During the COVID-19 pandemic, we have heard a lot about this new opportunity to promote self-care in delivering leg ulcer management. Legs Matter aims to empower patients and their carers to manage leg conditions better, so it is a positive development to get legs onto the NHS agenda, especially at such a critical time. The Legs Matter coalition has taken every opportunity to highlight our work and the positive outcomes for some during this crisis. Leanne Atkin, a vascular nurse specialist and the chair of Legs Matter, was interviewed on a local radio news show and we were delighted to support a feature in Daily Mail online where a couple described the support they received to manage the husband's leg ulcer at home. The National Wound Care Strategy Programme and NHS England are keen to promote this aspect of a community nurse's work and to highlight that the pandemic has triggered a positive change in approach (https://www.ahsnnetwork.com/covid-19-healthcare-professionals).
However, it is important to clarify what self-care means within the lower leg and foot condition context. It is certainly not a quick fix to reduce the burden on community nurses. The term ‘self-care’ is in danger of giving the impression that people are being left to fend for themselves with a few dressings and wraps. Unfortunately, this may well have happened to some. But, thankfully, we have heard that supported self-care or shared care is being promoted; these terms of ‘support’ or ‘shared’ more embody the ambition of what we are trying to do and are more likely to be reinforced with a plan of care.
For this to work well we need to ensure that there is a framework from which you and your patient work.
First, self-care can only come from a knowledge base. This is not a quick option. Education takes time, to build confidence in the patient's ability to manage their wound. This education needs to be delivered with leaflets, online videos of simple wound dressings and a step-by-step care plan that is discussed in layman's terms. Even with a weekly dressing, many patients feel daunted when expected to carry out what has been done ‘to them’. The supporting framework within which the patient can be managed safely needs to be one where there is a responsive service and this includes responding to calls and prescription requests in a timely manner as well as a system that allows the patient to send in photographs and measurements to inform the evaluation and review. Patients need to be helped to have good conversations; they need to understand what they are managing, what the risks are, what are the triggers for concern and how to report back so that all are on the same page.
‘The term ‘self-care’ is in danger of giving the impression that people are being left to fend for themselves with a few dressings and wraps … supported self-care or shared care are more likely to be reinforced with a plan of care’
Legs Matter provides some essential reading for patients to support this discussion—for example, the guide on ‘How to talk to your healthcare professional about your leg ulcer or foot ulcer’ (https://tinyurl.com/y3zjfmfk) There has also been a burst of videos and literature from providers, societies and industry aimed at supporting patients' self-management.
Second, supported self-management requires practitioners to view the world differently and understand the power we hold. We need to continue to provide our expertise but we also need to enable a shift in the power base if we are to increase people's confidence in their ability to self-manage their condition. We need to truly see people as the experts in their own health, to genuinely listen and to identify creative ways of managing their condition so that they are alert to any triggers of deterioration. We need to understand that, for supported self-care to work, the plan of care has to be shaped around their needs and preferences. The NHS Long Term Plan (NHS England and NHS Improvement, 2019) supports this drive; ‘patient activation’ is a term increasingly being used and ‘describes the knowledge, skill and confidence a person has in managing their own health and care’ (NHS England, 2020). If they do not have the confidence, then any plan will likely fail.
Finally, supported self-care needs to be evaluated for its effectiveness. Compression is the cornerstone of treatment (Ligi et al, 2016) and therapy needs to be optimised if it is to be effective and provide a therapeutic intervention. Effective compression also needs to provide a consistent dosage of greater than 40 mmHg for most individuals (Ligi et al, 2016). Efficacy is demonstrated through a reduction in exudate and wound size. If this is happening then whatever the care plan or compression regimen or compression dosage, that is success. For both the patient and clinician, understanding what is making the difference provides essential learning. If a wrap compression garment or hosiery kit is a new compression therapy for the patient then it is likely that any improvement seen is due to a superior level of consistent compression.
As a registered nurse you also need to reassure yourself and the patient that your system would recognise and manage any deterioration. If there is no mechanism to measure or respond in a supportive environment, then self-management may be unsafe in these circumstances and any deterioration should be recognised as harm and a clinical incident. The reasons for deterioration need to be understood and learnt from. The most common cause of deterioration is that the dosage of compression has reduced—that the patient stops using the hosiery or one of the layers, or the compression wrap is not used at the appropriate level. Compression therapy provides a potent therapeutic treatment, and as such the importance of maintaining the compression dosage cannot be underestimated. Yet few services monitor their healing rates. As a healthcare system, we are likely to only have anecdotal evidence that the drive for self-management actually improves outcomes and patient wellbeing.
We also need to recognise where patients are not suitable for self-management and this is not solely based on the patient's dexterity or mobility. We need to be cognisant of when a compression wrap or hosiery kit would not deliver effective compression or improve their outcomes. These are commonly when the site of the leg ulcer prevents adequate wound bed compression with these interventions, such as an ulcer behind the malleolus or on the foot. These wound sites often require additional localised pressure and this is difficult to achieve with garments (Hopkins et al, 2011). Also an adjustable compression wrap may need to be adjusted at least twice daily if it is to maintain its compression at an effective level; where this is not maintained, exudate or swelling will increase, swiftly increasing their risk of cellulitis.
Self-management is not an easy fix within this ongoing crisis. A supportive self-care framework will only be successful if the system invests in the initial set up of the care package and knowledge base of the patient; only then can the positive impact of patients' lives be seen alongside a reduction in nursing activity. To ensure we are working in the patient's best interest, we need to make sure that our service is responsive and can evaluate our effectiveness so that patients are not left to fend for themselves until the next virtual check in. With a focus on patient empowerment through knowledge and the raising of expectations, Legs Matter is here to underpin this focus on greater self-care where appropriate so that all lives are transformed for the better.