Editorials Questions from the guest lecture: Optimising wellbeing in people living with a wound

Questions from the guest lecture: Optimising wellbeing in people living with a wound

Complex wounds, Wellbeing and concordance

Question: What is the impact on professional care of using patients' diaries? António Gomes, Portugal

There is very little evidence on the impact of diaries within wound healing. However, evidence from areas such as critical care has shown varied results and highlighted potential issues such as the effect wearing off over time and some patients writing what they think clinicians want to read. Even so, some research has shown that the act of capturing feelings, concerns and fears has helped patients to deal with the situation they find themselves in, and may lower anxiety and improve mood.

If there is agreement with the patient that the diary can be shared with health care professionals, the diary can be used as a trigger to discuss care pathways and help in the shared decision-making. For example, if the diary shows that odour is a problem for the patient (even when it is not obviously an issue for others around them), this may prompt discussion and development of strategies in which the fear of odour can be addressed. Diaries may be particularly useful for issues such as pain control.


Question: Is there a simple way of measuring wellbeing that is not time consuming? António Gomes, Portugal

The points outlined in the Wellbeing consensus document on pages 6-8 offer simple steps for the assessment of wellbeing. The five questions listed in Box 4 on page 8 are indeed simple and will provide great insight into the patient's wellbeing. They can be asked whilst the care provider plans or implements care.

As a starting point for change in practice, health care practitioners need to acknowledge that wellbeing is important for those living with wounds. Using the suggestions in the Wellbeing consensus document, health care practitioners can seek individual's views on wellbeing as a component of 'standard' practice for the duration of their care. Practitioners can then help to address specific issues related to living with a wound and work towards improving the physical, emotional, social and spiritual aspects of the patient's life.


Question: How can clinicians give the patients confidence, when the wound therapy or NPWT outcome falls below expectation? Stanley, Hong Kong

In general, patients want honesty. In this situation, hope may be related to indicating that there are other treatment options, but for some patients the reality may be that their wound is non-healing.  It is important that clinicians work closely with patients and be open and honest about expectations of treatment outcomes.


Question: What is blunting? Anon

There are many ways of defining coping styles and strategies. One coping strategy is referred to as blunting, which is related to denial. People who use blunting as a predominant coping measure tend to avoid thinking and appraising situations. Another coping style is monitoring. People who monitor tend to constantly evaluate their symptoms and can become preoccupied with them. This can cause anxiety over any small change, whereas people who blunt may ignore small but important symptoms. It is important to realise that coping fluctuates and there is no ideal way of coping.


Question: Do you think that specific care settings are already ideally organised to act on wellbeing information? Helen, UK

When the  concept of an individual's wellbeing is raised with hospice and palliative care teams, the recurring message from these groups is ' This is what we do, these issues are important to us, this is the way we approach the development of individualised management plans which focus on the person's perspective and issues of concern for them'. If we can do this and do it so well for this patient population, why not carry it over to those living with a wound, recognising it to be just as important to get these four aspects of health and life 'in balance' for all in our care.


Question: Regarding patients' right of refusal in cases where the clinician believes it is important for the patient to proceed, what advice do you recommend giving them in order to achieve the best outcome? Nigel Freeman, Sydney

It is important that the individual is given full access to all relevant information to ensure they make an informed decision regarding their right to refuse care. The clinician must try to present the benefits of a treatment programme and then must respect the right to refuse that treatment. As long as the decision is based on an informed position, that is perhaps the best that can be achieved.

Sometimes the position may be changed by trying to understand the patient's perspective and the blocks to accepting treatment. When treatment is refused, the decision should be revisited regularly to ensure any changes in circumstances/opinion are identified.

In the UK, there is a reference guide to consent for examination or treatment that provides a guide to the legal framework that all health care professionals need to take account of in obtaining valid consent for any examination, treatment or care that they propose to undertake: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_103643


Question: Patient focus is often rushed due to an increasing work load at the hospital. Can you recommend any studies in particular, that I can give to my hospital management, which show the positive influence patient and nurse interaction has on understanding wound healing? Joe Starling, New Jersey, USA

There are certainly a number of studies that show that negative interactions can be a real issue. A relevant review was completed by Michelle Briggs (Briggs M, Flemming K. Living with leg ulceration: a synthesis of qualitative research. J Adv Nurs. 2007; 59(4): 319- 28). The focus here is that if time is not spent on this important aspect of care then the patients will not progress in a timely fashion and will ultimately increase costs for the facility.

Another interesting paper on the topic is: Morgan PA, Moffat CJ. Non healing leg ulcers and the nurse-patient relationship. Part 1: the patient's perspective. Int Wound J 2008; 5(2): 340-48. This paper identified that from the participant's perspective, nurses often showed little understanding of the complex issues patients were dealing with when living with a nonhealing leg ulcer. Patients often concluded that leg ulceration was an insignificant problem and that nurses had little interest in. The authors concluded that there is an essential need to establish and maintain a trusting therapeutic relationship with patients if they are to feel they matter, that they are important as individuals and that their suffering can be eased by sensitive collaboration.

The journal Patient Education and Counseling provides a wide range of articles on this general topic (see: http://www.elsevier.com/wps/find/journaldescription.cws_home/505955/description).


Question: What can the nurse or clinician do to improve the wellbeing of the individual with a wound, in the community? Daisy Suero, USA

The Wellbeing consensus document on pages 6-8 describes how to assess wellbeing. The five questions listed in Box 4 on page 8 will provide great insight into a patient's wellbeing. They can be asked whilst the care provider plans or implements care, and the answers can then be used to implement change as far as possible within local resource constraints.


Question: Do you think that it would be good for industry to promote educating carers and the patients themselves? Pilar Mozota, España

Yes and this is a developing area as the whole of healthcare is moving towards managing patients with chronic disease. Many companies already contribute via patient carer sections on their websites and by the production of product information and patient/carer advice leaflets. Indirectly, industry help through their support of international initiatives, eg European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009 (available at www.epuap.org).  


Question: How can one best manage psychosocial problems, such as rejection, in a patient with chronic (non-healing) wounds? Oladele Helen, Nigeria

The question of management is really important - but the question of how to go about it, will often depend on the resources that are available. As health care professionals we need to know the range of our own competencies and when to refer onto a different professional group.

If obvious causes of rejection, such as smell, have been dealt with through improved wound care, but deeper issues of rejection occur, referral to a psychologist may be appropriate. However, very few centres have access to psychologists and a different approach may be required.

The first phase would be 'building a therapeutic relationship' (page 6 of the Wellbeing consensus document) to allow the patient to build a relationship of trust with their caregiver to try to work on an understanding that their whole experience is important (not just the management of their symptoms). Once this relationship is strong, it will be time to try to involve family members and informal caregivers in the additional needs of the patient so that issue of inclusion and their need to feel an important part of the family can be discussed. This type of informal support can be really invaluable and has been shown to have a really positive effect on outcomes.


Question: Why does self-esteem have a direct effect on wound healing? deiris2012

We are uncertain whether the impact of self-esteem on wound healing is direct or indirect, or both.  Self-esteem is very closely related to feelings of self-worth and self-efficacy, which impact on a person's ability and willingness to participate in self-care and adhere to treatment. All interventions that improve adherence to treatment and involvement in care can lead to better patient outcomes;  many of these intervention are successful as a result of empowering the patient to participate in their care (Price, 2011). In 2005, Horne et al suggested that  'Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments',  so we shouldn't underestimate the potential that improved self-esteem can have.  This area relates to the proposal by Price (2008) that instead of making 'the patient fit the treatment, maybe we should make the treatment fit the patient'.

Horne R, Weinman J, Barber N, et al. Concordance, adherence and compliance in medicine taking. In: Report for National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NSCCDO), London, 2005.

Price PE. Education, psychology and 'compliance'. (2008) Diabetes Metab Res Rev 208; 24(s1): S101-5

Price PE. Understanding the patient experience: does empowerment link to clinical practice. EWMA Journal 2011; 11(3): 16-18.

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