Empowering patients to takecontrol of leg ulcer treatmentthrough individualised managementLeg Clubs have been established to empower patients to become stakeholders in

their own treatment. This case report describes how attendance at a Leg Club

resulted in healing in a patient who previously was non-concordant with treatment

quality of life; holistic care; empowerment; concordance; leg ulcer; social model

S. Hampton, MA, BSc(Hons), DpSN, RGN,Tissue Viability Consultant,Eastbourne, UK;

E. Lindsay, BSc (Hons),RN, DN, CPT, DipHE,

Independent SpecialistPractitioner, AssociateLecturer CRICP,Thames

Valley University. London,U K, and Visiting Fellow,Queensland University of

Technology, Austral ia,Email: ellie@legclub.org

238

According to Billings and Cowley,1needs

assessment is a priority issue in com­munity health. Health-care team mem­bers need to examine their own areas ofspecialty to assess, analyse and identify

different health-care needs and share their findingswith the whole team.

Gillam and Murray2 suggested, however, that pri­mary health-care teams know little about definingthe needs of the practice population. Therefore,before the practitioner can begin to address factorsthat will influence the planning and delivery ofcare, a clear understanding of patterns of illnessand distress and of service use and provision amonggeneral practice populations is needed.3

If nurses are to fulfil their role in the 'helping rela­tionship', they need to understand basic needs andhow these affect people's lives.4 Unless a nurse isaware of patients' perceptions of their problems andneeds, and is prepared to try and see things fromtheir point of view, progress may be limited.5

Maslow" provided a guide to assessing prioritiesbased on physiological needs, safety, social/affilia­tive, esteem and self-actualisation. However, Brad­shaw's? taxonomy of needs is most widely used bygeneral practitioners to assess patients' needs. Thesecan be classed as:• Normative - based on expert judgement• Comparative - where one patient group is com­pared with another• Expressed - based on requesting assistance orintervention by a professional• Felt - what the individual says it is.

Cost implicationsGeneral practitioners require that patient treatmentand provider organisations are cost-effective. In theUK over £400m is spent annually on leg ulcer care,"and 25-65% of district nurses' time is spent caringfor patients with leg ulcers, with staff time andwound management costs continually rising.9

Leg ClubsHistorically, leg ulcer management has been under­taken by community nurses in the patient's ownhome or by a practice nurse in the surgery.IOHow­ever, care is also delivered in nurse-led ulcer clinicsand Leg Clubs.to Leg Clubs focus on addressing theneeds of the individual in a social, relaxed, non­threatening environment. According to Russell andBowles,11patients benefit from attending leg ulcerclinics and being with and talking to other peoplewho have a similar condition.

The Leg Club was conceived as a unique partner­ship between patients, community nurses and thelocal community. They aim to empower members,providing them with a sense of ownership andacknowledgment that they are stakeholders in theirown treatment. These Clubs are held in a commu­nity venue on an informal drop-in basis. Theirobjectives are listed in Box 1.

The ethos of care, social support, friendship andmedical treatment make this form of communitynursing care unique.12 Treatment takes place collec­tively, with two or three people having their legswashed and dressed in the same room. This givesthem the opportunity to compare healing and to dis­cuss treatment issues with members of the health­care team and/or carers, giving them a greater feeling

Box I. Leg Club objectives

To empower patients to be involved in makingdecisions about their own treatment

To meet the needs of socially isolated people by

providing a venue for social interaction and anopportunity to establish peer support

To implement strategies to rebuild the self-esteem ofpeople with leg ulcers

To provide an informal forum for health promotionand education

JOURNAL OF WOUND CARE VOl 14, NO 5, MAY 2005

of control over their own leg ulcer 'destiny'.Since the inception of LegClubs in the UKin May

1995 constant audit" has demonstrated high heal­ing rates and low recurrence. A recent randomisedcontrolled trial, conducted in Australia, that com­pared the same treatment given either at home or ina Leg Club highlighted significant benefits in termsof patient morale and pain reduction (p=0.02).14

Case studyJames, a 68-year-old with non-insulin dependentdiabetes, and his wife had recently moved from amajor city to a warden-controlled flat in a rural area.

James had become quite reclusive, yet strived toremain independent. After starting to show signs ofmultiple sclerosis (MS) 10 years previously, his wifehad been mostly bedridden. Throughout this time,and before their move, the appropriate services hadbeen unaware of the family's situation. His wifehad not been seen, assessed or received a diagnosisfrom a medical professional. Their youngest childhad had MS and had died of encephalitis. Three oftheir four remaining children were also diagnosedwith MS.

At the suggestion of his home warden, Jamesattended his local Leg Club, presenting with hyper­tension and recurrence of bilateral varicose eczemaand ulcers. These had been static for six months,and he had self-treated with topical ointments, lint,gauze and crepe bandages bought over the counter.James informed the nursing team that he had foundmost treatments difficult. He said staff at a Londonhospital and clinic had labelled him 'non-compli­ant' as he consistently removed his bandagesand dressings, and preferred to self-treat with over­the-counter products.

Throughout the assessmentJames expressed angerand despair at the health-care system and the lack oftreatment he perceived he had received. He was stillreluctant to involve a member of the primary health­care team in his home situation.

James had tried various treatments over the years,including four-layer compression bandages, whichhe cut off as soon as he arrived home due to discom­fort, the bulkiness of the bandages which causedfootwear problems, and a medicated paste bandage,which triggered a rash. He was allergic to penicillin,Betnovate, parabens and several types of dressing.

At6ft tall, James weighed 18 stone. He had bilateralleg oedema and evidence of ankle flare. His feetbecame dusky on dependence and had rapid refillof blood within the extremities. Around the peri­wound area there was eczema, which appeared raw,and he complained of discomfort. The eczema spreadto his feet as pustules, and James informed us that heoccasionally dispersed them with a needle.

According to Dale and Gibson1s a patient who hashad a leg ulcer for many years may develop low self-

JOURNAL OF WOUND CARE VOL 14. NO 5, MAY 2005

esteem. Consequently, they may lose the motiva­tion to persevere with treatment and give up anyhope of the ulcer healing, a belief that becomes aself-fulfilling prophecy as the patient ignores treat­ment advice and the ulcer does not heal.

As with all new patients, on first attending theLeg Club James was offered the option to havethe initial assessment in private, which he declined,On assessment, his ABPlwas 1.2 in both legs. Thepractice nurse treated the ulcers with a fibroushydrocolloid dressing (Aquacel, ConvaTec) in thisinstance, which was held in place using a bandageand elasticated viscose stockinette,

As a result of the ABPl measurements, compres­sion was considered the most appropriate treatment,Options were discussed at length with James and hechose cotton (short-stretch) inelastic bandages.

There are a number of cotton extensible short­stretch bandages on the market, including Compri­lan (BSN Medical), Rosidal K (Vemon-Carus) andthe cohesive short-stretch system Actico (Activa),

AsJames had restricted mobility, slept in a chair atnight and openly stated that he had removed andreapplied bandages in the past, the consensus was toprovide a bandage that would suit his lifestyle andreduce the potential for slippage that may occur dueto his larger leg size. Actico short-stretch (Activa)was selected as its cohesiveness means that it is

easily applied and removed and does not slip.Compression therapy is the gold standard treat­

ment for leg ulcers in patients with venous disease. 16

Selection relies on several factors such as:• Comfort (patient concordance)• Quality of life issues - can the patient maintainindependence?• Nurse familiarity with the product• Evidence of product efficacyY

Quality of life is a subjective issue, particularly interms of leg ulceration, as many factors affect theway patients perceive their ulcers and treatment.Odour, pain, difficulties with bandages, such asbandages falling down or an inability to wearnormal size shoes, and problems with mobility allconspire to affect or reduce quality of life. Further­more, the tightness of the bandage (required toprovide compression) offers comfort to some byreducing pain, but increases pain and discomfortin others.

In James's case, the assessing nurse consideredthese issues and offered treatment to meet his needs.There was concern about his eczema, and it wasdecided to manage this with a Zipzoc dressing(Smith & Nephew), a zinc oxide-impregnatedtubular stocking comprising 50% paraffin and 50%white petroleum jelly.

Following his initial visit to the Leg Club, thenurse visited James at home the next day to checkfor any sensitivity reaction and assess how he was

practice

References

1 Billings.].. Cowley. S.Approaches to communityneeds assessment: a

literature review. J AdvNursing 1995;22:721-730.

2 Gillam. 5.. Murray. S.Needs Assessment inGeneral Practice: Occasional

paper F3.The RoyalCollege of GeneralPractitioners, 1996.

3 Hopton.J .. Dlugolecka. M.Need and demand for

primary health care: acomparative surveyapproach. BMJ 1995; 310:1369-1373.

4 Blake. C. Care of the

patient requiring surgicalintervention. In: Hinchliff. S.,

Norman. S.•Schober.].(eds). Nursing Practice andHealth Care (2nd edn).Edward Arnold. 1993.

5 Walsh. M.. Ford, P'Rituals

in nursing.We always do itthis way. Nurs Times 1989;85: 41 , 26-32.

6 Maslow,A. Motivation

and Personality. Harper andRow, 1954,

7 Bradshaw.J.A taxonomyof social need. In: Gillam. S.,Murray. 5. NeedsAssessment in General

Practice: Occasional paperF3.The Royal College ofGeneral Practitioners. 1996.

8 Hawkins,J ..Mears.J.Avaluable service. J CommNurs 1992;November:18-20.

9 Thambiaya. K. Evaluationof a leg ulcer clinic. NursStandard 1996; 10;3 I:58-62.

10 Lindsay. E.What arePatients' Views of Leg UlcerManagement in a SocialCommunity Clinic! BScdissertation, University

College. Suffolk. 1996.I1 Russell. G .. Bowles.A.

Developing a community

based leg ulcer clinic. Br JNurs 1992; I: 7, 337-340.

12 Lindsay. E..Hawkins. J.Care study: the leg clubmodel and the sharing ofknowledge. Br J Nurs 2003;12: 13,784-790.

13 The Lindsay Leg ClubModel: a model of

evidence-based leg ulcermanagement. Br J CommNus 2004; 9: (6 Suppl). S 15-S20. ~

239

practice

14 Finlayson. K.. Edwards.H .. Courtney. M. et al.Chronic leg ulcers:effectiveness of a

community nursing

intervention on healing and

quality of Iife.AustralianWound ManagementAssociation. 5th NationalConference Proceedings.Hobart.Tasmania. 17-20March 2004.

15 Dale, ].J .. Gibson. B.Educating leg ulcer patientsand their carers. In:A

Guide to Leg UlcerManagement. Smith &

Nephew Healthcare. 1997.

16 Blair.D..Wright. D..Backhouse. C. et al.

Sustained compression andhealing of chronic venous

ulcers. BM] 1988: 297:1159-1161.

17 Hampton,S., Collins. F.Tissue Viability.WhurrPublications.2003.

18 Courtney. M.. Edwards.H .. Finlayson. K. et al.Randomised controlled

trial of a community

nursing intervention (or

managing chronic venousleg ulcers. Poster presentedat AWMA.Tasmania andInternational Research

Conference. Cambridge. UK.

interface

tolerating the Actico bandage. This remained in situand he said he found it acceptable. James made itclear that he did not want any input from socialservices, his GP or the community nursing service.

James's ulcer healed in 11 weeks, during whichtime the oedema reduced. He found treatmentacceptable. was concordant with compressiontherapy and his eczema resolved within a few days.

James attended the Leg Club each week andgradually integrated and became a valued memberof the group. He appeared to enjoy the socialoccasion, friendships were formed and it providedhim with respite from the situation at home.

When his ulcer healed, James was measured forcompression hosiery to minimise the risk of recur­rence and was transferred for 'well leg' monitoring.

ConclusionThe Leg Club model has the potential to reducecosts for the health service. increase social inter­action for elderly patients, and guide treatmentthrough evidence-based practice. IS Leg Clubs alsooffer education on prophylaxis, prevention of leg­related problems following healing. and generaladvice to promote well-being.

Sadly, within a week of his ulcers' healing Jamesdeveloped acute pancreatitis and died. He had pre­viously provided written consent for us to publicisethis case study and further consent was obtained

Bulletin board

Box 2. Maintaining the high standard

It is essential that patients such as James attending LegClubs can be confident in the knowledge thatconsistent, defined standards and procedures willapply. Only clinics that comply with documented LegClub model guidelines can use the Leg Club title.To this end, the wording and logo are protected by

registered trademark in the UK and Australia

from his family before publication.After James's death, the district nursing team

responsible for the Leg Club visited his wife to offertheir condolences, and found she was extremelywithdrawn and showed signs of clinical depression.Her son and the district nurses arranged for a refer­ral, which resulted in a medical assessment and adiagnosis of MS. Following a long hospital admis­sion and extensive physiotherapy, she returnedhome with a full social services home-care package.

The Leg Club provided James with physical careand psychological support and education about hisdisease. For the first time in many years. he was ableto socialise and live outside the limiting disciplineof caring for his disabled wife. He also had access tonurses who had expertise in dealing with the socialisolation that often accompanies leg ulcers. Thisempowerment enriched James's life in a way thatcould not have occurred if he had continued on theoriginal path of self-care.•

The editor welcomesinformation onresources,organisations and newproducts.Theseshould be sent to the

Journal of Wound Care,Greater London

House, HampsteadRoad,LondonNWI7EJ.Fax: +44 (0)20-78740386. Email: jwc@emap.com

Tissue viability coursesrange of modular coursesfor nurses in the field oftissue viability is being

offered by the School of PrimaryHealth Care at the University ofCentral England.

Options include a BScinClinical Nursing Studies, with atissue viability pathway leadingto a NMC specialist practitionerqualification. The course isoffered on a day-release basis.

A Diploma in ProfessionalStudies also includes a tissueviability pathway with separate

modules on the prevention andtreatment of pressure ulcersand leg ulcers. A double moduleon tissue viability covers theprinciples of wound manage­ment and complex wounds.

These modules give practicalinformation on tissue viabilityand are aimed at ward orcommunity-based nurses.• To find out more, contact Tissue Viabil­

ity Pathway Leader, Pat Davies, on 0121

331 7104 or email her at patricia .

davies@uce.ac.uk;for an application

pack call the Admissions Department on

0121 331 5500 or email: hcc@uce.ac.uk

Hydrocolloid sacraldressing

specially shaped dressing,designed to fit thesacrum, has been includ-

ed in 3M's range of hydrocolloiddressings. The manufacturers saythis will increase conformability,thereby extending wear time. Itis indicated for partial- and full­thickness pressure ulcers .

Tegasorb sacral dressing is avail­able in one size (16.1 x 17.1cm).• For more information, visit

www.3mhealthcare.co,uk/

woundresourcecentre

240 JOURNAL OF WOUND CARE VOL 14. NO 5, MAY 2005