VOL: 100, ISSUE: 32, PAGE NO: 58
Christine J. Moffatt, PhD, MA, RN, is professor of nursing, Thames Valley University, London; director, Centre for Research and Implementation of Clinical Practice, London; and nurse consultant, Leg Ulcer Service, St George’s Hospital, London
Practitioners often say that patients with leg ulcers are not concordant with therapy (Fig 1). Little research has been done to examine the credibility of such statements or to determine whether concordance is a major issue in leg ulcer management. It is possible that such negative attitudes reflect the complex interactions between practitioners and patients whose ulcers do not heal as expected.
Concordance has predominantly been studied from the patient’s perspective, with little attention given to the relationship between the patient and professional (Koltun and Stone, 1986). It is influenced by many factors that are often not directly associated with the patient’s condition. For example, a patient may have been told not to stand for long periods of time but her or his occupation may require exactly that.
Concordance is not a static event but can alter from hour to hour or on a daily basis according to life’s demands. Little acknowledgement has been given to the potential role of symptoms such as pain or sleeplessness on concordance (Franks and Moffatt, 1998).
Definitions of compliance and concordance
The traditional use of the term compliance in health care reflects the professional’s perspective of how a patient is expected to behave in relation to her or his illness and prescribed treatment.
A widely used definition of compliance is: ‘The extent to which a person’s behaviour (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health advice’ (Haynes, 1979).
Negative views towards patient compliance have been challenged by the growing emphasis on patient autonomy and the move from the authoritarian biomedical model to a biopsychosocial model of care. In recent years, the term compliance has been replaced with the notion of concordance.
Concordance is a new way to define the process of successful planning and delivery of health care based on partnership. It has three essential elements:
- Patient has knowledge to participate as a partner;
- Consultations involve patients as partners;
- Patients are supported during their treatment (adapted from Medicines Partnership - see the website www.medicines-partnership.org).
Despite these changes, some professionals continue to label patients who are non-concordant, and many of the techniques that are used to improve concordance fail to treat patients as responsible adults who are capable of making informed decisions.
Importance of assessment
Careful assessment remains the key priority in leg ulcer management (Moffatt and Harper, 1997). Without accurate knowledge of both the underlying aetiology and the wider factors affecting the patient, effective treatment cannot be provided and the factors that influence concordance cannot be adequately addressed.
The patient’s arterial status must be assessed before compression therapy can be applied safely. Assessment will identify patients with mild peripheral vascular disease (ankle brachial pressure index (ABPI): 0.8-0.9), who may find compression more painful than those with a normal pressure index measurement. A careful medical history will also identify conditions such as arthritis that may exacerbate pain.
It is acknowledged that patients with venous ulceration experience pain that is often inadequately assessed or treated (Gilmore and Hill, 1981). Charles reported that professionals are unwilling to listen to and accept patients’ accounts of their condition, and underplay the significance of pain and the ill-effects of treatments (Charles, 1995).
Leg ulcer management and concordance
Practitioners should be aware of how different aspects of leg ulcer treatment affect concordance. It is important to understand the patient’s attitude to care. At the start of treatment practitioners should consider how actively involved the patient wants to be. Previous bad experiences of treatment may influence their outlook on and belief in the effectiveness of treatment. It may be necessary to engage family or friends to help with practical problems such as immobility or isolation.
Skin-care regimens should always be included to reduce irritation associated with varicose eczema. Patients who scratch their legs frequently have problems with re-ulceration and may be blamed for the recurrence (Nelson and Farberow, 1980).
Exudate management and reduction of odour require appropriate selection and positioning of dressings.
Compression therapy, appropriately applied, reduces oedema and exudate levels. Yet inappropriate bandage selection and poor application are probably the most common clinical problems reported by patients.
A useful strategy is to slowly introduce compression over a number of weeks until the patient can tolerate high compression. It must be remembered that any level of compression is better than none (Cullum et al, 1999).
Little research has been done to evaluate factors that influence patients’ experience of compression. It is likely that psychological and social factors influence concordance, as well as the many other clinical conditions that these patients experience.
In the early weeks of treatment, pain may be problematic and the patient may require regular analgesia (Franks and Moffatt, 1998).
Psychosocial factors and concordance
Patients are influenced by many factors including lay beliefs and social group. In a longitudinal study of patients with chronic illness, Sherbourne et al (1992) found avoidant-coping strategies, poor physical health, and reduced role functioning were associated with reduced concordance. Aspects of the patient-professional relationship also affect concordance (Sherbourne et al, 1992).
Charles (1995) noted a number of psychological effects of ulceration including hopelessness, helplessness and lack of control. She also identified that nurses were often not interested in the patients’ condition and did not explain procedures to them. Patients stated that nurses lacked knowledge about the treatments and were resistant to their comments.
Edwards et al (2002) found that patients had poor knowledge about their condition, with little understanding of the underlying pathology of delaying healing.
Providing information to patients is complex and influenced by their coping strategies. Styles of coping such as monitoring - where patients closely monitor changes within themselves - and blunting - where patients ignore changes - have been linked to concordance and satisfaction with treatment (Steptoe and O’Sullivan, 1986). Patients who use monitoring strategies are constantly seeking information but may experience anxiety if they do not perceive they are making satisfactory progress. Patients who use blunting coping strategies are not as concerned about information and may seem less interested in their progress.
Effective coping requires the patient to appraise their situation and draw on resources to meet their needs (Lazarus, 1985). Patients who are socially isolated with no family or friends may be at risk of psychological problems such as depression or anxiety (Franks and Moffatt, 1998).
Use of denial as a major coping strategy may be particularly challenging. While denial is useful in acute situations, in long-term conditions such as leg ulceration it may lead to poor concordance and a refusal to actively engage in treatment.
Krasner (1988) noted the frustration patients felt with many aspects of their lives. Many patients have to make major life changes, such as retirement, because they realise that their lifestyle is preventing their ulcer from healing. Patients experienced considerable guilt when faced with a choice between following the practitioner’s advice and continuing with an activity they considered of greater importance.
Patients’ attitudes to treatment and healing
Little attempt has been made to examine the impact of patients’ attitudes and behaviour on healing and concordance. Salaman et al (1995) studied 45 hospital patients with venous ulcers, of whom 16 (36 per cent) were not considered to be making satisfactory progress.
Patients were questioned about their knowledge and attitude to their ulcer and its treatment. Only eight of those not making satisfactory progress (50 per cent) claimed to have received explanations about its cause and treatment. Three-quarters of these patients appeared to understand the importance of compression, although 62 per cent felt it was not effective. Only seven (44 per cent) believed their ulcer would ever heal.
This study raises issues about the impact of patient beliefs on healing, the effectiveness of patients’ coping strategies, and their ability to tolerate and follow treatments they do not believe will help them.
Professional reactions to non-concordance
The dilemmas of ‘non-healing’ have generally been studied from the patient’s perspective, with little attention paid to the impact on professionals. Over the past decade, improvements in assessment and treatment of leg ulcers have led to heightened expectations of healing as an outcome. Healing rates are considered the most important outcome of leg ulcer care but little is known about factors that influence ulcer healing or recurrence (Franks et al, 1995a; Franks et al, 1995b).
Professionals who are unable to heal a wound often feel impotent and may become anxious when faced with increasing pressure from the patient and family.
Professionals have great difficulty containing their anxiety when observing suffering and death (Menzies, 1959), maybe partly because professional practice often fails to adequately deal with patient suffering.
Perceived professional failure, such as failing to heal a leg ulcer, may lead to defensive behaviour. Menzies (1959) described how practitioners developed defensive routines such as task allocation and ritualistic practice to protect them from the anxiety generated from caring for the sick and dying. Such beliefs act as a defence against acknowledging the ‘failure’ of professional care.
Professionals often appear unaware or unwilling to acknowledge the expertise the patient has developed about their condition, and their need to exercise control over areas of their care they consider important.
English and Morse (1988) suggested that controlling behaviour among professionals is likely to increase passive and dependent behaviour in patients. They found that non-healing was largely blamed on non-concordance.
English and Morse discussed the ‘difficult’ patient and concluded that this type of behaviour often emanates from patients’ perceived unmet needs and bad communication. They postulated that improved communication gives patients a greater sense of control, and that withdrawal of information leads to increasingly ‘difficult’ behaviour.
Practitioners reported that patients used manipulative behaviour by favouring practitioners who were easier to influence and rejecting others. This often led to a lack of team cohesion.
While a robust research basis for improving concordance in leg ulceration is lacking, practitioners can still do a great deal to help patients come to terms with their condition and be concordant.
Leg ulcer assessment is often conducted using a medical model of care rather than embracing the issues raised in this article.
Health care practitioners must develop skills in reflective professional practice and consider how their attitudes and behaviour may contribute to poor concordance. Poor relationships and negative attitudes to patients affect the emotional health of both patients and professionals.
- The full version of this article was published in Journal of Wound Care. Moffatt, C.J. (2004) Perspectives on concordance in leg ulcer management Journal of Wound Care; 13: 6, 243-248.