It would be easy to conclude, as I come to an end of my community placement, that the majority of people over the age of 75 have at least one venous leg ulcer.  Mr O’Leary was no exception – in fact his was particularly painful and had so far resisted all attempts to heal.  Like so many of the older folks in the community, he suffered the pain stoically.  As he squelched his way into his living room for the daily bandage change, I glanced at the exudate stained leather of his shoes and the soggy mass of  bandaging and was reminded of the embarrassment endured by these patients.  Mr O’Leary smiled warmly, gently rolling his fingers in Parkinsonian rhythm as he enquired after my health in a soft Irish lilt.  I desperately wanted to find a way to promote healing, and started searching for any hints in the research literature.  It surprised me to find that until the 1990s, although the UK Department of Health knew that a major proportion of community health expenditure went into treating leg ulcers, it was not known how much that was, neither was the prevalence of leg ulcers known, nor what treatments were being used and whether they worked.  In fact little was known at all.  A systematic review of available research was commissioned for the first time to try to answer these and other questions about leg ulcers.  The results were not encouraging.  The majority of the questions remained unanswered or where there were answers those answers were unclear.  I realised that nursing research has a place in identifying further research needs as well as answering clinical questions.  Fortunately what has been described as an ‘evidence desert’ spurred the NHS into funding a suite of systematic reviews of wound care in 1997.  It is now widely accepted that compression bandaging is the main treatment for venous leg ulcers (Cullum et al 2001), and that no conclusive evidence favouring any particular dressing beneath the compression bandaging has emerged (Palfreyman et al 2006).   Unfortunately Mr O’Leary was not able to tolerate significant compression, and seldom remembered to elevate his legs to aid venous return.  I had no Panacea to help him, and it was clear that we still need further research into this area.  ‘I’ll see you at the same time tomorrow Mr O’Leary’ I said having completed the dressing.  What was my next visit?  Oh yes, another venous leg ulcer.

Cullum N, Nelson EA, Fletcher AW, et al.. Compression for venous leg ulcers. Cochrane Database Syst Rev 2001;(2):CD000265

Palfreyman SJ, Nelson EA, Lochiel R, et al. Dressings for healing venous leg ulcers. Cochrane Database Syst Rev 2006;(3):CD001103

It is hard to ignore the politics in nursing.  Every time a qualified community nurse leaves, they are replaced by an untrained Health Care Assistant.  What is going on here?  I do not want to do HCAs down, as many of them do a superb job, but if the job can be done as well by an HCA as a staff nurse, then what is the point in spending three years studying and living on a student grant.  Are the accountants taking over primary care?  Do ‘they’ not realise that carrying out nursing interventions requires more than mechanistically following a care plan.  A few days ago we all trooped to the hospital to listen to the senior manger explain how primary care is moving to a commissioner -  provider model.  Now having been a manager myself in a previous life, I have more sympathy than most for these unfortunate, overpaid individuals, but their talk of corporate identity, metrics and strategic positioning was a real turnoff for us clinicians.  “Tesco,” lectured the speaker, “can sell holiday insurance, mobile phones, in fact almost anything.” The bewildered nurses gazed at each other as the quagmire of mutual misunderstanding between speaker and audience widened.  They had signed up to care for sick patients, were they to sell insurance?  “We must all review our strategic marketing position,” burbled the manager from another planet, but it was too late, the audience was lost.  “We must leverage our core competencies to create a paradigm shift,” she pleaded faintly. To be fair, she had little hope from the start.  The majority of nurses, I believe, nurse because they care about patients, and have no wish to become business savvy; it is incompatible with their approach to patient care.  If we must run like a business, so be it, but nurses should focus on what they are trained for and do best, and accountants should allow them to do so.