Julie Green

The impact of chronic venous leg ulcers: a systematic review

OBJECTIVEnChronic venous leg ulcers are common, intractable and often recurrent, but care tends to be wound focused, potentially overlooking the significant impact the condition has on patients lives. A systematic review was undertaken to explore the factors that impact on the quality of life of patients with chronic venous leg ulceration.nnnMETHODnEligible articles published between 1990 and 2013 were identified via electronic searches of research databases (MEDLINE, CINAHL, BNI, EMBASE, PsycINFO, AMED and HMIC, Cochrane Collaboration database and Google Scholar).nnnRESULTSnThere were 23 studies (11 qualitative and 12 quantitative) that met the inclusion criteria. There were then the subject of a full review. The qualitative studies were collapsed into four core themes: physical, psychological, social implications and the nurse-patient relationship. The quantitative studies were grouped according to the tool applied. The review demonstrated that chronic venous leg ulcers impact negatively upon all areas of daily living. Pain, exudate, odour and the impact on mobility were daily challenges. The ability to engage with everyday functioning was restricted either owing to the ulcer, the dressing or to a self-imposed isolation in response to the impact of symptoms. Depression and low mood were common and yet, despite this, some studies reported that participants remained hopeful.nnnCONCLUSIONnStudies suggest that chronic venous leg ulceration negatively affects the quality of life of the patient and that such issues receive inadequate attention during current consultations. If such negative implications are to be effectively addressed, key issues need to be considered during every consultation.nnnDECLARATION OF INTERESTnThis study was funded by West Midlands Strategic Health Authority. The authors have no conflicts of interest to declare.

The challenge of multimorbidity in nurse education: An international perspective

The rise in prevalence of chronic diseases has become a global healthcare priority and a system wide approach has been called for to manage this growing epidemic. Whilst healthcare reform to tackle the scale of chronic disease and other long term conditions is still in its infancy, there is an emerging recognition that in an ageing society, people often suffer from more than one chronic disease at the same time. Multimorbidity poses new and distinct challenges and was the focus of a global conference held by the Organization of Economic Cooperation and Development (OECD) in 2011. Health education was raised as requiring radical redesign to equip graduates with the appropriate skills to face the challenges ahead. We wanted to explore how different aspects of multimorbidity were addressed within pre-registration nurse education and held an international (United Kingdom-Sweden) nurse workshop in Linköping, Sweden in April 2013, which included nurse academics and clinicians. We also sent questionnaire surveys to final year student nurses from both countries. This paper explores the issues of multimorbidity from a patient, healthcare and nurse education perspective and presents the preliminary discussions from the workshop and students survey.

A new quality of life consultation template for patients with venous leg ulceration

OBJECTIVEnChronic venous leg ulcers (CVLUs) are common and recurrent, however, care for patients predominantly has a focus which overlooks the impact of the condition on quality of life. The aim of this study was to develop a simple, evidence-based consultation template, with patients and practitioners, which focuses consultations on quality of life themes.nnnMETHODnA nominal group was undertaken to develop a new consultation template for patients with CVLUs based on the findings of earlier qualitative study phases.nnnRESULTSnA user-friendly two-sided A4 template was designed to focus nurse-patient consultations on the quality of life challenges posed by CVLUs.nnnCONCLUSIONnCVLUs impact negatively on the quality of life of the patient but this receives inadequate attention during current consultations. This new template will help to ensure that key concerns are effectively raised, explored and addressed during each consultation.nnnDECLARATION OF INTERESTnThe NHS West Midlands Strategic Health Authority funded this study. The authors have no conflicts of interest to declare.

Development of an international comorbidity education framework.

CONTEXTnThe increasing number of people living with multiple chronic conditions in addition to an index condition has become an international healthcare priority. Health education curricula have been developed alongside single condition frameworks in health service policy and practice and need redesigning to incorporate optimal management of multiple conditions.nnnAIMnOur aims were to evaluate current teaching and learning about comorbidity care amongst the global population of healthcare students from different disciplines and to develop an International Comorbidity Education Framework (ICEF) for incorporating comorbidity concepts into health education.nnnMETHODSnWe surveyed nursing, medical and pharmacy students from England, India, Italy and Sweden to evaluate their understanding of comorbidity care. A list of core comorbidity content was constructed by an international group of higher education academics and clinicians from the same disciplines, by searching current curricula and analysing clinical frameworks and the student survey data. This list was used to develop the International Comorbidity Education Framework.nnnRESULTSnThe survey sample consisted of 917 students from England (42%), India (48%), Italy (8%) and Sweden (2%). The majority of students across all disciplines said that they lacked knowledge, training and confidence in comorbidity care and were unable to identify specific teaching on comorbidities. All student groups wanted further comorbidity training. The health education institution representatives found no specific references to comorbidity in current health education curricula. Current clinical frameworks were used to develop an agreed list of core comorbidity content and hence an International Comorbidity Education Framework.nnnCONCLUSIONSnBased on consultation with academics and clinicians and on student feedback we developed an International Comorbidity Education Framework to promote the integration of comorbidity concepts into current healthcare curricula.

Enhancing assertiveness in district nurse specialist practice

District nurse (DN) care delivery has undergone substantial change in recent years due to changing demographics and service delivery demands that have called for a move of care delivery from secondary to primary care. The title District Nurse is recorded with the Nursing and Midwifery Council (NMC) on completion of the Specialist Practice Qualification in District Nursing (SPQ DN), which purports to be a transformational course that prepares future caseload holders to manage their team and prioritise care delivery effectively. This article explores the need for assertiveness skills in this role in response to Australian research, and outlines the pedagogic interventions implemented during the SPQ DN course to enhance this skill. Assertiveness scores were monitored for the duration of the course and demonstrated a significant increase-a topic that is now the subject of a future, funded study.

Using a modified Delphi methodology to gain consensus on the use of dressings in chronic wounds management

OBJECTIVEnManaging chronic wounds is associated with a burden to patients, caregivers, health services and society and there is a lack of clarity regarding the role of dressings in improving outcomes. This study aimed to provide understanding on a range of topics, including: the definition of chronicity in wounds, the burden of illness, clinical outcomes of reducing healing time and the impact of early interventions on clinical and economic outcomes and the role of matrix metalloproteinases (MMPs) in wound healing.nnnMETHODnA systematic review of the literature was carried out on the role of dressings in diabetic foot ulcer (DFU), and venous leg ulcer (VLU) management strategies, their effectiveness, associated resource use/cost, and quality of life (QoL) impact on patients. From this evidence-base statements were written regarding chronicity in wounds, burden of illness, healing time, and the role of MMPs, early interventions and dressings. A modified Delphi methodology involving two iterations of email questionnaires followed by a face-to-face meeting was used to validate the statements, in order to arrive at a consensus for each. Clinical experts were selected, representing nurses, surgeons, podiatrists, academics, and policy experts.nnnRESULTSnIn the first round, 38/47 statements reached or exceeded the consensus threshold of 80% and none were rejected. According to the protocol, any statement not confirmed or rejected had to be modified using the comments from participants and resubmitted. In the second round, 5/9 remaining statements were confirmed and none rejected, leaving 4 to discuss at the meeting. All final statements were confirmed with at least 80% consensus.nnnCONCLUSIONnThis modified Delphi panel sought to gain clarity from clinical experts surrounding the use of dressings in the management of chronic wounds. A full consensus statement was developed to help clinicians and policy makers improve the management of patients with these conditions.

Non-disclosure of symptoms in primary care: an observational study

BackgroundnSymptoms form a major component of patient agendas, with the need for an explanation of symptoms being a prominent reason for consultation.nnnObjectivesnTo estimate the prevalence of different symptoms pre-consultation, to investigate whether intention to mention a symptom in the consultation varied between patients and across symptoms, and to determine how patients intended agendas for mentioning symptoms compared with what was discussed.nnnMethodnWe videorecorded consultations of an unselected sample of people aged 45 and over consulting their GP in seven different practices in UK primary care. A pre-consultation questionnaire recorded the patients agenda for the consultation, current symptoms and symptoms the patient intended to discuss with their GP. The videorecorded consultation was viewed and all patient agendas and symptoms with intention to discuss were compared with the actual topics of discussion.nnnResultsnTotally, 190 patients participated. Eighty-one (42.6%) were female and the mean age was 68 (range 46-93). Joint pain was the most commonly reported symptom. One hundred thirty-nine (81.8% of those reporting symptoms) patients reported intention to discuss a symptom. In 43 (22.6%) consultations, 67 symptoms (27.2%), where an intention to discuss had been expressed, remained undisclosed. Tiredness and sleeping difficulty were more likely to be withheld than other symptoms after an intention to discuss had been expressed. Of the more physically located symptoms, joint pain was the most likely to remain undisclosed.nnnConclusionnThis study suggests that the extent of symptom non-disclosure varies between patients, physicians and symptoms. Further work needs to explore the consequences of non-disclosure.

Chronic venous leg ulcer care: Putting the patient at the heart of leg ulcer care. Part 1: exploring the consultation

This article, the first of two, summarises a study that explored the lived experiences of patients with leg ulcers and the impact of this condition on their quality of life. The study had four study phases; phases 1 and 2 employed qualitative methods and are reported here. Initially, unstructured interviews were held; these revealed significant issues for the patients including the dominance of pain, issues relating to exudate and odour, social isolation and psychological effects. A checklist based on these issues was completed by the researcher during observations of routine care for these same patients; this revealed the extent and depth to which these matters were addressed. On many occasions, significant issues were not disclosed or explored during consultations. These findings confirmed that participants with chronic venous leg ulcers have concerns far beyond wound care.