Journal of Community Nursing - page 108

108
JCN
2013,Vol 27, No 4
individual patient, before adopting a‘no
bandage, no treatment’attitude.
It is well documented in the
literature that patients with leg
ulceration and/or chronic oedema
find it difficult to tolerate compression
for a number of reasons, including
increased pain on application,
reduced mobility, sleep disturbance,
previous poor experience of therapy,
lack of understanding of the theory
of treatment, and social pressures,
such as an inability to carry out work
(Hopkins and Worboys, 2005; Moffatt,
2007; Moffatt et al, 2009).
Clinician-related reasons for
non-concordance with compression
therapy such as inappropriate bandage
selection and poor application are also
commonly reported (Moffatt, 2007).
Patients labelled as non-concordant
are considered difficult to manage and
clinicians may use negative language,
communicate poorly and blunt their
emotions to patients’suffering.This is
obviously detrimental to both patient
care and the therapeutic relationship
(Hopkins andWorboys, 2005).
Instead, we need to work with
the patient to overcome the obstacles
to compression wherever possible
(Brown, 2011). This can often be as
simple as increasing analgesia or
initially applying reduced compression
while the patient becomes tolerant,
or it may involve us as clinicians
identifying our limitations and seeking
further training if needed.
In every case, to improve patient
concordance, clinicians should
be prepared to understand and
empathise with the difficulties that
the patient is experiencing on a day-
to-day basis. My colleagues and I
recently wore a variety of compression
bandages for different 24-hour periods
as part of an investigation into sub-
bandage pressures.
Throughout we were all struck
by the practical restrictions placed
upon our normal activities of daily
living while wearing the bandages.
Showering, dressing and driving were
all negatively affected. Fitting into
our normal footwear was difficult, if
not impossible.
After wearing compression for
several hours, we observed a reduction
in oedema in our bandage limbs,
which also resulted in a high degree
of bandage slippage which, in real
practice, would result in time being
wasted on inefficient treatment
(Hopkins and Worboys, 2005).
Our sleep patterns were disturbed
as a result of the discomfort arising
from bandage slippage and/or the
raised temperature of the bandaged
limb. As we all had healthy limbs and
only wore compression for a short
period of time, our experience did not
the aims, and importance of the
compression therapy.
A male patient with leg ulceration
was recently referred to our tissue
viability team. For a period of four
years he had been unable to tolerate
compression bandaging and was
considered to be non-concordant
with his management plan. With the
patient we discussed and explored
other compression options working
to resolve his concerns. We found
that he was able to tolerate and
use a compression leg ulcer kit that
resulted in his ulcer healing fully
within three months.
Another case involved a male
patient with leg ulceration who
had to wear safety shoes as a legal
requirement at work. As multi-layer
compression bandages meant that his
shoes did not fit, he was faced with
the decision of no treatment or no
work. Again, the use of a less bulky
leg ulcer kit meant that he was able to
concord with his treatment while also
being able to continue working.
Perhaps if from the start these
patients had been offered a range of
bandage and hosiery options, with
the clinicians involved in their care
understanding why they could not
accept or tolerate the initial treatment,
then maybe their concordance would
have been gained from the start.
However, to do this, the clinician
must not only have an awareness of
current guidelines, but also be flexible
enough in their clinical practice to
consider alternatives.
This demands an understanding
of the different compression products
available, including bandaging
systems and hosiery, and knowledge
of the theory underpinning how the
products work. It is not enough to be
competent in one type of bandaging;
presenting a single compression
solution as the only way forward can
leave a patient feeling they have no
option but to decline treatment, as
highlighted in the cases above.
It is also not acceptable to apply
bandaging incorrectly. However, the
benefit of appropriate cross-referring
to other disciplines or colleagues may
‘Showering, dressing and
driving were all negatively
affected. Fitting into our
normal footwear was difficult,
if not impossible.’
reflect that of patients with wounds,
oedema, exudate and pain, but it did
provide a small insight.
We were left with a new
appreciation of the impact of
compression upon patients’lives
and the need for flexibility in finding
solutions that provide effective
clinical outcomes but which are also
compatible with the patient’s lifestyle.
Frequently, non-concordance leads
to a request for specialist intervention
(Moffatt, 2007), and in our experience,
such referrals often involve rebuilding
the patient’s trust.
Taking the time to explain to the
patient the theory behind compression
therapy, and that alternatives exist if a
compression system is unsuccessful or
unacceptable, may help the patient to
think differently about their treatment.
For example, explaining to the patient
that compression bandaging is a
relatively short-term treatment that
will be followed by the use of hosiery
can help them to tolerate the initial
disruption and discomfort.
For compression therapy to form a
successful part of management there
needs to be a working relationship
between clinician and patient, with the
clinician aware of the patient’s needs
and the patient fully understanding
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