I am in the privileged position of hearing about the experiences of managing venous leg ulcers from community nurses from all over the UK. Recently a group told me that wound care made up 70–80% of their daily caseload, and of these wounds, the majority concern the lower limb, with approximately 50% of patients having bilateral conditions. There is no doubting the rise in these types of wounds since I was a community nurse, and that the reasons behind it are complex. The impact of such a caseload on nursing lives is enormous and rather soul destroying, and that is not considering the impact that living with these wounds has on patients.

However, we do know that where there is a history of investment in specialist intervention over many years, this caseload of wounds accounts for less than 30% (Hopkins and Worboys, 2015). This demonstrates both that faster healing is possible and that change is possible.

As clinicians, we need to reframe the discussion and community narrative around people with leg ulcers and the role of compression therapy in creating sustainable change. We have to move away from a lack of belief in the power of compression and think that achievement equates to a patient keeping their bandages on and up. There is way more power in our hands to bring about significant change for our patients and our workload.

What we do know is that high compression therapy is the treatment for venous ulcers (Partsch and Mortimer, 2015; Lim et al, 2018) and a significant adjunctive therapy for others aetiologies of lower limb ulcers (Dini et al, 2016), and this includes the oedematous ischaemic limb (Mosti, 2016). Despite at least 30 years of evidence, access to such important therapy remains a post code lottery for patients. The use of ‘reduced’ compression is too often the default position even once assessed as having a venous ulcer (Hopkins et al, 2017). We know that most areas have a waiting list, sometimes of many months, for Doppler ultrasound and assessment. Can you name another condition where such a delay would be acceptable?

Clinical knowledge of compression theory is limited; it has been taught as a task and so many myths abound and seem fixed (Wounds UK, 2018). The theory of how compression works, the role of the different materials, the impact of stiffness or how you can safely adapt layering to the person and limb in front of you has been lost. Compression is known to reduce venous hypertension and resulting oedema but its role in reducing inflammation is less well known. Strong compression has been shown to reduce the presence of pro-inflammatory cytokines and create an increase in anti-inflammatory cytokines (Ligi et al, 2016). The speed of the impact reflects the potency of this valuable tool in the hands of competent nurses.

In the face of such powerful evidence, it seems rather tragic that thousands of patients around the country are denied such a simple yet compelling therapy. There is a dominant belief that patients rarely tolerate high compression and that ‘a little is better than none’; the use of light compression is now prevalent. In the majority of cases, this level of compression is delivering sub-optimal care; the compression will be ineffective because it will not be delivering the anti-inflammatory dosage of compression required for healing. We would not be stating that we were giving pain relief with half a Paracetamol; if this did not produce the expected pain relief we would review the dose. It is not surprising then that we all lose heart and a community nursing workload is dominated by non-healing legs ulcers and wet legs.

Conversely where healing rates are high, there is a culture of high compression use and the belief that people will indeed tolerate this if the compression therapy is applied well and consistently. The nurses have a greater understanding of compression and understand that this powerful therapy needs to be sold, their patients then tailored to meet their individual needs. The local system and leadership supports access to a variety of compression materials and the belief that one size will not fit all. Importantly, there is self-critique if the compression is not working; this means that the technique and skill of the bandager is reviewed before blame is centred on the patient for their lack of tolerance.

We need to listen to the words we use when discussing people with leg ulcers and their treatment. Challenge the narrative, the stories you hear or the negative influences will embolden you to be an advocate for your patient and your team. We need to challenge the prevailing view that non-compliance is the key reason for lack of healing; the onus needs to move to the clinician to deliver care differently.

Where a compression system is seen as a product to be put on a leg, then its anti-inflammatory properties and assignment of a treatment plan and dose to create an effective outcome, will not be comprehended or valued. If we constantly talk about leg ulcers as chronic, does this language reduce our collective belief that healing is possible? And finally ‘light’ compression should be described as mild (WUWHS, 2018) and is only suitable for less than 10% of your caseload. For the others this mild compression delivers a sub-optimal dose; simply questioning this at case reviews may be the start of change. The north star on leg ulcer management is to get nearly everyone into moderate to strong compression as early as possible. This demands your creativity and focus. It also demands that we collectively look at how the fear of ‘doing it wrong’ creates inaction and outweighs our realisation that many are not getting the treatment they require.

We need to allow our inner voice to critique the normalisation of non-healing leg wounds and ulcers and wet legs. When powerful and effective treatment is available but not utilized, this is a tragedy for you and your patients.  Understand that you have a potent anti-inflammatory product in your hands; increase this dose so that when the therapeutic level is delivered, the anti-inflammatory effect on the limb and ulcer can be seen. You will then transform the lives of your patients and your team.