Clinical negligence claims for pressure injuries from the perspective of a tissue viability medico-legal nurse expert.

Clinical negligence claims for pressure injuries against the NHS continue to rise annually. This article will discuss the number of claims and financial costs to the NHS, together with the legal processes involved. Issues such as duty of care, breach of duty and harm and how these are interpreted in law will be explained, together with advice on how to avoid a potential negligence claim in the future. The author will discuss scenarios specific to primary care, such as non-adherence to pressure injury prevention strategies and how to manage these effectively. The importance of accurate, concise, relevant and factual documentation will also be discussed in detail.

Legal implications of pressure injuries: experience of a tissue viability nurse expert.

NHS Resolution manages the Clinical Negligence Scheme for Trusts, and aims to reduce the cost of litigation in terms of clinical negligence claims. To achieve this, potential clinical negligence claims are screened to assess whether to defend the claim or to provide an out-of-court settlement. Nurse experts from all nursing specialties are engaged to review all documentation and patient records to offer an opinion on the viability of a claim. This article describes the processes involved in assessing tissue viability clinical negligence claims, providing examples of evidence that guided decisions and advice on how nurses can protect their organisation from costly litigation.

Managing exudate and maceration in venous leg ulceration within the acute health setting.

Exudate has beneficial effects in normal wound healing but detrimental consequences for chronic wounds. Practitioners need to identify and treat its cause, and manage the exudate and prevent if from damaging periwound skin. Management involves dressings of the most appropriate absorbency and other products, and avoiding maceration of periwound skin; compression therapy is the gold standard treatment for treating oedema and venous leg ulceration. Nurses in acute settings may not have the skills to implement or maintain compression therapy; this article is intended for nurses who may have to manage these patients temporarily while they are admitted to secondary care and may not have the skills.

The Inverse Relationship between the Microstructural Variability of Amygdala-Prefrontal Pathways and Trait Anxiety Is Moderated by Sex.

Anxiety impacts the quality of everyday life and may facilitate the development of affective disorders, possibly through concurrent alterations in neural circuitry. Findings from multimodal neuroimaging studies suggest that trait-anxious individuals may have a reduced capacity for efficient communication between the amygdala and the ventral prefrontal cortex (vPFC). A diffusion-weighted imaging protocol with 61 directions was used to identify lateral and medial amygdala-vPFC white matter pathways. The structural integrity of both pathways was inversely correlated with self-reported levels of trait anxiety. When this mask from our first dataset was then applied to an independent validation dataset, both pathways again showed a consistent inverse relationship with trait anxiety. Importantly, a moderating effect of sex was found, demonstrating that the observed brain-anxiety relationship was stronger in females. These data reveal a potential neuroanatomical mediator of previously documented functional alterations in amygdala-prefrontal connectivity that is associated with trait anxiety, which might prove informative for future studies of psychopathology.

Phases of the wound healing process.

This is the first in a six-part series on wound management. It describes the stages of the wound healing process and explains how they relate to nursing practice. Nurses need to know how to recognise and understand the different phases so they can identify whether wounds are healing normally and apply the appropriate treatments to remove the barriers to healing. Part 2 (page 14) focuses on wound assessment.

The principles of holistic wound assessment.

This article is the second in a series designed to enhance nurses' knowledge of wound management. It highlights the importance of assessing patients holistically, and provides an overview of the key factors that should be considered when assessing a wound. A well-designed template enables nurses to carry out a comprehensive assessment that ensures accurate documentation to monitor wound healing.

The assessment and treatment of wound pain.

This article is the third in a series on wound management. Poor pain management leads to distress and can impede the healing process. This article describes the different types of pain and the psychological aspects of pain that should be taken into account when deciding on a wound-management strategy. It discusses assessment tools, along with pharmacological and non-pharmacological interventions for pain management.

Canadian Triage and Acuity Scale: testing the mental health categories.

PURPOSE: The study tested the inter-rater reliability and accuracy of triage nurses' assignment of urgency ratings for mental health patient scenarios based on the 2008 Canadian Triage and Acuity Scale (CTAS) guidelines, using a standardized triage tool. The influence of triage experience, educational preparation, and comfort level with mental health presentations on the accuracy of urgency ratings was also explored. METHODS: Study participants assigned urgency ratings to 20 mental health patient scenarios in randomized order using the CTAS. The scenarios were developed using actual triage notes and were reviewed by an expert panel of emergency and mental health clinicians for face and content validity. RESULTS: The overall Fleiss' kappa, the measure of inter-rater reliability for this sample of triage nurses (n=18), was 0.312, representing only fair albeit statistically significant (P<0.0001) agreement. Kendall's coefficient of concordance for the sample was calculated to be 0.680 (P<0.0001), which signifies moderate agreement. Although the sample reported high levels of education, comfort with mental health presentations, and experience, accuracy in urgency ratings measured by the percentage of correct responses ranged from 0.05% to 94% (mean: 54%). Greater accuracy in urgency ratings was recorded for triage nurses who used second-order modifiers and avoided the use of override. CONCLUSION: Specific focus on the use of second-order modifiers in orientation and ongoing education of triage nurses may improve the reliability and validity of the CTAS when used to assign urgency ratings to mental health presentations.

Strategies to reduce or eliminate wound pain.

Wound pain is often underestimated and poorly managed. This article explains the different types of pain and how to assess wound pain, and gives practical advice on how to manage or minimise the pain experienced by patients with wounds.

Reducing uncertainty in triaging mental health presentations: examining triage decision-making.

Little is known about how emergency department (ED) nurses make decisions and even less is known about triage nurses' decision-making. There is compelling motivation to better understand the processes by which triage nurses make decisions, particularly with complex patient populations such as those with frequently emotive mental health and illness issues. While accuracy and reliability of triage decisions generally have been improved through the introduction of standardised triage scales and instruments, other factors such as lack of knowledge or confidence related to mental health issues, past experiences that may elicit transference and countertransference, judgments about individuals based on their behavioural presentations may impact on decisions made at triage. In this paper, we review the current research regarding the effectiveness of triage tools particularly with mental health presentations, present a theoretical framework that may guide research in understanding how triage nurses approach decision-making, and apply that framework to thinking about research in mental health-related triage. Developing a better understanding of how triage nurses make decisions, particularly in situations where issues related to mental health and illness may raise the levels of uncertainty, is crucial to ensure that they have the skills and tools they need to provide the most effective, sensitive, and compassionate care possible.

Encouraging patients to self-care - the preliminary development and validation of the VeLUSET©, a self-efficacy tool for venous leg ulcer patients, aged 60 years and over.

Venous leg ulceration has a high recurrence rate. Patients with healed or frequently recurring venous ulceration are required to perform self-care behaviours to prevent recurrence or promote healing, but evidence suggests that many find these difficult to perform. Bandura's self-efficacy theory is a widely used and robust behaviour change model and underpins many interventions designed to promote self-care in a variety of chronic conditions. By identifying areas where patients may experience difficulty in performing self-care, interventions can be developed to strengthen their self-efficacy beliefs in performing these activities successfully. There are currently a variety of self-efficacy scales available to measure self-efficacy in a variety of conditions; but not a disease-specific scale for use with venous ulcer patients. The aim of this study, therefore, was to develop and validate a disease-specific, patient-focused self-efficacy scale for patients with healed venous leg ulceration. This scale will need further validation studies; however, it is ready for use in clinical practice and will enable practitioners to identify those patients who may need additional support in performing self-care activities to prevent recurrence.

The role of debridement in the healing process.

Guidance on wound debridement has been updated. This article discusses the most commonly used debridement methods recommended in the guidance and gives an overview of new technology. It provides practice points on how to debride a wound successfully.

Implications of patient shared decision-making on wound care.

This article discusses the Government's drive to promote health professional and patient partnership working within healthcare, with a focus on enhancing wellbeing and how this relates to tissue viability. The literature has demonstrated how wounds impact negatively on a patient's sense of wellbeing. Assessing the impact of a wound on patient wellbeing is an essential as part of an holistic assessment process, but is even more important when the wound is chronic or recalcitrant to treatment. Scenarios are presented that illustrate how working in partnership with patients with chronic wounds can result in a therapeutic and concordant relationship when the patient's priorities of care are established, even if they differ from those of the health professionals caring for them. The article also discusses objective and subjective methods of measuring wellbeing as a means of demonstrating alternative clinical outcomes of nursing interventions within a healthcare culture where the need to meet wound healing targets still remains the norm.

Drawtex: breaking the vicious circle of cellular and molecular imbalances.

Uncontrolled cellular and molecular activity in the inflammatory phase of healing will determine whether a wound becomes chronic. Assessment and interventions designed to remove the barriers to healing are essential in order to break the vicious cycle and to kick-start healing in chronic wounds. This product focus gives an overview of the inflammatory phase of the wound healing continuum; discusses how the imbalance of matrix metalloproteinases/tissue inhibitors of matrix metalloproteinases occurs; how this imbalance manifests itself clinically within the wound; and what health professionals can do in order to tip the balance in favour of healing. It discusses a new wound dressing, Drawtex, which combines three modes of action to maintain a moist wound environment in order to debride, manage exudate and reduce bioburden by locking harmful proteases into its core. Case studies are presented where Drawtex has been used to achieve healing in wounds that were not responding to treatment.

The structural and functional connectivity of the amygdala: from normal emotion to pathological anxiety.

The dynamic interactions between the amygdala and the medial prefrontal cortex (mPFC) are usefully conceptualized as a circuit that both allows us to react automatically to biologically relevant predictive stimuli as well as regulate these reactions when the situation calls for it. In this review, we will begin by discussing the role of this amygdala-mPFC circuitry in the conditioning and extinction of aversive learning in animals. We will then relate these data to emotional regulation paradigms in humans. Finally, we will consider how these processes are compromised in normal and pathological anxiety. We conclude that the capacity for efficient crosstalk between the amygdala and the mPFC, which is represented as the strength of the amygdala-mPFC circuitry, is crucial to beneficial outcomes in terms of reported anxiety.

Chronic leg ulceration in the community: changing the focus.

Compression therapy is considered the gold standard for healing chronic venous leg ulceration, and impressive healing rates are achievable for many patients. Unfortunately, this condition is chronic, characterized by frequent recurrences and, for some patients, ulcer healing may never occur. Within community services, commissioners of nursing services tend to focus on complete ulcer healing within a defined timescale as quality indicators. The challenge, therefore, will be for community nurses to demonstrate alternative but equally effective patient-centred outcome measures for nursing interventions when healing is delayed or does not occur. The current government health policy encourages active patient involvement in treatment, with an emphasis on self-care/management for patients with chronic conditions. Self-management interventions, such as the Expert Patient Programme (Department of Health, 2001) for chronic conditions, have been positively evaluated and have demonstrated considerable benefits for patients in terms of pain reduction and improved psychosocial wellbeing. This article briefly discusses the outcomes of such interventions and suggests that nurse-led self-care programmes could be adapted for leg ulcer patients in order to provide alternative outcome measures for nursing interventions when ulcer healing may not be achievable. This article also gives an overview of current innovations developed to encourage patient involvement and self-care in this client group.