Leg Ulcer Policy SH CP 108. Version: 1. Summary:

Transcription

1 SH CP 108 Version: 1 Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: The policy establishes a standardised framework for healthcare professionals (HCP) undertaking care of a patient with leg ulceration, HCP s must attend specialist tissue viability education to be deemed competent in all aspects of leg ulcer management. Competency frameworks are detailed for all staff grades. TVN specialist support is available and referral guidelines detailed. Venous Leg Ulcers, Varicose Ulcers, Leg Ulcers, Lower leg wounds, Arterial Leg Ulcers, Mixed Aetiology Ulcers, Diabetic Ulcers Clinical-ICS, CCT s, Community Hospitals, G.P s, Practice Nurses, Adult Mental Health, Older Persons Mental Health and Learning Disabilities, Leg Ulcer clinics Next Review Date: March 2017 Approved by: Quality & Safety Committee Date issued: Date of meeting: 12/2/2013 Author: Sponsor: Lisa Rice, Jane McFarlane and Jane Barker, Tissue Viability Specialist Nurses Sue Harriman, Chief Operating Officer. 1

2 Version Control Change Record Date Author Version Page Reason for Change 1/10/2014 Lisa Rice V1 7 Change of name of Aseptic Procedure 1/10/2014 Lisa Rice V1 12 Change of name of Aseptic Procedure 1/10/2014 Lisa Rice V1 15 Change of name of Aseptic Procedure 1/10/2014 Lisa Rice V1 11 Updated Leg Ulcer Management Pathway Reviewers/contributors Name Position Version Reviewed & Date Area Matrons SHFT (1) December 2012 WISH/Tissue Viability Link Nurses SHFT (1) December 2012 Paula Hull Head of Nursing and Quality (1) December 2012 Tissue Viability Specialists in Acute Trusts (1) December 2012 Rachel Gray Record Keeping (1) December 2012 Sharon Gomez LEAD (1) December

3 Contents Page 1. Introduction 4 2. Scope 4 3. Definitions 4 4. Duties/ responsibilities 4 5. Assessment 5 6. Referral for Specialist Advice to Leg Ulcer / Tissue Viability 5 Service 7. Patient Education and Information 5 8. Prevention of Recurrence/Primary Prevention 6 9. Training Requirements Monitoring Compliance Policy Review Associated Documents Supporting References 7 Appendices A1 Training Needs Analysis (TNA) 8 A2 Referral Pathway for Leg Ulcer Service 11 A3 Self-Assessment Competency Statement - Doppler (Ankle 12 Brachial Pressure Index ABPI) Assessment A4 Self-Assessment Competency Statement - Application of 15 Compression Bandage Therapy A5 Equality Impact Assessment (EqIA) 18 3

4 1. Introduction 1.1 Leg ulcers are a debilitating and painful condition that has been estimated to affect approximately 1% of the population of Britain and cost the NHS a minimum of million (Healthcare Commission, 2004). 34% of people with a leg ulcer also have complex aetiologies. Moffatt et al (2007). They frequently become chronic, with patients suffering recurrent or long-term ulceration (Cullum, 1994). 1.2 This leg ulcer policy along with the Leg Ulcer Standard Operating procedures are intended to establish a standardised approach and framework for health care professionals undertaking care of patients with an active ulcer or at risk of ulceration. 1.3 The guidelines and policy are based on current best practice statements, position documents, expert opinion, national guidelines and research evidence where it exists. 2. Scope 2.1 The contents of this leg ulcer policy apply to all community teams in all community settings within Southern Health NHS Foundation Trust. 3. Definitions 3.1 A Leg Ulcer is not a clinical condition by itself. There is always an underlying problem which causes the skin to break down and healing may be delayed by contributing factors. However, for the purposes of this document, we are defining a leg ulcer as: Tissue breakdown on the leg or foot due to any cause (Cullum, 1994). 4. Duties / Responsibilities 4.1 The Trust will provide training to ensure that all staff who manage leg ulcers are aware of the policy and treatment of leg ulcers. 4.2 The Trust will provide and the managers should ensure availability of the tools for assessment and treatment of leg ulcers e.g. Doppler, cameras and tracing grids. 4.3 All managers in clinical areas must ensure they have access to an appropriate service or individual who is able to provide leg ulcer assessment and management. 4.4 All managers in the relevant clinical areas must ensure that appropriate staff received training and are supported to achieve and maintain competence. 4.5 All Healthcare Professionals, who care for patients with leg ulceration, must complete the self assessment competency framework for Doppler assessment and compression bandaging (appendix 3 and 4) as evidence in their Knowledge and Skills Framework portfolio, annually as part of their appraisal. 4

5 4.5a Band 4 staff who care for patients with leg ulceration must have their competency framework for Doppler and compression bandaging assessed by a competent trained nurse as evidence in their Knowledge and Skills Framework portfolio, annually as part of their appraisal. 4.6 All Health Care Professionals who care for patients with leg ulceration must ensure that they receive appropriate education and demonstrate competence in aetiology, assessment and treatment of leg ulcers. 5. Assessment 5.1 Assessment, clinical investigation and treatment plan must be undertaken by a healthcare professional trained in leg ulcer management. 5.2 The assessment process is ongoing and involves an initial assessment and weekly reassessment, which is to be recorded on RIO (For SHFT staff only). 5.3 The assessment must be holistic and include information regarding lifestyle in its approach and encourage patient involvement in the decision making process. 5.4 The assessment must be documented using the Trust leg ulcer assessment tool (see appendix 1 of the leg ulcer guidelines) with photographs and or tracings at regular intervals. (For SHFT - staff please complete the leg ulcer assessment, vascular assessment and wound assessment on RIO). 5.5 All patients must have an initial Leg ulcer and Doppler assessment which is documented and repeated at 6 monthly intervals. Reassessment should be undertaken more frequently if ulcer deteriorates. A new episode of ulceration requires a new holistic Leg Ulcer Assessment and Doppler assessment. 6. Referral for Specialist Advice to Leg Ulcer / Tissue Viability Service 6.1 Tissue Viability Link Nurses where available should be used as the first point of contact. 6.2 All patients referred by a Health Professional will have completed a leg ulcer referral / assessment form including arterial screening (Doppler) attempted if not completed faxed to the Tissue Viability Team on All Venous or mixed aetiology leg ulceration with no significant healing, or deterioration after 4 weeks from initial assessment and commencement of compression therapy. (Sign 2010) to be referred to next line of management e.g. link nurse or specialist. All patients with arterial ulcers should be referred urgently to a vascular surgeon. 6.4 All staff must liaise with and refer to the appropriate health care professional to aim to meet all individual patient health care needs. ` 7. Patient Education and Information 7.1 All patients are entitled to and should be offered accessible and appropriate health promotion information on their condition and documented in the patient record. 5

6 7.2 An information leaflet should be given to each patient describing clearly and simply the rationale for treatment and self help strategies. 7.3 The patient should be made aware they should contact a health care professional if they have a recurrence of symptoms or have concerns. 8. Prevention of Recurrence/Primary Prevention 8.1 The Trust encourages and supports the development of well leg clinics /follow up services for Primary prevention or healed ulcers. 8.2 All Health Care Professionals must use and implement the Well Leg Pathway (See Appendix 4 of the Leg Ulcer Guidelines). 9. Training Requirements 9.1 The staff education and training will include epidemiology, aetiology, predisposing, presenting and perpetuating factors, ulcer management options, bandaging and Doppler skills. 9.2 Leg ulcer assessment and management training content will be planned and delivered by specialist practitioners and co-ordinated by LEAD and this will be advertised on the intranet and website. 9.3 The training includes a workbook to be completed as part of pre course preparation, the 2 day taught Leg Ulcer Course, with Doppler and compression Bandaging workshops. 9.4 Core competencies are to be completed and assessed in clinical practice and are the responsibilities of the HCP and their line manager to complete. 9.5 All health care workers should have as a minimum, achieved competency as demonstrated by the completion of the self assessment framework. 10. Monitoring Compliance 10.1 The table below outlines how the implementation of this policy and associated guidelines will be monitored. Reporting Element to be monitored Lead Tool Frequency arrangements Principles outlined in this policy and Leg Ulcer Standard Operating Procedures Lisa Rice Helen Alger Clinical audit 6 Monthly Annual report to relevant Committee Leg Ulcer Healing Rates Lisa Rice Helen Alger Snap Tool/ RIO Quarterly Quarterly report to commissioners 11. Policy Review 11.1 Annual review in first year then every 4 years 6

7 12. Associated Documents 12.1 Leg Ulcer Stand Operating Procedures 12.2 Physical Assessment guidelines 12.3 Aseptic Technique Policy and Guidelines 13. Supporting References Recommendations for Practice. DOH London: HMSO Cullum, M (1992) Prevalence of chronic leg ulceration and severe chronic venous disease in western countries. Phlebology 7 (suppl):6-12 Healthcare Commission (2004) National Audit of the Management of Venous Leg Ulcers, London: Healthcare Commission, DOH Moffatt. C, Martin, R, Smithdale R (2007) Leg Ulcer Management skills for nurses. Blackwell Publishing, Oxford Royal College of Nursing (1998) The management of patients with venous leg ulcers. RCN Institute, London SIGN (2010) Scottish leg Ulcer guidelines 7

8 APPENDIX 1: LEaD (Leadership, Education & Development) Training Needs Analysis Training Programme 2 day Leg Ulcer course Frequency Course Length Delivery Method Trainer(s) Once then to complete annual self assessed competencies 2 days consecutive Pre course work book, 2 day face to face training, assessed competencies in practice. Tissue Viability specialist Team Directorate Division Target Audience Adult Mental Health MH/LD ICS Corporate Services Learning Disabilities Older Persons Mental Health Specialised Services TQtwentyone Adults Children s Services Dental All (HR, Finance, Governance, Estates etc.) Recording Attendance LEAD Qualified and Unqualified Nurses from Community Care Teams, and Community Hospitals Strategic & Operational Responsibility Strategic- Head of Nursing and Quality Operational- Tissue Viability Team 8

9 Training Programme Compression bandaging and Doppler updates Directorate MH/LD ICS Corporate Services Frequency Course Length Delivery Method Trainer(s) As identified from completion of annual self assessed competencies Division Adult Mental Health Learning Disabilities Older Persons Mental Health Specialised Services TQtwentyone Adults Specialist Services Children s & Wellbeing Dental All (HR, Finance, Governance, Estates etc.) Each course is 1/2 day Face to face training with practical workshops Tissue Viability specialist Team Target Audience Recording Attendance LEAD Qualified and Unqualified Nurses from Community Care Teams, and Community Hospitals Strategic & Operational Responsibility Strategic- Head of Nursing and Quality Operational- Tissue Viability Team 9

10 Training Programme Well Leg training As part of CPD opportunities 1 day Directorate MH/LD ICS Corporate Services Frequency Course Length Delivery Method Trainer(s) Division Adult Mental Health Learning Disabilities Older Persons Mental Health Specialised Services TQtwentyone Adults Specialist Services Children s & Wellbeing Dental All (HR, Finance, Governance, Estates etc.) Face to face training with practical workshop Tissue Viability specialist Team Target Audience Recording Attendance LEAD Qualified and Unqualified Nurses from Community Care Teams, and Community Hospitals Strategic & Operational Responsibility Strategic- Head of Nursing and Quality Operational- Tissue Viability Team 10

11 APPENDIX 2: Leg Ulcer Management Pathway Week Weeks Diagnosis Treatment Outcome 4-6 weeks Outcome 12 weeks Patient presents with a wound to the lower leg. Record activity on RIO as appropriate If recurrent Leg Ulcer refer to secondary care Specialist for further investigation Arterial and PVD risk factors Smokes Intermittent claudication Pain on rest/elevating limbs Hypertension MI, Angina, IHD,TIA,CVA Rheumatoid arthritis and Refer all mobile patients to LU Clinic or PN. House bound patients to CCT Complete Leg Ulcer Assessment by end of second week of admission to caseload Record LU assessment & Wound Assessment care plan on RIO Venous leg ulcer ABPI Biphasic/ Triphasic sounds Arterial ulcer ABPI 0.6 & below Mixed ABPI Biphasic pulses No history of arterial or PVD risk factors as listed below ABPI > 1.3 Triphasic or Biphasic pulses and no arterial or PVD risk factors ABPI 0.6 to 0.8 or ABPI greater than 1.3 With arterial and PVD risk factors Education Commence compression bandaging according to ankle circumference and wound formulary Education Refer to GP for onward vascular referral as appropriate Dressing as per wound formulary Education Refer to TVN or link nurse with appropriate competencies to consider for reduced compression as wound formulary Education Refer to TVN / link nurse with appropriate competencies Consider for reduced compression as per wound formulary Apply dressings as per wound formulary Education Refer for 11 Duplex scan Ulcer heals Education Prevention of recurrence Hosiery Record healed status on wound assessment form Ulcer fails to heal Education/review current therapy At 4 weeks non healing refer to link nurse for review. If still non healing At 6 weeks non healing refer to TVN for review Other reasons for TV /link nurse referral Unable to tolerate compression Allergy Repeated infection No response to treatment at 6 weeks Record RIO activity. Record wound status at each visit and assessment weekly or if significant change to wound Ulcer heals Education Prevention of recurrence Hosiery Follow Well Leg Pathway Record healed status on wound assessment Ulcer continues to be non healing Refer for duplex scan

12 APPENDIX 3: Self-Assessment Competency Statement Doppler (Ankle Brachial Pressure Index ABPI) Assessment Surname: Dept & Ward / Unit: Forename(s): Job title / designation: Self-verification of competence is undertaken by assessment against the statements below. These statements are designed to indicate competence to undertake this skill. If you are in any doubt regarding your competence, you should seek education (consider self-directed learning, coaching and formal training) to bring about improvement. Your statement of competence will provide evidence towards the following dimensions in the knowledge and skills framework: Core dimension 1: Communication: Level 2 a,c,d,e Core dimension 3: Health, Safety and Security: Level 3 a, b, c, e, f Core dimension 5: Quality: Level 2 a, b, e, f Carry out an initial assessment. You must be able to answer Yes to all the questions before considering yourself to be competent. If you are not competent, instigate learning and then repeat self-verification. Ask yourself the following questions. Initial assessment date: Final assessme nt date: Have I undergone a programme of education to undertake ABPI assessment? Have I undertaken the ABPI assessment with the supervision of a competent nurse? Do I understand my accountability within the Code of Conduct (NMC 2004)? Can I describe the Trusts guidelines for ABPI assessment? Do I understand the principles of infection, prevention & control including hand hygiene, correct us of personal protective equipment, Aseptic Technique and waste disposal including safe disposal of sharps as set ou in the IP&C Trust policy Can I describe the indications for undertaking ABPI and the anticipated outcomes? Can I describe the contra-indications/precautions for undertaking ABPI? Can I describe what equipment is required for undertaking ABPI, and which gel should be used? Can I explain to the patient the reasons for having an ABPI completed and distinguish between arterial and venous blood flow? Can I explain and identify the difference between monophasic, bi-phasic and tri-phasic sounds? 12

13 Can I locate and name the 4 pedal pulses? Do I understand the need to gain consent and maintain privacy and dignity throughout the procedure? Do I know: How to calculate the ABPI? The reason for resting the patient prior to undertaking ABPI? When it is not appropriate/contra indications to do an ABPI? When to use a 5 MHz or an 8MHz probe? What is the difference? How to interpret the results and understand the significance? The appropriate referral pathways depending on the ABPI? That the ABPI is only part of the leg ulcer assessment. Can I explain why this is? Statement of Competence I certify that I am aware of my professional responsibility for continuing professional development and that I am accountable for my actions. With this in mind I make the following statement: I am competent to undertake without further training Signature: Date: I require further training before I can undertake in a competent manner Signature: Date: Keep this form in your personal portfolio or training record. Ensure your manager has seen the form when completed. Indicate how you plan to meet your learning needs: By when: 13

14 Yearly Statement of Competence I have re-assessed my competence against the statements overleaf and I certify that I am aware of my professional responsibility for continuing professional development and that I am accountable for my actions. With this in mind I make the following statement: I am competent to undertake. without further training Signature: Date: I have re-assessed my competence against the statements overleaf and I certify that I am aware of my professional responsibility for continuing professional development and that I am accountable for my actions. With this in mind I make the following statement: I am competent to undertake.. without further training Signature: Date: Adapted from Queens Medical Centre Nottingham competence statements 14

15 APPENDIX 4: Self-Assessment Competency Statement Application of Compression Bandage Therapy Surname: Dept & Ward / Unit: Forename(s): Job title / designation: Self-verification of competence is undertaken by assessment against the statements below. These statements are designed to indicate competence to undertake this skill. If you are in any doubt regarding your competence, you should seek education (consider self-directed learning, coaching and formal training) to bring about improvement. Your statement of competence will provide evidence towards the following dimensions in the knowledge and skills framework: Core dimension 1: Communication: Level 2 a,c,d,e Core dimension 3: Health, Safety and Security: Level 3 a, b, c, e, f Core dimension 5: Quality: Level 2 a, b, e, f Carry out an initial assessment. You must be able to answer Yes to all the questions before considering yourself to be competent. If you are not competent, instigate learning and then repeat self-verification. Ask yourself the following questions. Have I undergone a programme of education to apply compression therapy? Have I applied compression bandages with the supervision of a competent nurse? Do I understand my accountability within the Code of Conduct (NMC 2004)? Do I understand the principles of infection, prevention & control including hand hygiene, correct us of personal protective equipment, Aseptic Technique and waste disposal including safe disposal of sharps as set ou in the IP&C Trust policy Can I describe the Trusts guidelines for the application of compression therapy? Can I describe the contra-indications/precautions for compression therapy? Can I describe which bandages are required to apply compression therapy? Which bandages are applied using a figure of eight, and which bandages are applied using a spiral technique? Can I explain to the patient why they are having compression therapy? Can I explain the causes of venous hypertension? Initial assessment date: Final assessmen t date: Do I understand the need to gain consent and maintain 15

16 privacy and dignity throughout the application of compression bandaging? Do I know: What Laplaces Law is? Why the ankle circumference should always be measured prior to application of compression bandages? When it is not appropriate to apply compression therapy? The difference between short stretch and long stretch bandages? How much overlap is required, and what is the significance of this? What is reduced compression and why might you use this? What to do if the ulcer has not improved/healed within 12 weeks? Why it is important to always apply padding prior to applying compression bandaging? Statement of Competence I certify that I am aware of my professional responsibility for continuing professional development and that I am accountable for my actions. With this in mind I make the following statement: I am competent to undertake without further training Signature: Date: I require further training before I can undertake in a competent manner Signature: Date: Keep this form in your personal portfolio or training record. Ensure your manager has seen the form when completed. Indicate how you plan to meet your learning needs: By when: 16

17 Yearly Statement of Competence I have re-assessed my competence against the statements overleaf and I certify that I am aware of my professional responsibility for continuing professional development and that I am accountable for my actions. With this in mind I make the following statement: I am competent to undertake. without further training Signature: Date: I have re-assessed my competence against the statements overleaf and I certify that I am aware of my professional responsibility for continuing professional development and that I am accountable for my actions. With this in mind I make the following statement: I am competent to undertake.. without further training Signature: Date: Adapted from Queens Medical Centre Nottingham competence statements 17

18 APPENDIX 5: Southern Health NHS Foundation Trust: Equality Impact Analysis Screening Tool Equality Impact Assessment (or Equality Analysis ) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups. It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. For guidance and support in completing this form please contact a member of the Equality and Diversity team. Name of policy: Policy Number: SH CP 108 Department: Tissue Viability Lead officer for assessment: Lisa Rice: Advanced Clinical Nurse Specialist- Tissue Viability Date Assessment Carried Out: December Identify the aims of the policy and how it is implemented. Key questions Briefly describe purpose of the policy including How the policy is delivered and by whom Intended outcomes Answers / Notes This leg ulcer policy along with the Prevention, Assessment and Management of Leg Ulceration Guidelines are intended to establish a standardised approach and framework for health care professionals undertaking care of patients with an active ulcer or at risk of ulceration. 2. Consideration of available data, research and information The policy establishes a standardised framework for healthcare professionals (HCP) undertaking care of a patient with leg ulceration, HCP s must attend specialist tissue viability education to be deemed competent in all aspects of leg ulcer management. Competency frameworks are detailed for all staff grades. TVN specialist support is available and referral guidelines detailed. Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings 18

19 Recent research findings (local and national) Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and voluntary/community organisations Analysis of records of enquiries about your service, or complaints or compliments about them Recommendations of external inspections or audit reports Key questions 2.1 What is the equalities profile of the team delivering the service/policy? Data, research and information that you can refer to The Equality and Diversity team will report on Workforce data on an annual basis. 2.2 What equalities training have staff received? All Trust staff have a requirement to undertake Equality and Diversity training as part of Organisational Induction (Respect and Values) and E-Assessment 2.3 What is the equalities profile of service users? The Trust Equality and Diversity team report on Trust patient equality data profiling on an annual basis 2.4 What other data do you have in terms of service users or staff? (e.g results of customer satisfaction surveys, consultation findings). Are there any gaps? Studies suggest that the majority of leg ulcers are associated with venous disease (estimates range from 40 to 80%), but other risk factors can include immobility, obesity, trauma, arterial disease, vasculitis, diabetes and neoplasia (Cornwall et al 1986; Moffatt et al. 2004; Simon et al. 2004). The management of leg ulcers places a significant economic burden on the NHS. Southern Health will use this Impact Analysis to identify key areas of inequality. It is known that some of the risk factors for leg ulcers, for example obesity, have a social gradient where the prevalence of obesity is higher in low socio-economic status women (Rennie &Jebb 2005). Furthermore, it is known that the risk of both venous insufficiency and peripheral arterial disease are positively associated with cigarette smoking (Gourgou et al. 2002; Willigendael et al. 2004). 2.5 What internal engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? Service users/carers/staff 2.6 What external engagement or consultation has been The Trust is preparing to implement the Equality Delivery System which will allow a robust examination of Trust performance on Equality, Diversity and Human Rights. This will be based on 4 key objectives that include: 1. Better health outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and included staff 4. Inclusive leadership 19

20 undertaken as part of this EIA and with whom? What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target. In the case of negative impact, please indicate any measures planned to mitigate against this. 20

21 Age Disability Gender Reassignment Marriage and Civil Partnership Pregnancy and Maternity Positive impact (including examples of what the policy/service has done to promote equality) The service will promote equality of opportunity for all age groups The location of services will take into account the needs of disabled people access and design. Risk assessments will comprise of privacy and dignity for the assessment process and reassessment of patients Negative Impact Venous leg ulcers affect around 1 in 500 people in the UK. Although this rate rises sharply with age with an estimated 1 in 50 people over the age of 80 developing venous leg ulcers. Increased risk of developing a venous leg ulcer due to immobility No negative impacts have been identified at this stage of screening No negative impacts have been identified at this stage of screening There may be an increased risk of venous leg ulcer in pregnancies Action Plan to address negative impact Actions to overcome problem/barrier Resources required Responsibility Target date Race Southern Health will respond positively to requests for interpreting and translation Assessment/Patient Education and Information: There may be a potential adverse impact if a patient s first language is not English. There is a higher prevalence rate of Sickle Cell Disorder in BME communities and leg ulcers are more common with people with sickle cell 21 Interpreters and Information leaflets can be translated into appropriate formats trough Access to Communication

22 anaemia (Cackovic et al 1998). s Religion or Belief Cultural beliefs will be acknowledged during the assessment process with particular regard to the removal of clothing for assessment purposes. South Asians are 6 times more likely to have Type 2 Diabetes and this may impact on the risk for the development of a diabetic foot ulcer (DFU). Cultural and religious beliefs should be taken into account when deciding on compression therapy as some forms of religious worships require individuals to be barefoot for prayer Sex No negative impacts have been identified at this stage of screening Sexual Orientation No negative impacts have been identified at this stage of screening 22