists between oral health and malnutrition in the elderly in a long-term care facility.nnnDESIGNnSystematic review.nnnDATA SOURCEnMedline, Cochrane and Cinahl were systematically searched for to identify articles published between January 1985 and May 2011. Reference lists were checked for additional publications.nnnREVIEW METHODSnPublications were included if they explored the association between oral health status and malnutrition. As no consensus about terminology was found, a sensitive filter was developed. The methodological quality of the studies was assessed. Two independent reviewers performed all methodological steps.nnnRESULTSnSixteen studies met the criteria for inclusion. Eleven studies used a multivariate approach; nine of these found an association between oral health status and malnutrition. Four studies found a relationship between masticatory problems and malnutrition. Five studies found an association between malnutrition and dental condition, number of oral problems, tongue alteration, problems with saliva flow, and candidiasis. Overall, the methodological quality of the studies was medium.nnnCONCLUSIONSnTentative evidence indicates an independent association between oral health status and malnutrition in the elderly residing in a long-term care facility. Caution is needed for the interpretation of these results because of the absence of a gold standard to define and assess malnutrition and oral health status and the presence of methodological limitations throughout the studies.

How evidence-based is venous leg ulcer care ? A survey in community settings.

AIMnThis paper is a report of a study to describe venous leg ulcer care regarding compression, pain management and lifestyle advice in community settings and to identify factors that predict the provision of lifestyle advice by nurses.nnnBACKGROUNDnIncongruence between evidence and practice in leg ulcer care has been reported. Little is known about predictive factors related to the provision of lifestyle advice.nnnMETHODnTwo focus interviews and a Delphi procedure were used to develop a self-administered questionnaire based on the Graham questionnaire. Nurses employed by community healthcare organizations and independent nurses in private practices participated (n = 789). The data were collected in 2006.nnnFINDINGSnCompression was applied in 58.7% of patients with venous ulcers. Pain was present in 82.9%. A third of patients with pain received analgesics, but half of these patients (52.1%) took analgesics as prescribed. Half of the nurses (50.8%) gave lifestyle advice related to the leg ulcer. It was mainly instructions about leg elevation (68.3%), promoting physical activity (39.8%) and optimizing nutrition (16.7%) that were provided. Nurses who perceived themselves to have adequate leg ulcer knowledge and skills were 3.75 times more likely to provide lifestyle advice compared with those lacking such knowledge and skills. Nurses who found leg ulcer care not rewarding, rarely successful or difficult gave statistically significantly less lifestyle advice than those who found it rather rewarding, successful and not difficult.nnnCONCLUSIONnPatients with leg ulcers receive less than optimum care and patient education. A particular challenge lies in leg ulcer education programmes and pain management.

Adherence to leg ulcer lifestyle advice: qualitative and quantitative outcomes associated with a nurse‐led intervention

AIM AND OBJECTIVESnExamining the (experienced) changes associated with a nursing intervention to enhance adherence to leg ulcer lifestyle advice.nnnBACKGROUNDnFew interventions to enhance adherence to leg ulcer treatment are developed and tested.nnnDESIGNnQualitative evaluation approach and pre-post-test design were used.nnnMETHODnTwenty-six patients with venous ulcers in a community care setting participated. Data were collected by means of interviews and participant observation. Frequency and duration of wearing compression, leg exercising and leg elevation, activity level, pain and ulcer size were registered at baseline, after the end of the intervention and three months later. Inductive content analysis and Wilcoxon signed-rank test were used.nnnRESULTSnKnowledge about leg ulcer advice increased. The education contributed to more consciously following of the advice. The rationale of the advice and its association with healing or recurrence remained often unclear. More patients performed exercises after the intervention and at follow-up. Patients often looked out onto a new perspective where enhancement of quality of life and even healing might be attainable. Some patients regained independence after learning how to apply and remove compression garments themselves. The frequency of exercising and the duration of exercises increased significantly. Step counts had not altered significantly. Patients not elevating the legs at baseline elevated the legs more and for a longer period of time after the intervention. This effect on leg elevation decreased after three months. No significant changes were reported on hours wearing compression.nnnCONCLUSIONSnThe perceived changes suggest that the intervention holds a promise for current home care. Combining qualitative and quantitative research assisted to determine the possible effects of the intervention, increasing the potential for a meaningful randomised trial in the future.nnnRELEVANCE TO CLINICAL PRACTICEnEducation about leg ulcer advice should be incorporated in nursing practice. Further testing of the intervention is recommended.

Guidelines for the management of venous leg ulcers: a gap analysis

BACKGROUND AND AIMnSince 1998, many leg ulcer practice guidelines were developed. The aim of this paper is to describe the methodological and clinical content quality of those guidelines. Methods PubMed, CINAHL, Cochrane Library and websites known for publishing or collecting clinical practice guidelines were explored from 1998 up to June 2006. Reference lists of all identified guidelines were reviewed for other guidelines to be included. Guidelines were eligible if they were written in English, Dutch, French or German, if the scope was the treatment of venous leg ulcers, if the guideline was systematically developed and if the steps in guideline development were reported clearly. Seven guidelines were critically appraised.nnnRESULTSnThe venous leg ulcer guidelines were clearly based on evidence. The stakeholder involvement varied during the development process. Especially patients perspectives were often not considered. There was no uniform method used to weigh the evidence. Limited attention was given to pain and lifestyle advice recommendations. A paucity of information on compliance, quality of life, organizational aspects of care and economic evaluation data was given. Most of the guidelines failed to consider the issues of dissemination and implementation. Revisions of the guidelines for leg ulcer treatment were often not available.nnnCONCLUSION AND IMPLICATIONS FOR FUTURE GUIDELINE DEVELOPERSnIt is recommended that leg ulcer guidelines should incorporate a multidisciplinary approach and patient involvement is necessary. Extensive background information and the formulation of the rationale are needed. The development of an implementation guide that addresses the barriers particular to the adoption of guidelines for leg ulcer treatment could support the process of implementation. Recommendations on pain, lifestyle advice, compliance and other quality-of-life issues should be incorporated in guidelines for leg ulcer treatment.

Development and psychometric evaluation of an instrument to assess venous leg ulcer lifestyle knowledge among nurses

AIMnDevelopment and psychometric testing of an instrument to assess venous leg ulcer lifestyle knowledge.nnnBACKGROUNDnNurses often lack knowledge to provide adequate leg ulcer advice. No valid and reliable instruments are available to assess knowledge on venous leg ulcer advice among nurses.nnnMETHODSnThe instrument was developed based on a literature review and patient cases. Content validity was evaluated in a Delphi procedure by nine leg ulcer experts. Item-analysis, construct validity and stability were assessed. A sample of 350 nurses and student nurses participated. Data collection took place between February and April 2009.nnnRESULTSnThe instrument included four topics: (1) Compression therapy, (2) Physical activity/leg exercises, (3) Leg elevation and (4) Pain management. Multiple-choice questions were developed to assess factual knowledge. Patient cases were developed to assess more complex cognitive skills. Content validity was established. The quality of the response alternatives varied between 0.01 and 0.68. The difficulty index for questions evaluating factual knowledge ranged from 0.12 to 0.78. Patient cases questions had a difficulty index between 0.07 and 0.60. The score of participants with (theoretically expected) more expertise was significantly higher than the score of participants with (theoretically expected) less expertise. The intraclass correlation coefficients ranged between 0.71 and 0.77. Eleven questions had moderate kappa-values (0.41-0.60), and in eight questions, there was fair agreement (0.30-0.40).nnnCONCLUSIONnAn instrument with an acceptable content validity and construct validity was developed. The instrument can be applied in nursing education, nursing practice and nursing research to evaluate venous leg ulcer advice knowledge.