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Non-healing leg ulceration

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VOL: 97, ISSUE: 35, PAGE NO: 49

CHRISTINE MOFFAT, MA, RN, is director, Centre for Research and Implementation of Clinical Practice and professor of nursing, Thames Valley University, London

The past 10 years have seen many advances in the treatment of patients with wounds such as leg ulcers (Moffatt et al, 1992). Reports in the literature before the 1990s found little reference to healing, with many patients having unhealed ulceration for years, if not decades (Callam et al, 1985; Cornwall et al, 1986). Such care was described as maintenance therapy given within Cinderella services (Bosanquet et al, 1993). Practice was ad hoc, using a wide range of wound care products with little evidence of effectiveness (Moffatt and Harper, 1997). Many patients were inadequately assessed and referral for specialist advice was uncommon despite the lack of healing (Cornwall et al, 1986).

The past 10 years have seen many advances in the treatment of patients with wounds such as leg ulcers (Moffatt et al, 1992). Reports in the literature before the 1990s found little reference to healing, with many patients having unhealed ulceration for years, if not decades (Callam et al, 1985; Cornwall et al, 1986). Such care was described as maintenance therapy given within Cinderella services (Bosanquet et al, 1993). Practice was ad hoc, using a wide range of wound care products with little evidence of effectiveness (Moffatt and Harper, 1997). Many patients were inadequately assessed and referral for specialist advice was uncommon despite the lack of healing (Cornwall et al, 1986).

Individual professional expectations of being able to heal patients with leg ulceration have undergone a major shift in the past decade, following developments in treatments and new ways of delivering services. Studies in the early nineties demonstrated that healing was possible and that nurses could play a prominent role in treating these patients (Moffatt et al, 1992).

However, the reality remains that some patients do not heal despite the very best professional intervention.

Evidence-based care
There has never been a time in the history of the health service where there has been a greater emphasis on the delivery of evidence-based care. Wound care is an area of nursing that has received particular attention, with the production of national guidelines supporting practice (RCN, 1998). There can be few nurses involved in wound care who would dispute these efforts or the continuing need to provide evidence on the effectiveness of treatments used in wound care.

The emphasis on healing
The view that healing the wound is the only acceptable outcome of treatment is very pervasive. There are a number of reasons why this is so. Researchers in this field have contributed to this emphasis by insisting that complete wound closure is the only desirable outcome (Morrell et al, 1998; Salaman and Harding, 1995). Previously, studies included reduction in area of wound as an outcome, but it was often difficult when reading these results to determine how significant the effect of the treatment was (Cullum, 1994). The implications of achieving complete wound closure are important for health care organisations. While reduction in the wound size often leads to reduced nursing visits, professional intervention will nevertheless be required while the wound is present, representing a cost to the health service (Bosanquet et al, 1993).

Interpreting outcomes of care
Given this emphasis on healing, how do organisations interpret the varying outcomes of wound care in their practice settings and seek to understand the reasons for the differences that may occur? If we use leg ulceration as an example, the literature would suggest that healing rates at 12 weeks vary from 20-80% with appropriate therapy (Cullum, 1994; Moffatt et al, 1992; Moffatt et al, 1999). Given the range of results, it is not surprising that organisations often expect unrealistic outcomes from treatment, failing to understand the factors that influence these findings (Franks et al, 1995a; 1995b; Margolis et al, 1999).

Frequently the results published in the leg ulcer literature are from randomised controlled trials which use a highly selected patient group, often with newer ulcers (Moffatt et al, 1999). In these patient groups it is often found that healing rates of around 70% are achievable. However, one of the major criticisms of the evidence-based care debate has been the applicability of trial results to wider patient populations that may be very different. The reality in clinical practice is that over 50% of leg ulcer patients would be unsuitable to enter such studies.

Randomised trials, by their very design, attempt to control for extraneous effects, and therefore people with complex medical problems or other aetiological factors will not be included. However, these patients remain the core of those seen in practice. Limited evidence suggests that the proportion of these individuals may be increasing within established services, given the demographic changes occurring in the population, and the healing of patients with simple ulceration (Stevens et al, 1997). The remaining patients present a new challenge to professionals who are now faced with patients for whom evidence-based practice has a limited or reduced effect.

Organisational performance
Comparison of organisational performance is a central feature of many of the government reforms with the introduction of bodies such as the National Institute for Clinical Excellence and the Commission for Health Improvement. The benchmarking initiatives (Department of Health, 2001) also encourage comparisons between practice settings. Will healing rates in patients with leg ulceration become a quality indicator of effective care in the way that development of pressure ulceration has become?

There are grave dangers in such a simplistic approach. Many of the differences in healing rates can be attributed to the patient population being studied rather than the care provided. (Moffatt and Franks, 1999). Factors such as the mobility of the patient and the size and duration of the ulcer may have an important impact on the healing rate (Franks et al, 1995b; Helliwell and Cheesbrough, 1994). More comprehensive and sensitive research will be required to tease out these issues and to begin to separate factors that relate to poor practice and those that relate to our limited understanding of what influences healing.

The impact of the biomedical model
The evidence-based care agenda supporting wound care is heavily entrenched in a biomedical model. The search for factors influencing healing continues to be dominated by attempts to alter factors within the wound. Despite the nature of nursing, and the prominent role that nurses play in treating patients with wounds, we seem to be having little influence over this agenda, or looking more holistically at factors that may be affecting outcome (RCN, 1998).

Many other areas of research, including cardiovascular research, highlight the importance of factors such as social class, employment status and social support in the development and outcome of a range of diseases (Krause, 1987; Marmot et al, 1984; Sherbourne and Hays, 1990). Yet few attempts in wound care research have widened the perspective to include factors in the patient's psychological and social environment that may influence healing (Franks and Moffatt, 1998). This is surprising, given the findings from the quality-of-life research in this field which demonstrate the high levels of social isolation, depression, anxiety and pain experienced by these patients (Franks et al, 1994; Keeling et al, 1996). These factors may be important predictors of healing as well as measures of the impact of the condition on patients and their family.

A knowledge of these issues is important at an individual patient level as well as at an organisational level. They challenge us to consider the role of nursing in this field, which is wider and richer than merely the use of technological procedures and use of appropriate wound care products, important as they may be.

Coping with a non-healing wound
Many of the issues concerning wound care that affect organisations also have a direct impact on individual practitioners caring for these patients. The positive culture of healing related to evidence-based care in this field leaves little room for discussion concerning these issues.

Yet how do professionals cope with the reality that, despite their best efforts, the patient's wound is not healing? The dilemmas and anxieties faced by professionals in these circumstances are not new.

Menzies (1959) described the development of social defences in response to such circumstances and highlighted how many nursing routines sought to distance nurses from situations they felt little control over and which caused them emotional trauma. Wound care is an excellent example of the development of these routines. In the literature patients with distressing wounds are presented not as a whole person, but as a graphic close-up picture of a wound (Moffatt and Harper, 1997). Even the ritualistic procedures concerning dressing techniques serve to isolate the wound from the patient, with elaborate procedures involving drapes and forceps, none of which have sound physiological or microbiological basis.

These procedures are now being challenged. However, it remains to be seen whether this will trigger professionals thinking concerning the reintegration of the wound as part of the patient, rather than a separate untouchable entity. Lack of wound measurement can also be seen as a defensive routine to protect the professional against the reality that treatment is failing.

While few would question the importance of the role of specialist nurses in wound care, they frequently fulfil a more complex role than is apparent, including allaying anxiety in other professionals when treatment is failing and providing reassurance that all options for individual patients have been considered.

Recent qualitative research with community nursing teams treating patients with non-healing ulceration highlighted the emotional distress felt by practitioners when 'correct' treatment failed to contain the situation(Moffatt et al, 2001). The nurses frequently sought to find reasons for these issues, often resorting to blaming and labelling the patient for the lack of progress. Professionals frequently rationalised that patients' adherence to treatment was linked to healing, even in the presence of overwhelming clinical reasons why the wound would not heal. Professionals often felt ill equipped to face the emotional and psychosocial issues raised by these patients.

The way forward
We must face the fact that healing is not always an achievable goal. As we learn to accept this reality we must look for changes in the way in which we care for patients who are effectively living with a chronic illness. The priorities for patients may change; control of symptoms such as pain, exudate and odour may become the dominant factors in helping them achieve optimum quality of life. Such situations may require that professionals relinquish control over choice of dressing regimes and the recognition that patients are now the experts in their own care.

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