Confidence and clinical judgement in community nurses managing venous leg ulceration - A judgement analysis.

BACKGROUND: The variation in the management of venous leg ulceration in the UK is partly attributable to an uncertain clinical environment but the quality of judgements is influenced by the how well nurses' confidence and accuracy are aligned. OBJECTIVES: To assess UK community nurses' confidence in the accuracy of their diagnostic judgements and treatment choices when managing venous leg ulceration. DESIGN: Judgement Analysis. SETTING: UK community and primary care nursing services. PARTICIPANTS: 18 community non-specialist nurses working in district (home) nursing teams and general practitioner services and 18 community tissue viability specialist nurses. METHODS: Using judgement analysis methods, 18 community non-specialist nurses and 18 community tissue viability specialist nurses made diagnoses and treatment judgements about compression therapy for 110 clinical scenarios and indicated their confidence for each judgement. An expert panel made consensus judgements for the same scenarios and these judgements were used as a standard against which to compare the participants. Confidence analysis was used to assess the nurses' confidence about their diagnostic judgements and treatment choices. RESULTS: Despite being very experienced, both non-specialist nurses' and specialist tissue viability nurses' levels of confidence were not well calibrated with their levels of accuracy. CONCLUSION: The results of this study are important as errors resulting from both over and under-confidence at the diagnostic phase of management may influence treatment choices, and thus increase the chances of treatment error.

A qualitative study of factors impacting upon the recruitment of participants to research studies in wound care - The community nurses' perspective.

OBJECTIVE: The focus of this study was to identify the factors that impact upon the recruitment of participants to research studies in wound care from the community nurses' perspective. METHOD: A qualitative approach utilising classic grounded theory methodology was used. Semi structured interviews were used to generate data and data analysis was facilitated by using QSR International's NVivo10 qualitative data analysis software (2012). RESULTS: Eight participants consisting of community registered nursing staff of differing levels of seniority took part in the study. Four main themes emerged from the data: CONCLUSIONS: There are a number of factors in addition to the eligibility criteria that influence community nurses when identifying potential participants for wound care trials. These factors limit the recruitment pool so may affect the transferability and generalisability of research findings to the intended population. The design of future recruitment strategies and the planning of study initiation training should take these factors into account.

A comparison of the management of venous leg ulceration by specialist and generalist community nurses: A judgement analysis.

BACKGROUND: Venous leg ulcer management in the UK varies significantly. Judgements made by nurses contribute to this variability and it is often assumed that specialist nurses make better judgements than non-specialist nurses. This paper compares the judgements of community tissue viability specialist nurses and community generalist nurses; specifically, the ways they use clinical information and their levels of accuracy. OBJECTIVES: To compare specialist and non-specialist UK community nurses' clinical information use when managing venous leg ulceration and their levels of accuracy when making diagnoses and judging the need for treatment. DESIGN: Judgement analysis. SETTING: UK community and primary care nursing services. PARTICIPANTS: 18 community generalist nurses working in district (home) nursing teams and general practitioner services and 18 community tissue viability specialist nurses. METHODS: Data were collected in 2011 and 2012. 18 community generalist nurses and 18 community tissue viability specialist nurses made diagnostic and treatment judgements on 110 clinical scenarios and indicated their confidence in each of their judgements. Scenarios were generated from real patient cases and presented online using text and photographs. An expert panel made judgements, and reached consensus on the same scenarios. These judgements were used as a standard against which to compare the participants. Logistic regression models and correlational statistics were used to generate various indices of judgement "performance": accuracy, consistency, confidence calibration and information use. Differences between groups of nurses with different levels of characteristics linked to expertise were explored using analysis of variance. RESULTS: Specialist nurses had similar cue usage to the generalist nurses but were more accurate when making diagnostic and treatment judgements. CONCLUSION: It is not obvious why the tissue viability specialist nurses were more accurate. One possible reason might be the greater opportunities for 'deliberate practice' afforded to specialists. However, restricting aspects of practice only to specialist nurses is likely to hinder the judgement performance of generalists.

Alginate dressings for venous leg ulcers.

BACKGROUND: Venous leg ulcers are a common and recurring type of chronic, complex wound associated with considerable cost to patients and healthcare providers. To aid healing, primary wound contact dressings are usually applied to ulcers beneath compression devices. Alginate dressings are used frequently and there is a variety of alginate products on the market, however, the evidence base to guide dressing choice is sparse.  OBJECTIVES: To determine the effects of alginate dressings compared with alternative dressings, non-dressing treatments or no dressing, with or without concurrent compression therapy, on the healing of venous leg ulcers. SEARCH METHODS: For this first update, in March 2015, we searched the following databases: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication. SELECTION CRITERIA: Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any type of alginate dressing in the treatment of venous ulcers were included. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, data extraction and risk of bias assessment. Meta-analysis was undertaken when deemed feasible and appropriate. MAIN RESULTS: Five RCTs (295 participants) were included in this review. All were identified during the original review. The overall risk of bias was high for two RCTs and unclear for three. One RCT compared different proprietary alginate dressings (20 participants), three compared alginate and hydrocolloid dressings (215 participants), and one compared alginate and plain non-adherent dressings (60 participants). Follow-up periods were six weeks in three RCTs and 12 weeks in two. No statistically significant between-group differences were detected for any comparison, for any healing outcome. Meta-analysis was feasible for one comparison (alginate and hydrocolloid dressings), with data from two RCTs (84 participants) pooled for complete healing at six weeks: risk ratio 0.42 (95% confidence interval 0.14 to 1.21). Adverse event profiles were generally similar between groups (not assessed for alginate versus plain non-adherent dressings). AUTHORS' CONCLUSIONS: The current evidence base does not suggest that alginate dressings are more or less effective in the healing of venous leg ulcers than hydrocolloid or plain non-adherent dressings, and there is no evidence to indicate a difference between different proprietary alginate dressings. However, the RCTs in this area are considered to be of low or unclear methodological quality. Further, good quality evidence is required from well designed and rigorously conducted RCTs that employ - and clearly report on - methods to minimise bias, prior to any definitive conclusions being made regarding the efficacy of alginate dressings in the management of venous leg ulcers.

Community nurses' judgement for the management of venous leg ulceration: a judgement analysis.

BACKGROUND: Nurses caring for the large numbers of people with leg ulceration play a key role in promoting quality in health via their diagnostic and treatment clinical judgements. In the UK, audit evidence suggests that the quality of these judgements is often sub optimal. Misdiagnosis and incorrect treatment choices are likely to affect healing rates, patients' quality of life, patient safety and healthcare costs. OBJECTIVES: To explore the diagnostic judgements and treatment choices of UK community nurses managing venous leg ulceration. DESIGN: A judgement analysis based on Brunswik's psychological Lens Model theory. SETTING: UK community and primary care nursing services. PARTICIPANTS: 18 community generalist nurses working in district (home) nursing teams and general practitioner services and 18 community tissue viability specialist nurses. METHODS: During 2011 and 2012, 36 nurses made diagnostic judgements and treatment choices in response to 110 clinical scenarios. Scenarios were generated from real patient cases and presented online using text and wound photographs. The consensus judgements of a panel of nurses with advanced knowledge of leg ulceration judged the same scenarios and provided a standard against which to compare the participants. Correlations and logistic regression models were constructed to generate various indices of judgement and decision "performance": accuracy (R(a)), consistency (R(s)) and information use (G) and uncertainty (R(e)). RESULTS: Taking uncertainty into account, nurses could theoretically have achieved a diagnostic level of accuracy of 0.63 but the nurses only achieved an accuracy of 0.48. For the treatment judgement (whether applying high compression was warranted) nurses could have achieved an accuracy of 0.88 but achieved only an accuracy of 0.49. This may have been due to the nurses giving insufficient weight to the diagnostic cues of medical history and appearance of the leg and ulcer and insufficient weight to the treatment cues of type of leg ulcer and pain. CONCLUSION: Clinical judgements and decisions made by nurses managing leg ulceration are complex and uncertain and some of the variability in judgements and choices can be explained by the ways in which nurses process the information and handle the uncertainties, present in clinical encounters.

Topical agents and dressings for fungating wounds.

BACKGROUND: Fungating wounds arise from primary, secondary or recurrent malignant disease and are associated with advanced cancer. A small proportion of patients may achieve healing following surgical excision, but treatment is usually palliative. Fungating wound management usually aims to slow disease progression and optimise quality of life by alleviating physical symptoms, such as copious exudate, malodour, pain and the risk of haemorrhage, through selection of appropriate dressings and topical agents. OBJECTIVES: To review the evidence of the effects of dressings and topical agents on quality of life, and symptoms that impact on quality of life, in people with fungating malignant wounds. SEARCH METHODS: For this third update we searched the Wounds Group Specialised Register in August 2013; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. SELECTION CRITERIA: Eligible studies comprised randomised controlled trials (RCTs) or, in their absence, controlled clinical trials (CCTs) with a concurrent control group. DATA COLLECTION AND ANALYSIS: Data extraction and risk of bias assessment was undertaken by one review author and checked for accuracy by a second. MAIN RESULTS: Four trials involving 164 people were included. One RCT in women with superficial breast lesions compared 6% miltefosine solution with placebo and found that miltefosine delayed tumour progression. The study reported that the time to treatment failure was significantly longer in the miltefosine group (median 56 days) than in the placebo group (median 21 days) (p value 0.007, log-rank test). A second trial compared topical metronidazole with placebo but the results up to the point of cross-over were not statistically significant. A third trial compared the effect of foam dressings containing silver to foam dressings without silver and found that more patients experienced decreased malodour in the foam with silver group than in the foam alone group (p value=0.049). The fourth trial compared the effect of manuka honey-coated dressings with nanocrystalline silver-coated dressings and found no statistically significant difference with regard to exudate, malodour and wound pain. All trials, however, had methodological limitations. AUTHORS' CONCLUSIONS: There is weak evidence from one small trial that 6% miltefosine solution applied topically to people with superficial fungating breast lesions (smaller than 1cm) who have received either previous radiotherapy, surgery, hormonal therapy or chemotherapy for their breast cancer, may slow disease progression. There is also weak evidence to suggest that foam dressings containing silver may be effective in reducing malodour. There is insufficient evidence in this review to give a clear direction for practice with regard to improving quality of life or managing wound symptoms associated with fungating wounds. More research is needed.

Managing wound exudate and promoting healing.

Exudate is a product of the normal wound healing process. It is usually clear or amber coloured but variations in the colour, consistency, odour and amount can indicate disruption to the normal healing process. Certain types of chronic wound commonly seen in the community can be associated with the production of excessive exudate. Copious exudate can be distressing for patients and expensive for community health-care providers. Effective management depends on the accurate diagnosis and treatment of the underlying condition and skill in selecting the most appropriate dressing regime.