Hospital clinicians' perspectives of using compression therapy on venous leg ulcers: a systematic qualitative review

A leg ulcer is an open lesion between the knee and ankle joint that remains open for more than 2 weeks (Atkin et al, 2021). Venous leg ulcers (VLUs) are the most common type (more than 70%) (O'Meara et al, 2012). VLUs are caused by venous insufficiency, resulting from problems with veins in the leg (such as damage to the valves, or blockages), or impaired action of the calf muscles. The ‘burden of wounds’ study (Guest et al, 2017) highlighted that leg ulcers, including VLUs, are the wounds causing the highest economic burden for the NHS, with an estimated 278 000 confirmed patients across the UK in 2012/2013 (Guest et al, 2015).

Clinical guidelines recommend compression therapy as a cost-effective first-line evidence-based treatment for VLUs (Royal College of Nursing, 1998; Iglesias et al, 2004; Scottish Intercollegiate Guidelines Network (SIGN), 2010; O'Meara et al, 2012; Ashby et al, 2014; National Wound Care Strategy Programme (NWCSP), 2020) as it can heal up to 86% of VLUs at 24 weeks (Finlayson et al, 2009; Ashby et al, 2014; Anderson, 2017; Gohel et al, 2019) and prevents ulcer recurrence by 70% (Finlayson et al, 2009). With national guidelines available, patients with VLUs should receive evidence-based care, irrespective of location (Douglas, 2002).

A literature review showed that, although compression therapy is widely used in community settings, it is often actively discontinued, or frequently not initiated, in secondary care (Anderson, 2017; Lian et al, 2022a; Lian et al, 2023). An NHS England/NHS Improvement report (2022) suggested that less than a quarter of the adult population with VLUs receive appropriate assessment and treatment. Across all NHS providers, only 37% of VLUs are healed after 12 months of treatment (Guest et al, 2020). Any disruption of evidence-based care means that, while in hospital, the time to recovery of patients' wounds will be extended.

A point prevalence audit in a large NHS hospital showed that 8.5% (80/931) of hospital inpatients had a leg ulcer. Of those inpatients, 45% were assessed for eligibility for compression therapy, of which 75% were eligible (Lian et al, 2022b). A subsequent online survey of woundcare specialists in 2020 reported that only 32% (32/101) of respondents are offering compression therapy in hospitals (NWCSP, 2020). This data shows that patients entering hospitals in the UK with a VLU have less than a 1 in 3 chance of receiving compression therapy when they need it.

The consequences of not implementing or partially implementing compression therapy in secondary care are unwarranted levels of patient suffering, the increased financial burden on the NHS and wasted health professional resources. The mean NHS cost for managing a VLU over 12 months was estimated at £7600 per patient. However, the cost of managing an unhealed VLU was 4.5 times greater (Guest et al, 2018). Untreated leg ulcers can result in lower limb cellulitis, leading to more than 400 000 bed days per year, and costing NHS England over £96 million annually (Atkin et al, 2021). Failure to manage lower-limb conditions can also lead to higher use of antibiotics, pain relief prescriptions and limb amputations (Atkin et al, 2021). NHS RightCare data suggested that sub-optimal care for leg ulcers costs providers £5673 per patient compared with £505 in the optimal scenario (NHS RightCare, 2017). As 4% of adults aged over 65 are diagnosed with a VLU (Atkin et al, 2021), the cost of managing VLUs will continue to rise as the population ages.

There could be several possible reasons for the sub-optimal implementation of compression therapy in secondary care. Such reasons include knowledge and skills deficits in the provision of compression therapy (Anderson, 2017), lack of prioritisation by care teams (Dealey, 1999), VLUs not being the main reason for admission, and care not within the expertise of the receiving team (Anderson, 2017). Additionally, inpatients with VLUs are frequently referred to multiple specialties, which leads to a lack of VLU management oversight (Lian et al, 2023). A limitation of current evidence on the management of VLUs is that evidence is predominantly from community settings and there has not been a systematic review to formally consider the quality of the evidence. This review aimed to identify, from the published literature, reasons for variable implementation.

Methods

This research protocol was registered at PROSPERO (ID: CRD42022337017).

Ethical considerations

This research project was a systematic review, so there was no requirement for ethical approval as primary research was not conducted.

Search strategy

The search text terms and indexing terms were guided by the mnemonic ‘PICo’: Population, the phenomena of Interest and the COntext (Joanna Briggs Institute, 2014):

• Population: clinicians caring for inpatients with venous leg ulcers
• The phenomena of Interest: compression therapy
• COntext: hospital.

Eligibility criteria

Criteria for including papers were those:

• Focused on venous leg ulcers and treatment with compression therapy
• Located in secondary care
• That included qualitative data regarding clinicians' views of therapy.

Studies were excluded if they:

• Focused on foot ulcers of any aetiology
• Exclusively concerned children aged under 18 years
• Were reviews, commentaries, reports or conference abstracts.

Information sources

The search strategy was applied to Medline, Ovid, Embase; CINAHL Complete, PsycINFO (EBSCO), Applied Social Science Index and Abstracts (ASSIA) and Scopus in June 2022. Grey literature sources were also searched – Ethos, ProQuest Dissertations and Thesis, OpenGrey, CORE, Google Scholar, the Cochrane Database of Systematic Reviews and the National Grey Literature Collection.

Reference tracking and citation tracking were also used. Hand searching was piloted to screen titles of all published articles in the past 5 years (June 2017 to June 2022) in one key specialist wound care journal (Journal of Wound Care). There was only one paper found that met the inclusion criteria, and this was duplicated in the database search. The hand-searching method was thus abandoned. Instead, the reviewer filtered all published articles by using the term ‘venous leg ulcer’ in the Journal of Wound Care between 1992 (first launched) and June 2022 (30 years). Area experts and key authors of the papers were contacted via email to identify any additional relevant publications and to minimise publication bias (Soilemezi and Linceviciute, 2018).

Study selection

Search results were exported into reference manager software – Mendeley Reference Manager – and then imported into Rayyan's Intelligent Systematic Review software. Articles written in English were examined in title and abstract screening stage. No restrictions were applied on publication dates to capture publications across all periods.

Two reviewers (YL and DW) independently screened titles, abstracts and papers against the inclusion criteria. At each stage, discrepancies between reviewers were resolved by virtual meeting discussions. Cohen's Kappa was calculated to provide a measure of agreement between the two reviewers. Reasons for the exclusion of each paper were documented.

Data extraction

Data extraction was undertaken by YL using a piloted bespoke data extraction form. The essential information from the included papers was extracted. The accuracy of data extraction was assessed by a third reviewer (LB) who checked data extraction for the four papers identified without finding any inaccuracies.

Quality appraisal

A transparent appraisal process is required in the qualitative systematic review process. This is to critically review all eligible studies to see whether they are fit for purpose before synthesising findings in the final stage (Soilemezi and Linceviciute, 2018). The critical appraisal process ensures that findings generated from the primary qualitative studies are rigorous, trustworthy, plausible and credible (Freshwater et al, 2010; Holly et al, 2011). The Critical Appraisal Skills Programme (CASP) checklist for qualitative studies (CASP, 2018) was used to review all included papers for overall methodological validity. An additional three questions were added to the CASP checklist in order to identify each paper's contribution to current understanding, future research and the wider population (Spencer et al, 2003). One point was awarded if questions were answered and half points were awarded if it was only partially fulfilled. YL independently appraised all four studies and LB checked for accuracy.

Data synthesis

Meta-ethnography was used for data synthesis for the following reasons. Firstly, meta-ethnography is one of the most commonly used approaches to synthesise qualitative data with clear stages provided (Bondas and Hall, 2007; Dixon-Woods et al, 2007). Secondly, it allows a wide range of research for synthesis while preserving the interpretative properties of primary data (Wittkowski et al, 2017). The data synthesis drew on the seven stages outlined by Noblit and Hare (1988) in their account of meta-ethnography. YL conducted the data synthesis and LB and DW reviewed the process for accuracy.

Results

Literature searches

In total, 5707 papers were identified from the databases, reducing to 29 after screening and removal of duplicates. After further assessment, three were included in the review, plus one identified via other methods (Page et al, 2021). Kappa coefficients at titles and abstract (stage one) and paper screening (stage two) were 0.4659 and 0.3 respectively. The kappa score in stage one had a moderate agreement between two reviewers (YL and DW) compared to a fair agreement in stage two. The main reason for less agreement in stage two is that the main reviewer (YL) is a health professional who is very familiar with the review topic, yet a novice researcher. The second reviewer (DW) is an experienced researcher who adopted a comprehensive approach to paper inclusions. The four papers that met the inclusion criteria were included for critical appraisal and data synthesis (Aldeen, 2005; Cullen and Phillips, 2009; Lumley et al, 2015; Kuhnke et al, 2019).

Study characteristics

Table 1 shows the characteristics of the four included studies. Three papers (Cullen and Phillips, 2009; Lumley et al, 2015; Kuhnke et al, 2019) used qualitative data analysis with results reported as themes. Aldeen (2005) presented qualitative data from a survey with open-text responses but did not present themes.

Quality appraisal

Following implementation of the CASP tool, the overall quality of studies was found to be good quality with one study (Lumley et al, 2015) being particularly good. None were considered to have a high likelihood of methodological flaws, although one study (Aldeen, 2005) did not conduct data analysis for participants' views and opinions. In line with other meta-synthesis using the CASP rating system, no papers were excluded on the basis of quality rating (Atkins et al, 2008). Instead, quality ratings were used to determine how much weight was given to papers in the overall contribution to the synthesis.

Summary of themes

The meta-ethnography identified three key themes: educational needs, patient factors and organisational resources.

Theme 1. Educational needs

Limited knowledge of clinical procedures

Limited knowledge is a fundamental barrier to the implementation of compression therapy in secondary care. Clinicians' educational needs for ankle brachial pressure index (ABPI) assessment and compression therapy were identified in two studies (Aldeen, 2005; Kuhnke et al, 2019). In Kuhnke et al (2019), a clinical manager was asked by educators for ABPI equipment, and they replied:

‘Why do they need ankle brachial index – Doppler, education, or training as staff are already applying compression without these devices and education?’

Participant 11, clinical manager; Kuhnke et al, 2019: S10

Several comments from participants refer to the challenge of maintaining skills:

‘Difficult for link nurses on wards to maintain skills as used infrequently. All patients admitted seen by TVN (tissue viability nurse) ….’

Hospital clinician, profession not given, Aldeen, 2005: 28

Theme 2. Patient factors

Clinicians identified concerns about patient compliance as being a limiting factor in the use of compression therapy. Patients' poor compliance with compression therapy was reported by hospital clinicians in two studies (Cullen and Phillips, 2009; Kuhnke et al, 2019). The following quote shows a UK vascular surgeon's eagerness to get patients to understand the underlying causes of VLUs and the role of compression therapy.

‘If they have better understanding of the disease, they would realize this is not a cure for the disease. It's just a cure for the acute problem they have. They have to understand how we treat it, and how to reduce other risk factors. If they are compliant, they will get better.’

Vascular Surgeon, UK; Cullen and Phillips, 2009: 372

A plastic surgeon from the USA also indicated that patients' adherence matters most, not compression products.

‘It's not the specific product. You could use anything for compression – an Ace wrap, a 4-layer wrap … As long as it's something being used and the patient is compliant, I don't think the specific exact product is that important.’

Plastic Surgeon, USA; Cullen and Phillips, 2009: 372

To improve patients' adherence with treatment options, clinicians described the need to provide educational materials to patients to help them understand their treatment:

‘Encourage clients to co-operate with health-care providers, engage the client in the care plan, [and give] clients' education to help with the care plan.’

Participant 18, Canada, profession not reported; Kuhnke et al, 2019: S8

Clinicians quoted in Kuhnke et al (2019) said patients can be trained to identify lower leg complications, ulcer recurrence, treatment options and to know when to report issues.

Theme 3. Organisational resources

This theme describes hospital clinicians' experiences of facing challenges due to a lack of organisational resources when caring for inpatients with VLUs. A number of organisational barriers were highlighted across all four studies (Aldeen, 2005; Cullen and Phillips, 2009; Lumley et al, 2015; Kuhnke et al, 2019). These barriers were a lack of appropriate clinical equipment and a lack of staff resources.

Lack of appropriate clinical equipment

The lack of appropriate clinical equipment resonated across three papers (Cullen and Phillips, 2009; Lumley et al, 2015; Kuhnke et al, 2019). An occupational therapist explained:

‘There is a need for smaller equipment like leg lifters … They used to fund it then we had an email saying that they weren't even funding … leg lifters never came back and they are so useful.’

Participant 2, occupational therapist, UK; Lumley et al, 2015: 3600

This is echoed by a vascular surgeon when he felt frustrated when not able to offer the best care for patients.

‘Disappointed that there is no immediate solution, you feel the patient is not getting the best care, for some surgeons this becomes – “I'm not doing my best for this patient”.’

Vascular surgeon, UK; Cullen and Phillips, 2009: 369

The consequences of not providing the essential resources could be the recurrence of VLUs:

‘Nurses effectively use compression [to] close the wound, then the wound reopens as maintenance stockings [are] not available.’

Participant 3, Canada, profession not reported; Kuhnke et al, 2019: S8

Lack of staff resources

Lack of time was reported as an issue for clinical staff providing training and leg ulcer care in three studies (Aldeen, 2005; Cullen and Phillips, 2009; Lumley et al, 2015). The following quote shows TVNs are struggling to provide leg ulcer competency training for hospital ward nurses due to time constraints.

‘TVNs try to see all patients with leg ulcers. Do not expect ward nurses to be competent to assess or diagnose. Not time to train to this level …’

Hospital clinician, UK, profession not reported; Aldeen, 2005: 28

The consequences of not offering training opportunities for clinicians who are caring for inpatients with VLUs can be detrimental to the overall provision of hospital services and patient experiences. For example, patient discharge may be delayed.

‘Limited staff with this training results in delay for patients. Often decision to apply compression is made just before discharge. If no one on the ward can compress, discharge may be delayed.’

Hospital clinician, UK, profession not reported; Aldeen, 2005: 28

Line of argument related to themes

This meta-ethnography highlights the barriers clinicians are facing in using compression therapy in hospitals. Hospital clinicians' knowledge of clinical procedures such as ABPI assessment and compression therapy is fundamental to the provision of compression therapy (Vowden and Vowden, 2001). This is because, in hospitals, clinicians, especially nurses, are the main health professionals conducting ABPI assessments and applying compression therapy (Cullen and Phillips, 2009). In addition, patients' adherence to therapy relies on the clinicians' knowledge and skill to make sure conversations are meaningful for patients. Clinicians need to have adequate knowledge and skills and allow plenty of time when explaining the venous disease process, the purpose of ABPI assessment and therapeutic compression therapy (Silva et al, 2014). Such positively engaged conversations could help patients make informed decisions and they might be more inclined to comply with compression therapy.

To ensure hospital clinicians are equipped with the knowledge and skills, TVNs who provide hospital wound care training need adequate time for training other staff (Kuhnke et al, 2019). It is also recommended that TVNs should target clinicians working in key clinical areas when providing a leg ulcer training package in order to target key personnel and use resources effectively (Anderson, 2017). At the same time, hospital clinicians require adequate and appropriate clinical equipment such as ABPI equipment, compression products and other associated kits for dressing changes and the application of compression therapy (Kuhnke et al, 2019).

Summary of findings

To the authors' knowledge, this is the first systematic review to explore hospital clinicians' perspectives on the use of compression therapy in secondary care. It provides new insight into the complexities encountered by hospital clinicians and barriers to using compression therapy. The meta-ethnography of four papers revealed three key barriers: hospital clinicians' knowledge about clinical procedures; patients' adherence; and lack of appropriate clinical equipment and staff resources. The results need to be examined within the context of the strengths and limitations of the review.

Strengths

A strength of this review is that the CASP checklist was rigorously followed to develop a consistent approach for the critique of the included papers (Aveyard, 2014; Majid and Vanstone, 2018). However, when applying the CASP tool, the authors found that research subjectivity could influence the interpretation of criteria. Furthermore, there is potential for the selection of direct quotes and analysis to be influenced by the main reviewer's ‘insider’ professional position. To address this, the third reviewer, LB, an academic researcher, but not a member of the main reviewer's profession, independently monitored the data extraction and data synthesis to minimise the opportunity for research bias. The process was further scrutinised by making sure inclusion and exclusion criteria were strictly adhered to throughout the process.

Limitations

There are five limitations. Firstly, excluding non-English language studies could have the potential to induce language bias for any other languages (Neimann Rasmussen and Montgomery, 2018). However, the resources required to translate other languages made the inclusion process unfeasible. Secondly, although the authors made extensive efforts to search all possible sources, the number of studies included remained small. Nevertheless, the research papers shared similar and consistent findings, which increase dependability. In addition, unlike quantitative studies, which require a larger number of papers for analysis, qualitative studies seek to understand each unique perspective from the data, meaning a small sample is valid (Green and Thorogood, 2014). Thirdly, of the four papers retrieved, none entirely focused on the research question of concern. Consequently, further work is required to validate the findings. Fourthly, the direct quotes from hospital clinicians were not easily identified as in three studies (Cullen and Phillips, 2009; Lumley et al, 2015; Kuhnke et al, 2019) clinicians recruited were from both community and hospital settings. Further research needs to centre on health professionals working in secondary care as this is where the greatest inconsistency in VLU treatment lies. Finally, while undertaking this study, the authors drew on the seminal guidance by Noblit and Hare (1988); there are more recent accounts of how researchers can improve their reporting of meta-ethnography reviews such as the eMERGe Reporting Guidance (France et al, 2019). Using the 19 eMERGe Reporting Guidelines in the review would have enhanced the clarity of procedures.

Discussion

ABPI testing is an essential component of a holistic leg ulcer assessment and is vital to the safe and effective use of compression therapy (Caruana et al, 2005; Newton, 2011; Hampton, 2015; Fletcher et al, 2019). This review found clinicians reported limited knowledge and low confidence in conducting ABPI testing and applying compression (Kuhnke et al, 2019). The lack of knowledge and confidence could impact clinicians' decisions on woundcare treatment options (Silva et al, 2014), and may lead to compression therapy not being offered to inpatients with VLUs even when clinically needed.

Venous ulcer care, including the application of compression, is perceived as more of a nursing concern than a medical one (Cullen and Phillips, 2009). However, ward-based nurses may be struggling to maintain compression skills as they might not see enough patients to become competent (Aldeen, 2005). This may be because the inpatient leg ulcer population can be widely spread across the whole hospital (Dealey, 1999). This challenge means that the hospital leg ulcer training package needs to be focused and target staff working in key clinical areas (Anderson, 2017). Hospital leaders have a professional duty to support staff by offering formal and consistent venous leg ulcer training packages (Kuhnke et al, 2019). Clinical leaders are identified as crucial to developing woundcare education and service as they make change happen by ‘valuing’ wound services through planned educational offerings, effective policies and procedures and improved clinical woundcare roles (Kuhnke et al, 2019).

This review found that TVNs stated they did not have time to train hospital nurses. This could be due to an intense focus on pressure ulcer care for many years (Holloway et al, 2019). Tissue viability services are often stretched, with pressure ulcer prevention being the NHS Trust priority (Aldeen, 2005). Hospital TVNs become pressure ulcer category verifiers with limited time for any other wound focus, which leads to inequitable care for patients admitted with VLUs (Holloway et al, 2019). As a result, leg ulcer services continue to struggle without adequate funding and are viewed as a low-priority service and not politically interesting (Douglas, 2002; Cullen and Phillips, 2009).

The consequences of not offering training opportunities for clinicians caring for inpatients with VLUs can be detrimental to the overall provision of hospital services and patient experiences. Firstly, when TVNs are not available, the inpatient leg ulcer care may be discontinued as the current NHS tissue viability services do not provide 24/7 services. The associated impact on patients will be continuous delays that affect their assessment and treatment (Lumley et al, 2015). Secondly, at an organisational level, the impact can be seen in terms of delayed discharges and extended lengths of hospital stay (Lumley et al, 2015). Delays in discharging patients could affect the flow of patients through the hospital and increase the burden on hospital beds, which are much needed for other patients waiting in the emergency department (The King's Fund, 2018). The All-Party Parliamentary Group on Vascular and Venous Disease (2019) recommended that all NHS organisations should provide appropriate training and education on VLUs.

The healing of VLUs requires a collective team effort and resource investment from clinicians and clinical leaders (Kuhnke et al, 2919). To provide compression therapy in secondary care, ABPI equipment, compression products and associated equipment need to be made available to hospital clinicians. This review found examples where hospital clinicians stated that essential equipment was not available. Although the extent and severity of such difficulties may differ between hospitals, secondary care services are often reported to be inadequately set up to meet the needs of inpatients with VLUs (Lumley et al, 2015). Difficulties in obtaining equipment could be due to a lack of organisational responsibility (Lumley et al, 2015). Clinicians often have a limited degree of control when dealing with a lack of appropriate clinical equipment, which results in frustration and dissatisfaction (Cullen and Phillips, 2009). It is a duty of care for clinical leaders, managers, TVNs and other stakeholders to work together to provide clinical equipment needed for inpatient care.

The healing of chronic VLUs is a joint effort between the patient and clinician (Flaherty, 2005). This review found that clinicians noted that patient compliance was as important as the product for successful VLU treatment. Patients' non-compliance has been reported as a significant barrier to receiving compression (Lindsay, 2001; Flanagan et al, 2001; Kuhnke et al, 2019). It is also a factor in the recurrence of a VLU (Meulendijks et al, 2020) and was rated as one of the top three treatment challenges (Cullen and Phillips, 2009). The Cambridge Dictionary definition of the term ‘compliance’ implies ‘passively obeying instructions’ and ‘subservient’ (Lindsay, 2001). Although ‘compliance’ and ‘adherence’ may be used interchangeably, strictly speaking, ‘adherence’ refers to ‘involving patients in decision-making’, ‘having a more equal relationship’ and ‘patient is agreeing to a plan, rather than having one imposed’ in the treatment process (Dunbar, 1980). There was evidence of supporting patient's adherence though involvement in care planning in the results.

Although several determinants have been reported to influence the extent of compliance such as disease features, treatment regimen features and the duration of therapy (Morris et al, 1992), evidence suggests that patients' compliance is closely linked to patients' understanding that they should wear compression products consistently (Cullen and Phillips, 2009). Clinicians also need to be aware that patients can be passive recipients of care and feel objectified, helpless or resigned to the disease, which affects their ability to engage in education and develop an effective relationship (Harker, 2000; Cullen and Phillips, 2009; Kuhnke et al, 2019). Patient information needs have been identified as one way to reduce anxiety and fear related to compression therapy (Kuhnke et al, 2019), which in turn promotes adherence.

Implications for further practice

Based on the barriers identified, the review set out solutions and recommendations for clinical practice. Firstly, it is crucial to identify key clinical areas for intense leg ulcer package training, acting on organisational and clinical factors. The educational package will make sure hospital clinicians are aware of evidence-based care so that they have the confidence to provide optimal leg ulcer care and challenge unsuitable practice (Bell, 1994). Secondly, patients' knowledge of compression could impact patient adherence (Kuhnke et al, 2019). Clinicians need to share essential information regarding compression and engage with patients' decision-making, which could promote healing and adequate adherence to treatment (Žulec et al, 2022). The development of a therapeutic relationship, active listening, identifying patient needs and responding appropriately to those needs can be demanding and time-consuming for hospital clinicians. However, it will be rewarding to see patients' behaviour change through active meaningful conversations and positive engagement in decision-making (Žulec et al, 2022). Žulec et al (2022) found that an educated patient is a valuable partner in venous leg ulcer treatment. The relationship between clinicians and patients can evolve from patient compliance to patient adherence, patients will then be expected to be active and make decisions regarding their own health (Žulec et al, 2022).

Implications for further research

This review has only scratched the surface of exploring barriers behind this complex clinical concern. The research articles examined in this review provided only an initial insight into various factors and complex interactions that may explain some struggles that hospital clinicians face in implementing compression therapy. While these research papers provide some insight, we still do not have a fully complete picture or explanation in the following areas. Firstly, there may be many factors contributing to the lack of resources in an organisation such as compression products and special equipment. The difficulties in obtaining equipment require further exploration. Secondly, there could be other barriers to implementing compression therapy not stated by participants in the included papers. The priority now is to explore clinical leaders' views on using compression therapy in hospitals and understand barriers and enablers to implementing this therapy. This will provide an opportunity to engage with hospital leaders, target any behaviours that require changing and encourage them to be part of this stakeholder group. Therefore, further qualitative research is required to explore views and opinions from hospital management teams and clinicians regarding the use of compression therapy, bearing in mind that there was no enabler identified from the review.

Conclusion

This systematic review explored hospital clinicians' views and experiences of using compression therapy as a treatment plan for inpatients with VLUs in secondary care. The search retrieved four original studies by undertaking a strategic systematic search strategy using the predefined eligibility criteria. The identified studies were critically appraised using the adapted CASP checklist. Three key themes were generated using the meta-ethnography data synthesis method. These themes are educational needs, patient-related factors and organisational resources. The themes indicated that the management of inpatients with VLUs using compression therapy presents challenges for hospital clinicians. These barriers are limited knowledge about clinical procedures, patients' compliance or adherence, lack of appropriate clinical equipment and lack of staff resources. Further research is needed to fill this evidence gap. With the number of older people set to increase, there is an urgent need to prevent unwarranted variations in leg ulcer care, provide evidence-based compression therapy in secondary care and facilitate achieving equitable care for patients with VLUs across NHS settings in the UK.

KEY POINTS

• There has been little information and research conducted in relation to compression therapy in secondary care
• The review generated three key themes in relation to the use of compression therapy: educational needs, patient-related factors and organisational resources
• The key themes indicated barriers to implementing compression therapy in secondary care are limited knowledge about clinical procedures, patients' compliance or adherence, lack of appropriate clinical equipment and lack of staff resources
• There is a need for further qualitative research to explore hospital clinicians' and senior management teams' perspectives on the use of compression therapy

CPD reflective questions

• What are the views and experiences of your hospital clinicians regarding the use of compression therapy for inpatients with venous leg ulcers?
• What are your hospital clinical managers' views on the use of compression therapy in secondary care?
• What barriers do you face when caring for inpatients with venous leg ulcers in your hospital?
• What enablers have you identified in your hospital that facilitate the implementation of compression therapy?