Questions from the guest lecture: Optimising wellbeing in people living with a wound
The following questions were submitted following an online guest lecture by Professor Christine Moffatt on optimising wellbeing in people living with a wound.
Wounds International would like to thank the expert group for their help in developing the recently published consensus document Optimising wellbeing in people living with a wound and for answering following selected questions that were posted during the online guest lecture:
- International consensus. Optimising wellbeing in people living with a wound. An expert working group review. London: Wounds International, 2012. Download from: www.woundsinternational.com.
This consensus document is available in English and will shortly also be available in French, German and Japanese.
Question: Which instruments exist to assess wellbeing in patients with a wound? How do clinicians access them? Joana Escorcio, Portugal
At present there are very few tools that focus on wellbeing as an outcome. The consensus document on wellbeing is a first step in trying to get consensus on the aspects of the lived experience that should be included in such an assessment. Many of the areas are covered in condition specific health-related quality of life tools and several reviews exist:
- Palfreyman S. Assessing the impact of venous ulceration on quality of life. Nurs Times 2008; 104(41): 34-37.
- Briggs M, Flemming K. Living with leg ulceration: a synthesis of qualitative research. J Adv Nurs 2007; 59(4): 319-28.
- González-Consuegra RV, Verdú J. Quality of life in people with venous leg ulcers: an integrative review. J Adv Nurs 2011; 67(5): 926-44.
- Hogg F, Peach G, Price P, et al. Measures of health-related quality of life in diabetes-related foot disease: a systematic review. Diabetologia 2012; 55(3): 552-65.
The consensus document indicates that, whilst these are helpful, they often do not capture the full essence of 'wellbeing' and clinicians may need to use a range of tools, just as they would to make a diagnosis of a physical condition.
Pages 8-10 of the document provide suggestions of informal ways of developing understanding of the issues in the clinical setting. Provided information is captured regularly, it should help clinicians to build a picture of the patient's sense of wellbeing and identify how clinical input can help to improve it.
Question: We would like to know what tools you consider valid in measuring the level of wellbeing in patients? Soledad Gallardo, Policlínica Miramar, Palma de Mallorca, Spain
Quality of life is regarded as a multidimensional construct that cannot be directly measured. In clinical practice, quality of life is evaluated by asking the patient or his relatives or caregivers about different areas of wellbeing. In research and in other evaluative conditions, simple questions are not sufficient to attain valid outcomes. Instead, methods have been developed through international research to assess different aspects of quality of life and wellbeing in a reliable way. It has been concluded from many studies that quality of life consists of physical, emotional and functional aspects, which can be evaluated by standardised questions. Accordingly, quality of life questionnaires normally consist of a series of single items, which are answered in standardised scales (mostly Likert scales). The answers are then transformed into numbers which can be analysed quantitatively. In most questionnaires, an overall value (sum or average score) is also calculated. These questionnaires measure either generic health-related quality of life or condition-specific quality of life. Taken together, validated instruments for the evaluation of quality of life are very helpful and reliable tools, which should also be used routinely in clinical practice. Typical validated questionnaires are the Cardiff Wound Impact Scale (CWIS) and the Freiburg Life Quality Assessment (FLQA-w), which can be used for patients with chronic wounds. These are both cited in the consensus document (see page 6).
Question: Is there a tool that I can use to measure the psychosocial effects of having a chronic wound for a study in my setting here in Nigeria? Oladele Helen, Nigeria
There are very few tools that are related to the specific psychological problems of having a wound (the closest are the condition specific quality of life tools). This is because psychological problems can arise from a wide range of health conditions but their expression can be very similar, eg depression has similar presenting symptoms regardless of the cause. Tools for the assessment of psychological problems are the domain of the psychologist and/or psychiatrist who will need to have taken additional training before they use them - and most of those will have been developed within the Western world. We suggest that you focus on the methods of assessment within the Wellbeing consensus document - which if you use them carefully, will allow you to develop a much deeper and consistent understanding of the experiences and concerns of your patients
Question: Most healthcare providers in Hong Kong only have a short period of time for consultation, diagnosis and treatment. How can they deal with the wellbeing of each patient in such a short time? Their concerns focus on the clinical outcome after medication, surgical operation or dressing treatments. Should this topic be raised by local health authorities? Please advise. William Wan, Hong Kong
The time invested in developing a therapeutic relationship between the patient and care provider does much to reduce the work burden. Maximising the wellbeing of those we are privileged to care for should be at the centre of all patient communication. Care interventions should be considerate of enhancing patient wellbeing, as well as patient rights and choice. The priority of the health care professional should be to foster empowerment in the patient and their participation in clinical care decisions when able. Wellbeing can best be advanced when we inform the patient of assessment outcomes and treatment options, and involve them in clinical decision making.
We suggest that a 'mind set' change is required generally by health care professionals and health care providers to focus not only on the physical elements of health (in this case clinical outcomes of wounds) but the individual's satisfaction with their life. How patients feel, and their ability to cope comes down to their unique experience. The wound may be infection free and slowly showing signs of healing (an example of common past focus of health care practitioners in wound management), but if the patient is isolated, lonely, and sad their perception of their life, ie their wellbeing, will be negatively influenced.
Question: It is interesting to see that within the eight principles on managing wellbeing, there is not an area that looks at the management of pain. Why is this? Julie Isitt, Christchurch New Zealand
Pain is seen as an ingredient that has influence across a range of the eight principles (see page 4 of the Wellbeing consensus document). Specifically, pain is considered in the principles: managing risk, movement, protection, the outside and the everyday.
In fit, removal, wear and management of dressing products, pain plays an important role, eg when designing patient-centred products which avoid the need for tough adhesives. Such products are designed to address the principles of movement, the everyday, the outside, and protection, and also deliver pain management. Pain therefore is not intentionally left out as a consideration. It is rather a consideration that has influence across a number of the principles.
Question: In my professional experience, people with chronic wounds suffer decreased wellbeing, in particular due to pain. Is pain the most important obstacle for this type of patient to overcome in order to achieve wellbeing? Emil Schmidt, Dunedin NZ
Pain is certainly a very important symptom that can have a profound effect on patients in terms of how they feel about themselves and their ability to 'carry on'. Many professionals believe that this is a really important place to start. There is very little research evidence to suggest whether or not this is the case, but certainly pain is often reported by patients as the most distressing part of having a wound so intuitively this makes sense. The only thing to be aware of is that once the pain is addressed, other symptoms will become the focus of attention so the path to wellbeing may well still need work as these other symptoms or issues may have been masked by the overwhelming nature of the pain experience.
Question: How do patients react to the need for continually monitoring their feelings and laying themselves open even further? António Gomes, Portugal
Patients should always be dealt with as individuals and for some sharing feelings is not what they wish or need to do. The process of monitoring should not be forced upon the individual: they should be able to contribute when they feel safe and ready to share their experiences. The health care professional should support the individual through the process at their own pace, and should seek further support from the multidisciplinary team if required.
The process of encouraging sharing of feelings may help to reveal issues for which the clinician needs to find proper solutions. Ideally, the therapeutic relationship should have an openness that does not close down and prevent issues of wellbeing being addressed.