Sykepleievitenskap . Omvårdnadsforskning . Nursing Science

Patient safety regarding leg ulcer treatment in primary health care Hilde Smith-Strøm, Senior Lecturer, MSc, RN – Ingun Thornes, RN

ABSTRACT Aims. The aims of this study were to survey how nurses collaborated with a hospital department of dermatology and how they treated chronic leg ulcers and to survey the nurses’ knowledge of leg ulcer treatment. Background. Patients with leg ulcers do not necessarily receive treatment based on best evidence. Improving wound treatment among patients with leg ulcers requires surveying areas in which the treatment can be improved. Methods. A descriptive study was used. The subjects were all registered nurses (N=158) who treated leg ulcers in primary health care in one Municipality in Norway. Data were collected using a standardized questionnaire. Findings. Not all patients had been diagnosed before the treatment started. Mainly nurses (57%) prescribed treatment when no diagnosis had been made. Nurses changed the treatment without consulting the department of dermatology. Compression and pain treatment were not standard procedure for all patients. Not all patients had continuity of provider in treatment. The main sources of the nurses’ knowledge were their own experiences and those of colleagues. Conclusion. The treatment of leg ulcer did not comply with international guidelines, and this can threaten patients’ safety. The nurses perceived their knowledge of wound treatment to be insufficient. KEY WORDS: leg ulcer treatment, district nurses, primary health care, patient safety, evidence-based practice

Introduction

During recent years, awareness has increased of the serious widespread quality problems in health care, including rising costs, difficult access and wide variation in safety and quality (1). Treating patients with leg ulcers is a challenge to health professionals, because venous leg ulcer is a chronic disease that often takes years to heal, recurrence rates are high and it is a major cause of morbidity, pain and health care costs (2,3). Improving patients’ safety and avoiding adverse events in wound treatment requires basing the quality of care on treatments of known efficacy, interprofessional collaboration and knowledge about wound treatments. Using treatments with known efficacy improves healing rates and the quality of life and reduces the cost of care (4,5). Studies (2–4) show that patients do not necessarily receive treatment based on best evidence. Studies focusing on nurses’ knowledge of leg ulcer treatment found that most district nurses believed that their knowledge of wound treatment was insufficient, and they felt uncertain about the treatment. The uncertainty included wound treatment, assessment, diagnosis and selection of dressing. The main sources of the nurses’ knowledge were their own nursing practice and their education (6,7). In another study (3), only half the patients received a diagnosis before treatment started. Not all patients were treated with compression; 15% of the patients had pain, but only 17% received some form of pain treatment. Ulcers were measured regularly for 11% of the patients. The mean number of nurses providing leg ulcer care to each patient was 19 (3). Ribu et al. (8) found very similar results. In addition, the treatments were poorly documented. Lack of exact diagnosis, compression therapy and pain treatment reduce patient safety and can lead to adverse events. However, in primary health care, patients are frequently referred to the care of nurses without the physician first determining the underlying cause of the leg ulcer or with insufficient support from general practitioners (9). The care of these patients is reported to occupy at least 25% of the working time of district nurses and takes up substantial health care resources (9,10). Increasing the training and knowledge of wound treatment and using treatments with known efficacy can reduce the cost and time spent on wound treatment (9,10). Research (9–11) has documented that nurses and physicians must collaborate closely to improve wound treatment. A study evaluating the implementation of a nurse-led service found that practical guidelines and enhanced cooperation with family physicians and specialists produced better healing rates and improved efficiency (4).

Moffatt & Franks (5) found that reorganizing leg ulcer service, including steering groups, resulted in improved professional practice, better patient outcome and more efficient use of resources. Few studies of wound treatment and care have been performed in Norway, which creates difficulty in evaluating the quality of leg ulcer care. The aims of this study therefore surveyed how district nurses collaborated with a department of dermatology and how they treated chronic leg ulcer and surveyed the district nurses’ knowledge of leg ulcer treatment as a basis for developing best practices. Methods

Population and design The total population of registered nurses in primary health care in nine districts in one Municipality in Norway in 2003 who treated leg ulcers was 158 (according to the Municipality health service). A census survey was designed for this population, and all registered nurses were asked to participate. No exclusion criteria were used. All nine districts in the municipality participated. We used a descriptive design, because the main purpose was to illuminate the district nurses’ treatment and knowledge of patients with leg ulcers. Data collection We used a questionnaire to collect data. It was pilot-tested on 20 district nurses in three municipalities in Norway. In the pilot study, the senior nurses delivered the questionnaires to the district nurses. Before we started to collect data in the main study, we held a meeting with all senior nurses from the districts to inform them about the study, the results of the pilot study and the procedure for data collection. In the main study, the procedure for data collection was changed to a personal meeting with the district nurses to increase the response rate in the districts. However, in three of the nine districts a personal meeting was not possible, and the senior nurses delivered the questionnaire to the participants. We sent reminders after 3 weeks to the senior nurses in these districts. Instruments The questionnaire was divided into three parts. In parts 1 and 2, we constructed questions on how chronic leg ulcers were treated in primary health care based on discussion with three district nurses and one dermatological nurse, a literature review, field research and the HILDE SMITH-STRØM OG INGUN THORNES

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Sykepleievitenskap . Omvårdnadsforskning . Nursing Science

researcher’s own experience from primary health care. The questionnaire had both closed and open questions. A Likert scale (1–5) was used for closed questions. The questionnaire in part 1 (11 items) included questions about whether a dermatologist had assessed the leg ulcer before treatment started, who ordered the treatment when no diagnosis had been made, waiting time before consulting a dermatologist and whether the nurses changed the treatment without consulting a dermatologist. In part 2 the questionnaire (10 items) included questions about whether the nurses were satisfied with the telephone consultation, the follow-up for wound impairment and the clinical procedures, whether compression, pain treatment and measurement of the leg ulcers were common procedures in treatment, how documentation was carried out and who treated the leg ulcers. Some of the questions left space for in-depth comments. Part 3 had four questions about the nurses’ knowledge; the nurses’ confidence in wound treatment, their knowledge of wound treatment, the sources of this knowledge and the nurses’ opinions on the most important factor in wound treatment. All four questions had space for in-depth comments. The questionnaire in part 3 had previously been used in a population of nurses in a city in Norway (6,7).

have a dermatologist assess the ulcer to determine the underlying cause before treatment started, was not standard procedure. The nurses changed the treatment without consulting the dermatologist. Compression and pain treatment were not standard procedure for all patients. Not all patients had continuity of provider in treatment. Most nurses believed that they had insufficient knowledge about wound treatment. The main sources of knowledge of the nurses were their own and their colleagues’ experiences and not from evidence-based knowledge. The results are further presented as text, tables and excerpts from the statements of the nurses.

Validity and reliability The content validity is the degree to which the items in an instrument adequately represent the universe of content (12). This was supported by the literature review on leg ulcer care, data gathered from the field and the researchers’ own experience in primary health care. To establish face validity, which is whether the tool appears to measure the concept intended (12), input was gained from experts in the field of leg ulcer care from both primary health care and a hospital department of dermatology and from nursing research. The construct validity is the degree to which an instrument measures the construct being investigated (12). This seemed to be satisfactory, because collaboration, knowledge and leg ulcer treatment and care are well-known concepts to the nurses. The nurses’ replies indicated good understanding of the questionnaire. The pilot study tested all parts of the questionnaire. This pilot test had three main foci: whether the questionnaire was clear and easy to complete, whether questions needed to be added or removed and whether the data collection was going to be effective. We determined that the questionnaire was clear and easy to complete and made no important changes for the main study. In the main study, all the questions were answered properly, which indicates that the reliability was reasonably good. One factor that could reduce the reliability is that only the researchers analyzed the data.

Waiting time for the first dermatological consultation Figure 1 shows that the nurses said that 3 weeks elapsed on average before the first consultation at the department of dermatology.

Data analysis A descriptive and interpretative data analysis was carried out. We summarized the quantitative data and presented them as frequencies, means, percentages and standard deviations and analyzed them using the statistics program NSD-stat. Data from the open-ended questions were transcribed verbatim, read and categorized according to what emerges from the data (13). The nurses’ qualitative statements are presented as excerpts of the comments and are italicized.

Nurses also changed the treatment without consulting the department of dermatology. Of 98 nurses, 10% did this often, 46% sometimes and 44% never. The qualitative data from nurses (n=49) who reported that they changed the procedure without consulting a dermatologist showed different reasons for doing this: long time before access (n = 11), they trusted their own knowledge (n = 10), treatment prescribed by the dermatologist was the worst treatment (n = 12), improved wound healing (n = 9), insufficient communication between the department of dermatology and the district nurses (n = 4), the treatment ordered by the department of dermatology was too expensive (n = 2) and the nurse was not capable of following the prescribed procedures (n = 1).

Approval The management of the Department of Health and Social Care of the Municipality, the senior nurses in all nine municipal districts and the Norwegian Social Science Data Services approved the study. A letter about the study was sent to all nurses in primary health care, assuring them of anonymity and confidentiality and informing them that participation was voluntary. No written consent was required, because completing the questionnaire was voluntary. Results

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Ninety-nine district nurses (63%) completed the questionnaire. The response rates were lower in the districts where the senior nurses delivered the questionnaire. Overall, the findings showed that offering to VÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 29–33

Who assessed the cause and prescribed the treatment? Not all patients had an assessment by a dermatologist to determine the underlying cause of the ulcer before treatment started in the municipal health service. Of 99 nurses, only 22% reported that the patients always had a diagnosis before treatment, 45% often, 32% sometimes and 1% never. Of 74 nurses, 57% mainly decided the treatment when there was no underlying diagnosis, 43% reported that the general practitioner ordered the treatment, and a common statement from the general practitioner was «treat the leg ulcer as you normally do».

Figure I: Waiting time for the first dermatological consultation, (%), (n=91) 70 59 60

Mean: 3,1 SD (0,68)

% of nurses

50 40 28

30 20 11 10 1

1

0 1 w eeks

2 w eeks

3-4 w eeks > 2 months > 3 months

Clinical procedures, telephone consultation and follow-up from the department of dermatology when the patient is registered in the system The nurses were asked whether they were satisfied with the clinical procedures they received from the department of dermatology. Of 99 nurses, 96% were satisfied and 4% were not. Table I shows that the district nurses were mostly satisfied with the contact with the department of dermatology for patients registered in the system.

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Discussion Table I. Contact between the department of dermatology and district nurses for patients registered in the system, (%), (n=99)

Questions Telephone consulting

Very good Good Moderate Poor Very poor Mean (SD) 16%

41%

27%

15%

1%

2.44 (0.97)

Offering a new consultation for wound impairment

5%

34%

41%

15%

5%

2.82 (0.93)

Follow-up by the department of dermatology for wound impairment

17%

57%

24%

2%

2.11 (0.7)

Methodological considerations The sample comprised all the district nurses in one Municipality in Norway. The reply rate was 63%, which indicated that the results are considered reliable and can be generalized. The response rate was lower among nurses in districts in which the senior nurses delivered the questionnaire. The reasons for this include not receiving the questionnaire, not being motivated to fill in the questionnaire or the senior nurse having a negative attitude.

Collaboration between the department of dermatology and primary care nurses Successful treatment in wound care requires close collaboration between nurses and specialist physiciOrganization of leg ulcer care in the municipal health service ans to improve wound treatment (3,5,11). In this study, nurses reporThe 99 nurses were asked whether giving compression to patients with ted good collaboration with the department of dermatology on folloinsufficient venous flow was standard procedure, and 32% reported wing up wound impairment, telephone consultations and clinical proalways, 53% often, 17% sometimes and 1% never. Eighteen percent cedures. Nurses were least satisfied with the ability of the department always gave drugs to patients with leg ulcers, 52% often and 30% someof dermatology to offer new consultations for wound impairment. times. Only 5% of the nurses reported that they always measured the This could be why not all nurses followed the recommendations from surface area of the wound, 13% often, 57% sometimes and 25% never. the department of dermatology. Nurses reported that they changed trePersonnel other than registered nurses often treat wounds. Fifty-nine atment without consulting the physicians. One main reason was that percent of the nurses often delegated the wound treatment to auxiliary getting access to the department of dermatology took a long time. nurses, 33% sometimes, 2% always and 6% never. The three main However, such decisions should be made in cooperation with the spereasons for this were: few nurses in the system, auxiliary nurses had sufcialist, because wound impairment can have several different causes ficient knowledge about wound treatment and performing wound treat(14,15). Leg ulcer treatment is multidisciplinary, and nurses operating ment in connection with other nursing tasks was practical. Of the 99 alone cannot implement best practices (3). Not assessing the right caunurses, 14% always used a primary nursing care model, 41% often, 33% ses for changing treatment can lead to inappropriate treatment and sometimes and 12% never. The nurses used several different documenadverse events (15). Establishing an ambulant team of specialist nurtation systems, such as evaluation reports (41%), electronic documentases in wound care from both primary health care and the department tion (24%), wound records (20%) and care plans (15%). of dermatology that is responsible for following up patients with wounds in primary health care will probably reduce these problems Nurses’ evaluation of their knowledge of leg ulcer treatment and increase patient safety. The team will improve continuity, docuOf 94 nurses, 65% said they did not have enough knowledge about mentation and the quality of treatment offered. Another important wound treatment of leg ulcer. These nurses wanted more knowledge alternative is frequent seminars on wound treatment for primary nurabout new methods and treatment of leg ulcers and new documented ses arranged by the department of dermatology. This will improve the products and dressings in the treatment of leg ulcers. Most nurses knowledge of the primary nurses on wound treatment. In addition, it (62%) sometimes felt uncertain in a wound treatment situation, 26% will also provide an opportunity for contact between the department of seldom, 8% often and 4% never. The qualitative data showed that they dermatology and the nurses in primary health care. were most uncertain in three main categories: whether the procedure Nurses also reported that not all patients had a diagnosis before the was the right treatment, when the procedure should be changed and treatment started, and nurses mainly ordered the treatment in such how often to change dressings. cases. This applies in other studies (2,3,8) and seriously threatens patient safety, because the underlying cause of ulcer must be determined Most important sources of nurses’ knowledge of leg ulcer and appropriate treatment choices made before treatment starts (14). treatment The long waiting time before patients get access to the department of The nurses could respond to more than one source of knowledge about dermatology was probably the main reason the patients had not been leg ulcer (Table 2). diagnosed before treatment started. In this study, most patients had to The main sources of the nurses’ knowledge were their own and collewait 3–8 weeks before being assessed by a dermatologist. This may agues’ experiences and courses in leg ulcer treatment. Books, journals lead to a difficult position, because the district nurses have to start treand guidance from the hospital department of dermatology seemed to be atment before diagnosis, which is not necessarily based on safe and the least important sources of the nurses’ knowledge. sound services. Treatment of leg ulcers is complicated, and clinical assessment of leg ulcers is difficult without training (15). In accordance with international guidelines, Table II. Most important sources of nurses’ knowledge of leg ulcer treatment comprehensive assessment is essential to determine the underlying cause and a dermatologist must pern** % form this (14). Clinical guidelines based on best eviFrom own experience 78 24 dence are reported to be a key vehicle for promoting Journals and books 47 14 evidence-based practice and should be a standard procedure in treating patients with leg ulcers (4). Colleagues 68 20 Studies in a community health service have also Brochures from pharmaceutical companies 24 7 showed that organized wound treatment based on Guidance from hospital department of dermatology 55 16 evidence-based service, including clear aims, collaCourses in leg ulcer treatment* 62 19 boration between professional groups, clinical gui* Hospital department of dermatology. ** Nurses could respond to more than one source of knowledge about leg ulcer.

delines and clear leadership, had managed to improve healing rates, reduced the average number of care visits and provided care to more patients HILDE SMITH-STRØM OG INGUN THORNES

Sykepleievitenskap . Omvårdnadsforskning . Nursing Science

without raising the cost (4,5). These principles are reported to improve the quality of care and can improve patient outcomes and cost-effectiveness (16). Methods of treating chronic leg ulcer in primary health care Even though compression, pain treatment and measurement of the leg ulcer surface area are essential in healing venous leg ulcers, this was not a common procedure among all nurses. Despite the strong evidence for the use of compression for venous leg ulcers (17), only 32% of the nurses reported that they always used compression therapy. Pain treatment is essential for patients with venous leg ulcers, but pain is often considered a sign of arterial disease or infection and has received little attention in the wound-healing literature. Misinterpreting pain can lead to poor management, and compression therapy may therefore be withheld (18,19). Regular measurement of the leg ulcer surface area is a reliable index for healing and is recommended in wound treatment (14,20), but only 5% of the nurses reported that they always did this. The absence of clear pain treatment, compression therapy and measurement may reflect the lack of knowledge and skills and lead to delayed healing and/or deterioration of the ulcer and increased cost (14). Other studies (3,8,20) also report these tendencies. The shortage of nurses in health care seemed to be the main reason why nurses delegated wound treatment to auxiliary nurses. This is similar to other studies (3,10,21). To change this, nurses must document to their supervisors how delegating wound treatment to the group of health care workers that has the least professional competence can affect the quality of care. Physicians and nurses should share responsibility for managing leg ulcer care, with assistance from auxiliary nurses to increase the quality of wound treatment based on best available evidence (2,11). Nevertheless, it is very positive that primary health care largely uses the primary nurse model. For patients, this means that they have one nurse (or at least very few) with whom they interact, more continuity in wound treatment, improved documentation and greater potential for active participation by the patient in care. Studies in which the primary nurse model has not been implemented showed a lack of continuity in assessing wounds, treating them, follow-up and documentation (22). This reduced the quality of the treatment offered to patients and increased costs. Nurses used different documentation systems. Only 20% of the nurses used a standardized wound record, although this form of documentation is recommended (23). Using a standardized wound record instead of continual evaluation reports improves the opportunities to assess the effect of treatment methods and procedures over a specific period of time and thereby assures high-quality treatment. Standardized wound records also provide a better basis for comparing current treatment with other types of intervention and can lead to new knowledge and new types of intervention with the aim of improving the quality of health outcomes. Primary health care should therefore increasingly attempt to use documentation systems that include good indicators for measuring the results of interventions.

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The districts nurses’ knowledge of leg ulcer treatment More than half the nurses reported that they had insufficient knowledge about wound treatment. The main sources for updating knowledge were their experience and that of colleagues. These are still the most common sources for decision-making in clinical practice among nurses and similar groups and may undermine best practice in wound treatment (6,7,24,25). However, personal experiences and those of colleagues are important in wound treatment but not sufficient and must be seen in connection with the best available evidence (25,26). Research-based evidence on wound treatment is increasing rapidly, and nurses need to be updated with the latest evidence to provide optimal care for patients with leg ulcers. Research-based evidence demonstrates how treatment and care affect health outcomes and thus helps to assure quality in nursing practice. Such knowledge will become even more important in the future as a result of national standards for quality assurance, such as those in Norway (27), and because patients increasingly know more about current methods of treatment and their rights. Wound treatment delivered by people who are ignorant of avaiVÅRD I NORDEN 3/2008. PUBL. NO. 89 VOL. 28 NO. 3 PP 29–33

lable research evidence will miss important opportunities to benefit patients and may cause significant harm and threat to the safety of patients (1). This study indicated that not all district nurses used best evidence to secure good care. Nurses have a central role in leg ulcer care. Their expertise must be allowed to grow by continual education and the stimulation needed for their important job. One way to improve the knowledge of nurses in wound treatment would be to educate them in the different steps in evidence-based practice: formulating an answerable question, searching and critically appraising the evidence, implementing and evaluating the outcome (25,26). Nurses who work and understand the principle of evidence-based practice and have a critical attitude towards the evidence and their own practice will probably increase patient safety. A study (6) found that nurses mentioned a high level of knowledge as an important factor in wound treatment. Most nurses also reported that they felt uncertain about wound treatment, especially whether the procedure was the appropriate treatment, when the procedure should be changed and how often to change dressing. Uncertainty may effect the wound healing and may threaten patients’ well-being and prolong the healing period. This indicates that nurses need to be better educated in wound treatment. Closer collaboration between specialized clinics and primary health care is also recommended to reduce this uncertainty. Improving clinical practice also requires that nurses use clinical guidelines for the treatment of wounds: user-friendly statements that bring together the best external evidence and other knowledge necessary for making decisions about wound treatment. This should be required for all patients with leg ulcers (14). Conclusion and implications

The treatment of leg ulcers in this study did not meet international guidelines, which can seriously threaten patient safety. Improving access to departments of dermatology may improve wound care treatment. The nurses’ lack of knowledge and skills must be taken seriously. The way they identified best practices was not in accordance with evidence-based practice. Further research is needed to investigate in depth the reasons for this and how to improve nursing knowledge to achieve safe health care based on best practices and high-quality care. Acknowledgement

We acknowledge Jane Mikkelsen Kyrkjebø, Associate Professor, Department of Health and Social Sciences, Bergen University College for important advice in finishing the article. Accepted for publication 22.01. 2008 Hilde Smith-Strøm, Betanien Diaconal University College, Vestlundveien 19, NO–5145 Fyllingsdalen. [email protected] Ingun Thornes, RN, Department of Dermatology, Haukeland University Hospital, Bergen, Norway References 1. Detmer DE. Addressing the crisis in US health care: moving beyond denial. Quality and Safety in Health Care 2003;12:1–2. 2. Lindholm C, Bergensen D, Lindhagen A. Chronic wounds and nursing care. Journal of Wound Care 1999;8:5–10. 3. Lorimer KR, Harrison MB, Graham ID, Friedberg E, Davies B. Venous leg ulcer care: how evidence-based is nursing practice? Journal of Wound Care 2003;30:132–142. 4. Harrison MB, Graham ID, Lorimer K, Friedberg E, Pierscianowski T, Brandys T. Leg-ulcer care in the community, before and after implementation of an evidence-based service. Canadian Medical Association Journal 2005;172:1447–1452.

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