Re: Article in January 2003 'Anaesthetic gel insertion during male catheterisation'.
I found this an extremely interesting piece of work, but find the concept a little difficult to understand. The author says:
'The catheter already in situ would be used to insert gel through as the catheter was withdrawn. The advantages would be that the outgoing catheter would be lubricated (which normally it is not), and the urethra would be properly filled with anaesthetic gel'.
Whilst I agree that the urethra would be filled with gel, I find it hard to understand how the catheter would be coated with it as the eyes of the catheter are towards the end of the catheter so the gel would be left in the urethra either behind or on top of the catheter. How can the catheter be coated with gel? My other concern is that of product and personal liability. What do the catheter manufacturing companies say about product liability? The author proposes a procedure: 'The funnel of the catheter is trimmed'.
Surely if anything then went wrong it would be the practitioners liability as catheters are not meant to be cut or adapted. I have spoken to one of the catheter manufacturers, who are looking into this concept, but their initial reaction was that you should not cut the catheter at all.
Louise Lee, Clinical Nurse Specialist Continence Service, Blackpool
On behalf of JCN, Ian Pomfret, District Continence Adviser at Chorley and South Ribble PCT replies:
- This is a descriptive article of a small study into the performance of a nursing/medical procedure.
- The author states that, 'The method uses no new material or appliance, though the order of the procedure is changed.'
- In the method of the study, 'Approval by the local ethics committee was gained prior to participant recruitment.'
- Each patient agreed to partake in the trial and signed a consent form.
- The author acknowledged that this was a small pilot study.
- Nowhere in the article does the author advocate this as a procedure for general implementation, in fact she acknowledges that the study has many faults in methodology.
- The author states, 'From the small amount of data collected, the indication is that a larger trial with improved methodology should be considered.'
I stand by my advice to publish the article as it was of interest, ethical and methodologically correct within the limitations, accepted and described by the author.
Following discussion with a colleague I would accept that there is a weakness in the study in the statement that insertion of gel during the removal of the existing catheter will protect the urethra as the (Foley) catheter is removed. The eyes of the catheter are proximal to the balloon (unless a Robert’s catheter is being used, which is unlikely), therefore, the author is correct in stating that the tip will be well lubricated, but incorrect that the balloon will be lubricated on removal.
Locally, I am advising nurses who approach me regarding this method of procedure, that if they wish to try it, I will be pleased to help them seek ethical approval as it is not in accordance with our Trust's agreed clinical procedure.
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Re: 'The adaptability of chiropody felt and its use in the seamless care of patients', Journal of Community Nursing (2002) Vol 16; Issue 11; pp 40-44.
I was very surprised to read the article advocating the use of adhesive chiropody felt; namely Carnation to treat foot and leg ulcers. This article appears to be primarily an advertisement for Carnation felt and does not mention any of the other makes of felt on the market, which are manufactured in different thicknesses.
The authors suggest that nurses should be encouraged to apply felt when required, but fail to tell them how to cut the felt, bevel the edges or apply it. This may be second nature to podiatrists but it is not part of nurse training. There is a risk of community nurses causing more harm than good if they follow the recommendations of this article particularly if they stick felt inside the shoes of neuropathic patients.
In our diabetic foot clinic we rarely stick adhesive felt to the patient's feet and tend to use total-contact insoles with bespoke/extra depth shoes. As stated in my article published in the Journal of Wound Care Vol 16;
Issue 5; pp 227–230, a dressing alone will not heal a diabetic foot ulcer and emphasis must be put on callus debridement, infection control, pressure relief and a good blood supply. It is, however, important that an appropriate dressing is used. Chiropody felt is not a dressing. Pressure relief is provided by the use of a cast such as the Scotchcast boot or Aircast. The Scotchcast boot is a lightweight, well padded, fibreglass cast, which is used in many diabetic-foot clinics in the UK.
Asking nurses to apply chiropody felt will not improve the multidisciplinary team approach, if they do not know how to use it and do not understand the aetiology and causation of leg and foot ulcers.
Ann Knowles, Specialist Diabetic Footcare Nurse, Central Manchester and Manchester Children’s University Hospitals
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I read with dismay your article on the use of 'chiropody' felt for pressure relief. There is no evidence that the use of felt has anything more than a placebo effect on patient treatment and for patients with foot function problems, research has shown that 'in shoe' orthoses in suitable footwear are the most effective method of treatment.
For patients with foot wounds eg diabetic or ischaemic ulcers, there are numerous products available with excellent guidelines including advice about frequent dressing changes. Pressure relief should be accomplished with casts, special shoes and total contact orthoses.
Compressed and semi-compressed felt is not a suitable product for either pressure relief or as a part of wound car. For purposes of personal hygiene alone having a sticky pad on your skin for long periods of time must be unacceptable. Podiatrists are moving away from the use of felt as a clinical product and it should be consigned to the pages of history.
Joan Gem, Podiatrist, Manchester North, Central and South PCT's
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I read with interest Chris Buswell's article 'Blowing the whistle' in the online edition of the Journal of Community Nursing Vol 17; Issue 2. Although we welcome the article as a means of safeguarding patients by increasing awareness of whistle-blowing protection, we are concerned that certain points in the article might lead a nurse or carer to think it is more difficult to get protection under PIDA than it actually is. They might then feel they do not have a safe alternative to silence.
By way of background I should explain that Public Concern at Work is an independent charity and we are closely involved in settling the scope and limits of PIDA. For the past 10 years we have run a help-line to advise individuals who have witnessed dangers or illegality at work on how to raise their concerns effectively and safely.
In our view, the article risks giving the impression that a nurse or carer needs to demonstrate they have met the grounds for wider disclosure in order to be protected for a disclosure to their employer. In practice, this might lead a nurse to think he has to prove a piece of equipment was unsafe and that this was going to be covered-up before raising his concern. In fact, the nurse need only demonstrate he had a genuine suspicion of a risk to be protected for raising the concern with a manager or doctor. This is because PIDA's highest protection is afforded those who raise their concern with their employer (or equally in the case of NHS staff, with the Department of Health). An individual need not be right to be protected, but they do need to have an honest suspicion of wrong-doing or a serious risk.
It is also misleading to state that workers who have signed the Official Secrets Act (OSA) are not protected by PIDA. If a disclosure were to breach the OSA (a criminal offence), it would not be protected. However, raising a concern about malpractice with a manager or the Civil Services Commissions would not breach the OSA and so could be protected.
I note that Chris Buswell concludes the article by stating that whistle-blowing is a matter of last resort after communication with management has become a problem. This may just be a difference in interpretation, but we feel that embracing whistle-blowing within organisations helps both staff and managers realise their rights and responsibilities.
Anna Myers, Deputy Director, Public Concern at Work, London
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