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An event that changed my practice

Una Adderley
DN RGN BA BSC Msc
Comunity Tissue Viability Nurse
Scarborough, Whitby & Ryedale PCT

In my case, I can trace my route to my current post to one particular patient who I met around 10 years ago, in my first week working in the community.
Following the birth of my second daughter I was offered a part-time temporary post as a community staff nurse. I joined a small team of five district nurses and one community staff nurse working with a GP team who served a small market town. I had never nursed in the community before but was fortunate in that the district nurse to whom I was attached was both experienced and caring. I was to spend the first week accompanying her on our visits before she started delegating some of the work to me.
The first week was a revelation. I was delighted to discover such diversity on my doorstep. When nursing in hospital I had always warmed to those patients who challenged hospital routine. My caseload was now full of such characters, and I realised that I may have found my niche.
During that first week we visited an elderly lady with ulcerated legs who I'll refer to as "Mrs Smith". We knocked at the door of a large dark house and, after a long delay, heard the key turning. The door opened a fraction and Mrs Smith peered out at us. When she recognised my colleague she let us in, locked the door behind us, and slowly led the way to an unkempt sitting room where the curtains remained closed.
My colleague took down the dressings to reveal legs that were ulcerated from knee to ankle. I was shocked. At that time I had never seen such extensive, sloughy, malodorous wounds. We redressed her legs using a low-adherent wound contact layer, wadding and a retention bandage. My colleague tried to persuade Mrs Smith to consider admission to hospital for bed rest (and some much needed TLC), but Mrs Smith was terrified of leaving her home. When I returned to work a week later, I heard that Mrs Smith had been admitted to hospital with suspected septicaemia and had subsequently died.
I cannot begin to explain my sense of helplessness. Although my colleagues had been caring and tried to help, I sensed that none of them really knew enough about the subject to take a constructive approach. Therefore I did what I usually do in such situations - I started reading everything I could lay my hands on.
Initially I scanned the general nursing journals. I then went to my local bookshop and ordered A Colour Guide to the Assessment and Management of Leg Ulcers.(1) The bookshop assistant was horrified by the title, but I sensed that I was going to need a lot of pictures!
I then discovered a short course on leg ulceration in London. Inevitably my employers had no funds to pay for such a course, but several pharmaceutical companies kindly responded to my pleas and I managed to attend. By this stage, my post as a community staff nurse had become permanent and I was starting to get a structured picture of what we needed to do locally in order to meet these patients' needs. I also discovered other colleagues within my trust who shared my interest. We started working together to campaign for the needs of these patients.
To cut a long story short, over the succeeding years our trust has bought handheld Doppler machines for all our GP practices; we deliver local training on caring for patients with leg ulceration; we have developed policies and protocols for leg ulcer care; compression bandaging is now available on prescription; and knowledge and skills have improved to such an extent that our PCT was able to recruit a large number of patients for an NHS-funded leg ulcer trial. We still do not have leg ulcer assessment clinics, but I'm working on that one!
Although I was unaware of the concept of reflective practice when I met Mrs Smith, it probably explains my approach and subsequent actions. Atkins and Murphy developed a model which suggests that the practitioner becomes aware of uncomfortable feelings and thoughts, critically analyses feelings and knowledge, and as a consequence develops a new perspective.(2) This seems a reasonable explanation of how I dealt with the experience of meeting Mrs Smith.
For me, Mrs Smith was the prompt for my passion for wound care. I shall never forget my sense of helplessness. What she highlighted to me was the need to provide skilled wound care within the community setting. Mrs Smith desperately did not want to be admitted to hospital. Maybe we could have avoided her admission if we had had the right skills at an earlier stage. So, now, my aim is to help my colleagues develop and maintain those skills so that we can minimise situations like Mrs Smith's.

References

  1. Morrison M, Moffatt C. A colour guide to the assessment and management of leg ulcers. London: Mosby; 1994.
  2. Atkins S, Murphy K. Reflection: a review of the literature. J Adv Nurs 1993;18:1188-92.