Leg ulceration can cause a range of problems. Community nurses need tools to assess patients’ subjective experiences so they can improve their quality of life
Edwin Tapiwa Chamanga, RGN, MSC skin integrity skills and treatments (student), is tissue viability nurse, City and Hackney PCT.
Chamanga ET (2010) How can community nurses improve quality of life for patients with leg ulcers? Nursing Times; 106: 10, early online publication.
Researchers have explored how leg ulceration affects patients’ quality of life but little has been written about the role of community nurses in the assessment and management of life qualityin these patients.This article describes how leg ulcers affect quality of life and the challenges nurses face in understanding patients’ subjective experience. Practical recommendations are made for improving this aspect of care.
Keywords Quality of life, Assessment, Leg ulceration
- This article has been double-blind peer reviewed
- Nurses need to take a proactive role in the assessment of quality of life (QoL) in patients with leg ulcers.
- Leg ulcer assessment documentation should include consideration of QoL.
- Pain should be assessed using validated pain assessment tools.
- Nurses need access to user friendly QoL assessment tools designed specifically for patients with leg ulceration (such as the Venous Leg Ulcer Quality of Life (VLU-QoL) questionnaire or the Sheffield Preference Based Venous Ulcer-5D (SPVU-5D).
- Community nurses should be aware of services that can support and improve QoL for patients with leg ulcers.
Research studies have shown that patients with leg ulcers have a poor quality of life (QoL) (Price and Harding, 1996). Patients can experience multiple problems including pain, discomfort, social isolation, malodour, altered body image, leakage, reduced mobility and the discomfort and inconvenience associated with wearing bulky bandages (Stevens, 2006; Ellis, 2004; Persoon et al, 2004). Box 1 outlines a case study illustrating the effect of leg ulceration on QoL.
Box 1. Case study
Mr Gregory* is an 87-year-old man who served as a soldier in the second world war. He was married for over 50 years but his wife died 10 years ago and he now lives alone.
Mr Gregory has a four year history of bilateral non-healing venous leg ulcers, which cause him pain. He says:
“The pain disturbs my sleep … at times I get worried about going to bed.”
As a result of pain from the leg ulcers, Mr Gregory’s mobility has been reduced and he now needs a walking stick to move around his house.
His reduced mobility has resulted in social isolation and loneliness:
“At times I feel the need forsomeone close I can talk to about simple things… I used to go out to functions, parties, countryside, football matches and shopping…”
*The patient’s name has been changed.
Extent of the problem
Leg ulcers are defined as any skin damage below the knee that takes more than 4-6 weeks to heal (Royal College of Nursing, 2006; Benbow, 2005). They may take several months to heal but some patients live with them for many years (Nemeth et al, 2007; Moffatt et al, 2006;Graham et al, 2003). Two-thirds of patients whose ulcers have healed will have at least one recurrence (Morris and Sander, 2007).
It is estimated that 1-2% of the general population in the US, Canada, UK, Europe and Australia will suffer with a leg ulcer at some point in their lives (Myles, 2007; Edwards et al, 2005a).
As older people are at increased risk of developing arterial and venous incompetence, which are underlying causes of leg ulceration, improved life expectancy means the number of people with ulcers is likely to rise (Franks and Moffatt, 2007). Even at their current incidence leg ulcers are a major economic burden; it is estimated that treating them costs between £400m and £600m of the UK health budget per year (Hopcroft and Forte, 2008; Myles, 2007).
There have been major advances in our knowledge about how to treat leg ulceration and the range of dressings available. Nursing care usually focuses on wound care and the application of compression bandaging (Persoon et al, 2004) and there is concern that nurses focus on the ulcer rather than the whole patient (Heinen, 2007; Persoon et al, 2004). There has also been considerable research into the negative effects of leg ulcers on patients’ QoL but there is a lack of practical guidance on how to address this problem.
Measuring quality of life
The World Health Organization (1998) defined QoL as “an individual’s perceptions of their position in life, in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns”.
Studies which focus on leg ulcers and QoL have used a range of different QoL assessment tools (Palfreyman, 2008; Franks et al, 2003; Smith et al, 2000). This makes it difficult to compare and generalise the results. These assessment tools measure the general health status of patients with leg ulcers, rather than the actual impact of living with these wounds.
Out of 16 reviewed research articles, four employed a QoL assessment tool: World Health Organization Quality of Life Assessment (WHOQOL-100) (Park et al, 2008); EUROQOL (ED-5D) (Mathias, 2000); and Health Related Quality of Life (HRQOL) (Hareendran et al, 2005; Franks and Moffatt, 2006). Five used SF-36 (Nemeth et al, 2007; Franks et al, 2003; Smith et al 2000; Walters, 1999; Garratt et al, 1993), which is a measure of general status. Five used the Nottingham Health Profile (Franks and Moffatt, 2001; Franks et al, 1999a; Franks et al, 1999b; Harmer et al, 1994; Lindholm et al, 1993). The other research studies did not use an established assessment tool to assess quality of life. Jones et al (2008) used the Hospital Anxiety and Depression Scale.
The study on the impact of QoL by Palfreyman et al (2007) was aimed at developing an effective QoL assessment tool for patients with leg ulcers. Using a QoL assessment tool designed specifically for this patient group addresses all the factors related to these wounds. Examples include the Venous Leg Ulcer Quality of Life (VLU-QoL) questionnaire (Hareendran et al, 2007) or the Sheffield Preference Based Venous Ulcer-5D (SPVU-5D) (Palfreyman, 2008).
National guidelines and quality of life
Clinical Resources Efficiency Support Team (1998), Scottish Intercollegiate Guideline Network (1998) and Royal College of Nursing (2006) have published guidelines on assessment and management of leg ulcers. While these emphasise the need for competent practitioners who assess the physical effects of leg ulcers, they do not address the importance of assessing patients’ QoL in detail. The overall recommendation of these guidelines will ultimately help to improve quality of life and the assessment of QoL, but how it is affected by leg ulceration is not specifically addressed.
Effect on daily living
Patients’ experiences of living with leg ulcers have been explored in detail (Persoon et al, 2004; Krasner, 1998; Walshe, 1995) and researchers have also looked at single issues affecting QoL, for example, the impact of exudate and odour from chronic venous leg ulceration (Jones et al, 2008). However, research evidence suggests that chronic leg ulcers have physical, psychological and social costs for patients and thus have a negative impact on their QoL (Franks and Moffatt, 2006; Walshe, 1995). These are summarised in Box 2.
Box 2. Effects of leg ulceration on quality of life
- Physical – pain, sleep disturbance, poor mobility
- Psychological - altered self image, ulcer preoccupation, depression, feelings of fear, anger and frustration, loss of control
- Social - isolation as a result of pain and reduced mobility, which has an impact on employment and financial status
Sources: Briggs and Flemming (2007); Franks and Moffatt (2006); Persoon et al (2004); Walshe (1995)
The research studies reviewed for this article did not consider how leg ulceration affects patients’ QoL or community nurses’ duties and responsibility in managing this aspect of care. In addition there is little guidance on how nurses could use QoL assessment tools in their clinical practice.
It is important to question whether nurses should use objective patient QoL assessments specifically designed for those with leg ulceration, such as the VLU-QoL (Hareendran et al, 2007) and the SPVU-5D (Palfreyman, 2008) as part of their everyday patient assessment.
A longitudinal study (Nemeth et al, 2007) and a case report (Lay-Flurrie, 2001) both identified that patients’ assessment and documentation is being compromised by lengthy assessment tools which community nurses find difficult to use and time consuming to complete. There are a number of possible reasons that nurses experience these problems, including lack of training on how to use the tools and the use of standard clinical assessment forms rather than disease specific forms.
QoL is subjective and depends on a number of social factors which give it a personal meaning for the patient (WHO, 1998). This can be difficult to capture on standardised forms. While researchers have explored factors which can alter QoL, community nurses need practical tools to help them to consider how these factors affect patients’ activities of daily living (Barret and Teare, 2000). Standard nursing leg ulcer assessment forms do not always allow for a comprehensive social and psychological assessment, making it difficult to evaluate patients’ QoL (Lay-Flurrie, 2001).
While many patients with leg ulcers experience pain, and this can have a marked effect on QoL, Stevens (2006) and Persoon et al (2004) pointed out that pain assessment tools are rarely used for patients with leg ulcers compared with those who are terminally ill. Stevens (2006) suggested that practitioners could design a specific pain assessment tool for patients with leg ulcers; on the other hand, they can effectively employ existing pain assessment tools to improve patients’ QoL.
Recommendations for community practitioners
Community nurses need to take a proactive role in assessing the QoL of patients with leg ulcers. In order to do this they need user friendly nursing QoL assessment tools designed specifically for this patient group. Further research is also required to explore community practitioners’ role in promoting QoL for patients with leg ulcers.
Community nurses spend approximately 50% of their time treating patients with leg ulcers (Morris and Sander, 2007) and witness the impact of these chronic wounds on patients’ everyday lives. They need to use this experience to influence local leg ulcer assessment guidelines and nursing assessment documentation to ensure that they incorporate QoL. Tissue viability specialist nurses should be asked to work with community teams to set up ongoing quality improvement measures and clinical audits aimed at improving patients’ QoL.
Thorough and regular pain assessment and the use of pain assessment tools could help to improve pain management and also have a positive impact on patients’ QoL (Benbow, 2008; Stevens, 2006).
Lorimer (2004) and Lorimer et al (2003) suggested that standardised assessments and regular scheduled patient reassessments are important in managing QoL in patients with leg ulcers. These can be incorporated into local guidelines and patients’ care plan.
Research studies and reports have shown that leg clubs have been successful in promoting health by improving socialisation and reducing isolation in patients with leg ulcers (Gordon et al, 2006; Edwards et al, 2005a; 2005b). Community nurses need to be aware of such services in their areas that can support and improve their patients’ QoL.
Community nurses have an important role in assessing and improving patients’ quality of life. However, this is not a responsibility they can take on alone, they need to collaborate with other members of the multidisciplinary team and develop appropriate assessment tools designed for use in clinical practice with patients who have leg ulcers in order to promote their QoL.
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