Nurse-patient consultations in leg ulcer care do patients disclose - - PowerPoint PPT Presentation

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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. j.green@keele.ac.uk

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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

• ver 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
• verview 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

• f 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

• n 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
• dour
• Emotional effects
• f 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

• bserved.
• Each participant

underwent four

• bservations, providing

20 observation

• pportunities 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
• verall:
• 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
• ften 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

• bservations revealed:

Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 16 2 1 8 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

• bservations revealed:

Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 3 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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