Nurse-patient consultations in leg ulcer care do patients ... · PDF fileNurse-patient...
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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.
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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:
Score 0 Score 1 Score 2 Score 3 Score 4 Score 5
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:
Score 0 Score 1 Score 2 Score 3 Score 4 Score 5
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:
Score 0 Score 1 Score 2 Score 3 Score 4 Score 5
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:
Score 0 Score 1 Score 2 Score 3 Score 4 Score 5
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:
Score 0 Score 1 Score 2 Score 3 Score 4 Score 5
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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