In February 2011, a multidisciplinary group of clinicians and researchers met at the Wounds International conference in Cape Town, South Africa, ahead of a consensus meeting in Brussels in May 2011. The aim of the meeting was to explore patient wellbeing in relation to wound management. Several themes were discussed and are presented in this article. The key points raised will form the starting point of the consensus meeting which will aim to provide three key stake holders — clinicians, healthcare organisations and industry — with a framework to ensure that patient wellbeing is optimised when delivering effective wound management.

INTRODUCTION
A meeting was held at the Wounds International conference in Cape Town on 1 February 2011 with the goal of gathering information on how patient wellbeing could be optimised by clinicians, healthcare organisations and industry while providing wound management. The meeting was attended by healthcare professionals from the USA, Europe and Australia.

It was identified that patient wellbeing and the impact of a wound concerned far wider issues than just pain, the main focus of much of the literature on patient quality of life (QoL). Achieving optimal wellbeing in patients with wounds requires a coordinated approach with a significant responsibility resting with the clinician [Fig 1].
The resultant consensus document aims to provide guidance to clinicians, organisations and industry on how to provide wound care that optimises patient wellbeing.


What is patient wellbeing?
'Wellbeing is a dynamic state, in which the individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others, and contribute to their community[1].
In the meeting it was discussed that quality of life (QoL) was a component of wellbeing. The World Health Organization (WHO), as far back as 1948, identified that a patient who is technically 'cured' may not necessarily be well and went on to demonstrate three aspects of wellbeing:

• Physical wellbeing: the ability to function normally in activities such as bathing, dressing, eating and moving around
• Mental wellbeing: this implies that cognitive faculties are intact and that the patient is free from fear, anxiety, stress, depression or other negative emotions
• Social wellbeing: the ability to participate in and engage with family, society, friends and workers[2].

Thus, wellbeing goes further than measuring QoL and more incisive indicators are needed for its assessment.


Issues in wound care affecting QoL and wellbeing
Living with a wound can negatively impact upon a patient's quality of life (QoL)[3-13].
Pain has a significant impact on QoL, emotional state and a patient's sense of wellbeing [14-16]. A Cochrane review of patients with venous leg ulcers found that as many as 80% of patients reported acute or chronic wound pain, with half of them rating pain as moderate to the worst possible [17]. Patients with venous leg ulceration cite pain as being of overwhelming concern, [6, 18,19] and the physiological stress it causes can have an adverse effect on healing[20-24].
Hofman and Lindholm[25] investigated 140 patients at two centres (Oxford and Uppsala, Sweden) and found that 64% of patients with venous leg ulcers reported severe pain, and for 38% the pain was continuous. Living with pain on a day-to-day basis disrupts daily activities such as walking, standing, climbing stairs, etc - all of which may trigger pain, affecting personal, social and family life, as well as work [19, 26].

Immobility can lead to social isolation which can prompt depression. It has been seen that talking with other patients with wounds, for example at Leg Clubs, can help patients not to feel so alone with their condition[27].
McCaffery[28] states that pain is whatever the patient says it is and so management of pain not only requires pharmacological agents, but also listening to the patient and their experience. Stress and anxiety can also lower the pain threshold, leading to a vicious cycle of pain, anxiety and heightened awareness of pain. By removing or reducing stress or pain, quality of life can be improved which will have a positive influence on a patient's wellbeing.
It is crucial that healthcare professionals acknowledge that anxiety can occur both in anticipation of and at dressing-related procedures, and adopt strategies to help allay this stress[26] and develop a therapeutic relationship which can improve treatment outcomes and patient concordance[29].

In addition to pain, anxiety may be caused by delayed wound healing, fear of amputation, body disfigurement, odour, exudate leakage and social isolation.

Jones et al[30] studied the prevalence of anxiety and depression in 190 patients with chronic venous leg ulcers across nine trusts in the northwest of England using the Hospital Anxiety and Depression Scale[31]. Fifty-two patients (27%) scored above the cut-off for being categorised as depressed, and 50 patients (26%) scored above the anxiety cut-off.
Cole-King and Harding[32] also explored the link between chronic wound healing and anxiety and depression, using a 5-point Likert scale to rate wound healing and the HADS to measure anxiety and depression.  They found that delayed wound healing  was associated with a higher mean HADS score, thus demonstrating the association between depression and anxiety and chronic wound healing.

The two symptoms most associated with anxiety and depression were pain and odour. Phillips et al,[4] also found that patients who were psychologically distressed and suffering from depression, anxiety or social isolation may have difficulties in tolerating compression therapy. Thus, psychological factors should be considered when managing patients with wounds.

Franks et al[33] observed changes in 200 patients' perceived health in both an outpatient setting and in patients' homes.     

Phillips et al[4] assessed the financial, social and psychological implications of leg ulcers on 73 patients with chronic leg ulcers. Data were collected by personal interviews covering several domains that were selected to determine the impact of a leg ulcer on overall QoL.

A significant number of patients had moderate to severe symptoms, principally pain related to the leg ulcer. Eighty-one percent believed that their mobility was adversely affected by the ulcer; the dominant predictor of impaired mobility was swelling of the leg (p<0.001). For younger, working patients, leg ulceration was correlated with time lost from work (p< 0.001), job loss (p<0.01), and adverse effects on finances (p< 0.02). Fifty-eight percent of patients found caring for the ulcer burdensome. There was a strong correlation between time spent on ulcer care and feelings of anger and resentment. Sixty-eight percent of patients reported that the ulcer had a negative emotional impact on their lives, including feelings of fear, social isolation, anger, depression and negative self-image.
Odour can also force patients to stay at home for fear of embarassment[34,35], again perpetuating social isolation.
Different coping strategies of patients with chronic and/or complex wounds have also been looked at by Vermeiden et al[36] using the Utrecht Coping List (UCL). While the study was limited by the small sample size, they found that inadequate coping skills can increase stress which, in turn, affects the healing process and influences QoL[37].  
The findings in the literature are consistent that poor wound management and living with a wound impact on QoL and the patient's 'lived experience'[38,39].

The group agreed that the evidence now needs to be translated into practice, with baseline principles being established against which service provision can be benchmarked to ensure that all stakeholders - clinicians, organisations and industry - are striving to promote patient wellbeing.

It is also vital to recognise that a wound affects many aspects of a patient's life. Pain may well be a concern, but the greatest impact could be felt in their social wellbeing.  The group acknowledged that the current gateways to care are designed to meet the needs of the clinicians and the organisation, not the patient, and that the balance needs to be redressed to consider issues of importance to patient wellbeing.