Lack of commissioned leg ulcer services

In some areas, the lack of specifically commissioned leg ulcer services was mentioned as a barrier to the provision of appropriate compression therapy; in these areas leg ulcer care was provided as part of general community nursing services: ‘It’s just wrapped up in district nursing.’ (014co). Community nurses discussed the challenge of offering optimal care, either because of perceived lack of skills in compression therapy or because of other responsibilities, resulting in apparently eligible people not receiving compression: ‘You’re not able to follow up….and like offer the treatment as they should anyway because of all the other things you have to worry about.’ (002co). Non-housebound patients were not eligible for home visits from community nursing services; in some areas they could attend community nurse-led clinics but in others they received leg ulcer care from practice nurses at their GP surgery, and these nurses were perceived as less likely to be trained in compression therapy: ‘Sometimes the practice nurses are not competent to do the compression bandaging.’ (004cl). These issues could affect the type of compression a patient was offered.

In areas with commissioned leg ulcer services and leg ulcer clinics, the clinics were highly thought of and seen as facilitating good quality care, incorporating appropriately trained staff and continuity:

The leg ulcer clinics in [name of area] are fabulous. Fabulous for patients, great for continuity, but also, great for anybody who has joined the district nursing team to make sure we’ve got that consistency across the [area]. (014co).

Questions were, however, raised about the accessibility of some clinics, and it was suggested that patients may have difficulty getting to clinic locations on multiple/frequent occasions.

Delays in initial leg and wound assessment

The importance of fast, timely, initial assessment of someone with a suspected VLU was a universal theme: ‘Getting the treatment in place quickly, because otherwise it can become….like the chronicity increases and the chance of healing decreases.’ (004cl). However, delays in initial assessment were often described. This could be because community nurses did not recognise the need for specialised assessment of a wound: ‘Nobody’s thought about doing a Doppler. And that might be because they’re not experienced, so hadn’t thought about it.’ (006co); or that they lacked the skills to carry it out: ‘There’s only a select few of us within the team who can complete the Doppler assessment……there’s just not enough of us.’ (005co); (the Doppler assessment measures Ankle-Brachial Pressure Index (ABPI) and is an important component of initial assessment prior to compression use). Delays in access to Doppler were also ascribed to the general pressure of work in the community:

So, pressure of work most definitely is a barrier……you could go in, see the patient……you know put the dressing on. You are in and out of that house in 15 minutes, aren’t you? You can also send your unregistered, or registered but non-nurse members of the team and so, even though our leg ulcer pathway, if you like, says, the gold standard, after two weeks you should be doing a Doppler, pressure of work, if you’ve got loads and loads of visits and not many staff and you’ve got low grades of staff, well then, that can slip can’t it? (014co).

Even in areas with dedicated leg ulcer clinics delays in getting an initial assessment were described:

There needs to be more of them [leg ulcer clinics], because patients are still waiting too long for assessment. So we see lots of patients in vascular [clinic] that have waited three, four months. So they’ve been seeing the district nurses, waiting three or four months to go and see the leg ulcer clinic, and in that time their leg’s getting worse and worse and worse, and in the end, the GP’s referred them to Vascular. So they’ve ended up in secondary care, because the waiting lists in primary care are too long. (003cl).

Two interviewees highlighted the value of specific assessment clinics which had been established to enable timely assessment and one spoke about a new role that she had undertaken providing community vascular support, which she said could lead to more timely assessments. More broadly, interviewees spoke about promoting awareness of leg care. One talked about ‘a Legs Matter week….what they tend to do is promote healthy legs and promote compression and promote good skincare’ (006co) and another suggested ‘it’s not just patients, just nurses in general need [awareness raising]’ (001cl).

Lack of continuity of care

A lack of continuity of nursing care, with different staff attending patients, was perceived as a barrier to effective compression therapy. It was more a problem for community teams than in leg ulcer clinics, and could result in staff not having an overview of a patient’s care, knowledge of their disease or treatment history, or reasoning behind clinical decisions. A nurse explained:

The teams are so large, what will happen is, somebody will start the reduced compression. And then obviously, a different person goes in next time, and they will think they’re in reduced compression, because they’ve got a problem with their arterial line. And no one will ever increase that compression, because they assume, because they’re in reduced compression, that they’ve got some, you know… (003cl).

This situation could be exacerbated by the lack of availability of electronic patient records in the community. A vascular clinic nurse commented:

So that’s another thing that adds to it. When everyone’s on different [patient record systems]. ‘We can’t access the [electronic] hospital records’. I don’t think the district nurses have got access. We have but they don’t. (010cl).

Lack of continuity in staffing was perceived as leading to a situation where ‘somebody else thinks somebody else’s, you know, it’s somebody else’s responsibility’ (006co). One interviewee described a change in working practices, ‘zonal working’ where a smaller group of nurses covered a defined geographical area, as increasing the likelihood of staff continuity. In addition, patients having contact details for the nursing team, for example, through a telephone help-line, was thought to enhance continuity of care and communication between staff and patients.

‘Joined up’ services and multidisciplinary teams

A lack of communication between different services was identified as a barrier to optimal care. A patient with a VLU could be seen by hospital vascular services, leg ulcer clinics and district nursing services, as well as have contact with primary and secondary care services for issues other than their VLU. It was reported that these services did not necessarily communicate well with each other, resulting in unnecessary duplication (eg, where a patient gets referred to both a leg ulcer clinic and a vascular clinic) or unnecessary referral (eg, where a patient had undergone investigations while a hospital inpatient but the results of these investigations were not communicated to the other services). Patients not receiving their compression therapy while hospital inpatients was frequently mentioned:

Another barrier to our work is that we can be working really hard with a patient, they become unwell, they're admitted to hospital for something completely different. And the first thing they do is take the compression bandages off their legs and just stick a plaster on. Because nobody within hospital can do that treatment either. (001cl).

Conversely, good liaison between vascular or leg ulcer clinics and community nursing teams was described as a facilitator of good care. Often a patient would be seen in a vascular or leg ulcer clinic, a treatment plan drawn up and they would be returned to community teams to continue the treatment. The majority of both clinic-based nurses and community-based nurses reported good communication and liaison between the two: ‘Any of the patients now that come to see me leave this clinic with a concise treatment plan……I’ve got good established links with community’ (003cl); ‘We have the numbers of all the vascular specialist nurses, so if we feel like we just need to ask a little bit of advice… they’ll get back to us straight away’ (013co).

Multidisciplinary teams, including nurses, physiotherapists, podiatrists and social workers working well together, were described as facilitating high quality VLU care and compression therapy. The importance of working with the care system was also highlighted in terms of care workers being able to support patients with their compression therapy. One nurse also suggested working with care workers on training:

The care providers, because they’re often quite low-paid, so they have minimal training and that’s why we’re, our vision is joint training. Because, if they could come on our leg ulcer morning or updates, so that they understand the importance of the compression. (014co).

Prescribing issues

Compression therapy is a prescribed treatment. Nurses who had been trained as independent prescribers were able to prescribe compression, others had to ask a patient’s GP to prescribe the treatment. This could cause delays and could result in patients not having prescribed treatment in time for their next nurse appointment:

[Patient takes] your form to the GP. It has to sit at the GP’s for 48 hours. They then do a prescription. The patient has to pick the prescription up, take it to the chemist. You might wait another 48 hours to pick your prescription up. (001cl).

Most clinic nurses and some community nurses had stocks of compression which they could use if necessary (patients were often started off in their compression from these stocks), but this was not always the case.

Application of compression as physically hard work

Four interviewees reported that application of compression therapy, in some circumstances, can be physically hard work, particularly where the application takes place in patients’ homes without any aids including treatment couches at the correct height. One interviewee commented: ‘for district nurses it will often be on the floor on their hands and knees….so it is physically a little bit tricky’ (004cl) and another: ‘we’ve had a couple of staff that had got either bad backs or bad knees. So that takes them out of being able to do it for a couple of weeks’ (012co). Suggested facilitators were working in pairs, and spreading out compression visits over several days in order to avoid having too many on one day, but these solutions often depended on adequate staffing.

Getting patients ‘on board’

All interviewees described the importance of getting patients ‘on board’ with their treatment, that is, in agreement with and involved with it, from the beginning: ‘I think if they’re not on board from the beginning, you’re fighting a losing battle.’ (005co). This could be difficult: ‘Getting them on board to comply with the compression, and the correct compression. I think basically, that’s the biggest one that we have a problem with.’ (007cl). Explanations were seen as key to engaging patients: nurses were clear that if patients understood that their VLU was a symptom of an underlying long-term condition, and understood the mechanism of compression therapy, they were more likely to adhere to treatment.

In relation to explaining aetiology and compression therapy, interviewees talked about the availability and utility of written information to use with patients. A minority did not use written information at all and some thought that patients did not read information leaflets anyway. However, the majority of interviewees thought that written information could be useful:

So it just gives them something to read at their own leisure, and then next time you go, they’ve got a bit more of an understanding of what you’re talking about as well. So I find the leaflets do work quite well. (008co).

Some interviewees had access to ‘Trust leaflets’ and product company leaflets were also mentioned, although worries were expressed about bias, which may be indicative of variation in the quality of this information. In order to be useful all interviewees thought that leaflets needed to have very simple, clear explanations, some said that pictures were helpful, and one person suggested alternative information formats such as short films.

In terms of getting patients ‘on board’, the majority of interviewees also spoke of giving patients options or choices, which might make them more likely to adhere to their compression therapy. One nurse explained:

Like this is how I would feel you'd do best, however, these are your other options. And I’d rather give options at this point and formulate a plan, because you tend to get a little bit more concordance than saying well, this is what you are going to do. (001cl).

There were a number of situations in which it could be possible to offer options, for example, less obtrusive compression or being flexible with clinic appointments. All nurses agreed that it was important to build a relationship with their patient in which they could discuss treatment issues and work together towards the best outcome for the patient: ‘A lot of it is getting them on board, building that relationship up with your patients…….and it’s a journey together really.’ (007cl); ‘It’s teamwork, it’s not a one-way system.’ (002co).

Explaining time frames around healing

The difficulty in estimating how long a VLU may take to heal and explaining this to a patient could be a barrier to setting goals and the successful use of compression therapy. All interviewees said that patients always asked about how long healing would take: ‘I think that’s one of the first things they’ll ask you.’ (001cl). Nurses suggested that giving a specific time frame should be avoided: ‘The worst thing you could do is give the time. Because, then they’re going to sit and wait and say right it’s been this long, and it’s not healed.’ (008co). A number of things that interviewees thought helped in explaining time frames included being positive; talking about healing in small steps; describing what patients can do to speed up healing and issues that may slow healing; and being honest about ulcers that are likely to take a long time to heal, if at all.

One particular difficulty with trying to explain time frames around healing was that in many cases nurses suggested healing of a VLU does not take a straightforward trajectory over time, and a wound may appear to get worse. Interviewees described patients becoming ‘really disheartened’ (005co). There was consensus that there was usually a discernible cause for an ulcer deteriorating, thus the important thing was to identify the cause and address it: ‘You can try and look at a reason why it has happened, like infection. And then treat that cause…….and tell them [patient] that you’ve addressed that so there is some hope for them that will work.’ (004cl).

Gaps in knowledge and skills

There is some suggestion that not all community nurses have the necessary knowledge to recognise the need for a comprehensive leg and wound assessment, or the necessary skills to carry out this initial assessment (including ABPI). Interviewees also recognised a lack of skills among some community nurses in relation to the application of compression bandages: ‘The next district nurse that’s gone in is not competent in bandaging, so they’ve not been able to receive the treatment.’ (003cl); and the monitoring of compression therapy:

[Patient] who I sent back to the district nurses to look after……nobody had bothered to put it [compression bandages] back on because she didn’t really want it on. So nobody had gone through all the things again, why you need to have it, why it’s going to help you….nobody had bothered putting it back on because she’d said ‘Oh I don’t really want it’. (010cl).

Training

Interviewees identified issues with the provision of training to address the gaps in knowledge and skills as being a barrier to the provision of compression therapy. Although training provision was generally considered to be adequate for those working in more specialised roles, for community nurses this was not always the case. A minority of interviewees thought that the availability of training was not good, and a majority mentioned access being more of an issue—it could be challenging to take time out to attend training because of workloads: ‘The first thing that gets cancelled is training, unfortunately, ‘cos obviously the needs of the patient come before training.’ (005co). It was also noted that staff turnover in the community was high, so there was always a need for training. Some positive examples of training were given; a community nurse talked about training offered by her Tissue Viability Team which she described as ‘really good….we do it yearly, so we do have leg ulcer training yearly and compression training’ (005co). Various facilitators of training were suggested, for example, it was thought that provision of training ‘on site’ may get around issues of time to attend. Another interesting issue was the kind of ‘informal’ training that could be gained by nurses shadowing others in leg ulcer clinics, where these were available: ‘You could go and spend an afternoon there and it’s just that……The experts are there, great.’ (014co).

Encouraging compression use

All interviewees thought that frequent reiteration of explanations about compression being the best therapy was important in encouraging patients to continue using it. They talked about patients being able to ‘self-manage’ their care and compression therapy as a goal to be aimed for, which they perceived could contribute to the wider use of compression. However this ‘can be difficult sometimes, but we’re trying to encourage that self-caring as well and encourage them to take control over their care’ (002co). One nurse suggested that barriers to self-care involved not only patients but the thinking and attitudes of nurses themselves:

Self-management’s quite a new…when I say new, I mean sort of, in the last few years. But it was always, sort of, the nurse came and did your dressing, and the nurse looked after it. And, I think, even for staff who’ve been around a long time it’s hard getting that sort of, out of your head. So, it’s about, sort of, changing your whole attitude and going in from the start and with the idea [that the patient will self-manage]. (006co).

Response to non-adherence

Many interviewees spoke about how their response to a patient who was not adhering to compression therapy was important in terms of whether that person might carry on, or would try compression again in the future: ‘We have to ask why and is there anything else we can do to change that or make it better. Try and find the root of the cause of why they’re saying no and then take it from there.’ (002co). It was also universally agreed that there will always be patients who will not tolerate or adhere to compression therapy, and that this was another point at which there was a need to be sensitive in responding in order to support the patient and keep the door open for them to try compression again in the future:

I think if they are very sure they don’t want to, and we do see…we do see a few like that, you just, I mean, you just kind of say that you understand their choice and, of course, it is their choice what they have on and we understand the reasons why. But that they have to also understand that, you know, healing will be delayed, or indeed will be very difficult to achieve without compression, in a nice way. (004cl).

Variation in available bandaging systems

Bandaging systems available for use varied geographically, as recommended by local Tissue Viability or Leg Ulcer Teams. When asked whether she was constrained in what compression therapy she could use for a patient based on where a patient lived and the bandage system used there one clinic-based nurse replied: ‘I tend to because you just don’t want to make life any more difficult’ (003cl). Community nurses sometimes changed the compression type decided on by specialist services because they are not able to provide it in their geographical area: ‘We change them to [name of compression brand] because that’s what we can……that’s what our ordering system allows us to order’ (012co).