NOT FOR REPRODUCTION. Feelings of powerlessness in patients with venous leg ulcers. research

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1 Feelings of powerlessness in patients with venous leg ulcers G.M. Salomé, 1 RN, PhD; D.G. Openheimer, 1 Masters student; S.A. de Almeida, 1 RN M.L.G.B. Bueno, 1 Masters student; R.A.A. Dutra, 1 Masters student; L.M. Ferreira, 2 MD, PhD, Professor; 1 Professional Masters Degree Program in Sciences Applied to Health, University of Vale of Sapucaí-UNIVÁS, Pouso Alegre/MG, Brazil; 2 Division of Plastic Surgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil. salomereiki@ yahoo.com.br l Objective: To assess feelings of powerlessness in patients with venous leg ulcers. l Method: An exploratory, descriptive, analytic, cross-sectional study was conducted at the Plastic Surgery Outpatient Clinic of the São Paulo Hospital (HSP) and at the Outpatient Wound-Care Clinic of the Sorocaba Hospital Complex (CHS), Brazil, from May 2010 to April Sixty patients with venous leg ulcers (VLUs), of both sexes, aged 18 years, from the two outpatient wound-care clinics were selected to participate in the study. All participants responded to the Powerlessness Assessment Tool (PAT) for adult patients. Statistical analysis was performed using the, Mann-Whitney U test and Kruskal-Wallis test at a significance level of 5% (p<0.05). l Results: Forty-four (73%) patients were women and 38 (63%) were aged years. Eight (13%) patients were alcoholics and 46 (77%) were smokers. Thirty-two (53%) patients had a VLU for more than 10 years; the ulcer area ranged from cm 2 in 19 (32%) patients and was >30 cm 2 in 18 (30%) patients. Mean total PAT score was ± 7.99 and ranged from for 31 (52%) patients and from for 19 (32%) patients. l Conclusion: Most patients with venous leg ulcers reported high PAT scores, revealing the presence of strong feelings of powerlessness. l Declaration of interest: The authors have no conflicts of interest to declare. emotions; quality of life; leg ulcer; varicose ulcer A venous ulcer is a cutaneous lesion that affects the distal third of the leg, representing 70 90% of cases of leg ulcers. 1,2 Chronic venous insufficiency is the main cause of leg ulcers. Studies have reported prevalences of venous leg ulcers (VLUs) ranging from 1% 3% in the adult population. 1,2 Prevalence rates increase with age rising to over 4% in patients aged 65 years and represent a serious public health problem. 1-3 VLUs have a negative impact on the emotional state of patients, can affect individuals in their productive stage of life, may lead to pain, loss of mobility, and early retirement, and poses limitations on physical and social activities. They also interfere with daily living and leisure activities, which may impact quality of life. The patient may experience negative emotions, including feelings of loss, powerlessness, low self-esteem, anxiety, and depression. This condition necessitates a holistic and multidisciplinary approach to the management of affected individuals. 4-8 Although patients with ulcers have common characteristics, every individual has particular and specific needs and react subjectively to the illness. Therefore, an individual s response to the advent of a VLU is related to the level of emotional, social and financial support received by the patient at all stages of the treatment. Common problems experienced by patients with VLUs include pain, presence of wound odour and exudate, and prejudice and isolation from family members and friends. 9,10 The presence of a VLU affects the biological, psychological, social, and spiritual well-being of the individual, leading to changes in body image and self-esteem, and causing anxiety, depression, and feelings of powerlessness. Thus, assuming that the process of becoming ill may lead to the loss of control over a current situation, feelings of powerlessness can be seen as a loss. If the loss of control is the focus of unsuccessful attempts to change the patient s self-concept, the diagnosis of anticipatory grief or dysfunctional grief may be more appropriate. On the other hand, if the patient feels that nothing will change the course of events no matter what is done, then the diagnosis of powerlessness is more appropriate. 11,12 The aim of this study was to assess feelings of powerlessness in patients with VLUs. Method This was an exploratory, descriptive, analytic, cross-sectional study. The study was approved by the Research Ethics Committee of the Federal University of São Paulo (UNIFESP), Brazil (approval number CEP0383/10) and conducted in accordance with the ethical standards of the 1964 Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all patients prior to their inclusion in the study and anonymity was assured. Data were collected between May 2010 and April

2 Table 1. Demographic characteristics of patients with venous leg ulcers Characteristics N % Valid % Cumulative % p-value Sex Women Men * Age group (years) * Alcoholic No Yes * Smoker No Yes * Sixty patients of both sexes, aged 18 years, with VLUs participated in the study. All patients were attending either the Wound Unit in the Plastic Surgery Outpatient Clinic of the São Paulo Hospital (HSP) or the Outpatient Wound-Care Clinic of the Sorocaba Hospital Complex (CHS), Brazil. Patients with skin lesions other than VLUs and those who were unable to respond to a questionnaire due to physical or cognitive deficit were excluded from the study. Physical examination was performed on each patient upon inclusion by the same researcher, during which the ulcers were measured and assessed for the presence of wound odour and exudate. Two instruments were used for data collection: a questionnaire assessing sociodemographic and clinical characteristics of the patients and the Powerlessness Assessment Tool (PAT) for adult patients. The questionnaires were administered by interview and conducted by the same researcher. Smokers were defined as those who answered yes to the question Do you smoke? Alcoholics were defined as those who answered yes to the first two following questions and no to the third question: 1) Do you have a drink containing alcohol every day? ; 2) Do you have more than one drink containing alcohol per day? ; and 3) Are you able to control the number of drinks you have while you are drinking?. These questions were part of the demographic questionnaire. The PAT has been developed in Brazil and tested in a population sample of 210 adult patients from medical-surgical wards for item selection, reliability and validity; it shows good internal consistency (Cronbach s alpha coefficient of 0.80) and test-retest reliability (p>0.05). 11,13 The instrument consists of a 12-item measure of powerlessness rated on a 5-point Likert-type scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always). PAT scores range from 12 60, with higher scores corresponding to stronger feelings of powerlessness. Based on PAT scores, feelings of powerlessness can be rated as absent (score = 12), mild (scores 13 24), moderate (scores 25 36), strong (scores 37 48), and very strong (scores 49 60). The 12 items are grouped into three domains: 1) capacity to perform behavior or perceived behavioral control, which assesses the patients feelings regarding the degree of control they have over their own behavior; 2) self-perception of decision making capacity, which measures the patients perception of their ability to make their own decisions; and 3) emotional responses to perceived control, which assesses the patients feelings regarding their perceived loss of control over aspects of their life. 11,13 The chi-square test was used to compare the frequency distribution of categorical variables (sociodemographic and clinical variables). The Mann- Whitney U test was performed to compare PAT scores between two sociodemographic or clinical variables (e.g. PAT scores between men and women; according to the presence or absence of odour). The Kruskal-Wallis test was carried out to compare PAT scores among three or more sociodemographic or clinical variables [e.g. PAT scores among age groups (3 groups) or according to the time of lesion. All statistical tests were performed at a significance level of 5% (p<0.05). Results Of the participants, 44(73%) were women, 38(63%) were aged years; 39(65%) were smokers, and 8(13%) patients were alcoholics (Table 1). It was also found that 32(53%) patients have had VLUs for more than 10 years. Overall, the ulcer area 6 3 0

3 Table 2. Characteristics of the venous leg ulcers. Characteristics N % Valid % Cumulative % p-value Time of lesion (years) 2 to to > Presence of exudate No Yes * Ulcer area (cm 2 ) 5 to to to * > Table 3. Total Powerlessness Assessment Tool (PAT) scores for patients with venous leg ulcers Total PAT scores N % Valid % Cumulative % p-value 31 to to to * ranged from 5cm 2 to more than 30cm 2, with a mean size of 18cm 2. Nineteen (32%) patients had ulcers with areas ranging from cm 2 and in 18(30%) patients the ulcer area was >30 cm 2, with no significant difference in ulcer area distribution among patients (p=0.621). The presence of wound odour and exudate was observed in a significant majority (n=52; 87%) of patients (p<0.001), as shown in Table 2. Mean total PAT score was 47.83±7.99 and ranged from for 31(52%) patients and from for 19(32%) patients, as seen in Table 3. Most patients had emotional responses (feelings of powerlessness) to perceived control (n=48; 80%; p<0.001), reported capacity to perform behavior (n = 34; 56.7%), and had feelings of powerlessness in decision making capacity (n=33; 55%), as shown in Table 4. No significant differences in mean PAT scores (or feelings of powerlessness) were found between sexes, alcoholics and non-alcoholics, smokers and nonsmokers, and among different age groups (p>0.05), as seen in Table 5. There were also no significant differences in feelings of powerlessness (p>0.05) regarding the variables time of lesion and lesion size (Table 6). However, the presence of wound exudate and odour had a significant impact on the feelings of powerlessness (p=0.004) in the study population (Table 6). Discussion In many cases, VLUs are associated with pain, wound odour, exudate, edema, and impaired mobility. 2,3,9 Patients with VLUs experience a variety of feelings, such as fear, feelings of loss, grief, and powerlessness, which need to be regularly assessed. These feelings may be exacerbated due to the appearance of their lesion, daily dressing changes, and wound debridement. 6,12 Over the 2 year duration of the study, we assessed the feelings of powerlessness in 60 patients with VLUs. Most patients were women (73%) and aged 61 years (70%). This is in agreement with Brazilian and international studies that have reported that VLUs are more common in the age group years, with a higher incidence in women (range, 62-71%) than in men. 3,5,14-16 Leg ulceration, especially in the elderly, results in poor mobility, decreased functional capacity and pain, and may lead to reduced quality of life, low self-esteem, anxiety, and depression. 13,17,18 In the present study, the majority of patients were smokers (77%) and non-alcoholics (87%). Any type of addiction is a concern and may affect quality of life. Nicotine causes vasoconstriction, which increases the risk of ischemia and development of ulcers Smoking also causes oxidative damage to tissues, inhibits collagen synthesis, reduces immune responses, increases susceptibility to infection, and impairs the healing process, which may contribute to wound odour, exudate, and pain in individuals 6 3 2

4 with VLUs. 18,19 The majority of the participants in this study have had VLUs for more than 10 years. The ulcer area ranged from 11 20cm 2 in 32% of patients and was >30 cm 2 in 30% of them. The presence of wound odour and exudate was observed in 87% of patients. VLUs causes several changes to the patient s life. Large ulcers are usually painful, shows presence of exudate, emits foul odour, impairs mobility, and increases the patient s dependence on others. These factors may cause negative mood changes and adversely affect family relationships and the patient s social functioning These factors may also lead to unemployment or retirement, which may further result in low self-esteem, distortions in self-image, changes in sleeping patterns, depression, feelings of powerlessness, and overall reduced quality of life. 5,6,11,17,24 Factors related to quality of life that should be assessed in patients with VLUs include pain, mobility impairment, feelings of powerlessness, physical, psychological and social wellbeing, level of optimism, and beliefs about the future (expectations). 21,25 According to Braga and Cruz, 11 feelings of powerlessness, as a psychosocial response, are subjective and found across all cultures. They may be triggered by health problems or life events. Because feelings of powerlessness are subjective perceptions, psychometric instruments are required for their proper evaluation. 11 We observed that 52% of patients reported total PAT scores ranging from and that 32% of them reported total PAT scores from 41 50, indicating that these patients with VLUs had strong to very strong feelings of powerlessness and lack of control when facing difficulties of daily life and those related to their treatment. In a study on feelings of powerlessness and hope for cure in patients with lower-limb ulcers, the mean PAT score and Herth Hope Index were 53.3 and 16.5, respectively, for patients with diabetic foot ulcers and 34.3 and 27.5 for patients with VLUs (p=0.001). 26 These findings suggest that patients with diabetic foot ulcers have stronger feelings of powerlessness regarding their condition and less hope of recovery compared with patients with VLUs. 26 Our results revealed that the presence of wound odour and exudate was significantly associated with strong feelings of powerlessness (p=0.004). It has been shown that when VLUs show presence of exudate and odour, cause pain and impaired mobility, and require frequent dressing changes, patients feel discouraged and show frustration, depression, anxiety, and changes in self-image and sleep patterns. 5,11,17 A venous ulcer that is difficult to heal may lead to the patient s loss of independence, lack of energy, mood changes, social isolation, and loss Table 4. Powerlessness Assessment Tool (PAT) domains PAT Domains N % Cumulative % p-value Capacity to No perform behaviour Yes Emotional responses No to perceived Yes <0.001* control Capacity to No perform behaviour Yes Asterisks (*) indicate statistical significance (p< 0.05). of self-esteem. 6,7 When frustration and sense of failure (feeling of powerlessness) persist in the individual with VLUs, feelings of despair may arise, leading to decreased quality of life. Patients with a chronic ulcer are at risk of developing emotional problems, which may affect their physical and mental health. 15,25 Patients with positive feelings cope better with their situation and live life more fully, even when faced with adversities caused by the lesion and its treatment. 25 Table 5. Comparison of PAT scores between sociodemographic variables Variables n Mean SD Median p-value Sex Men Women Age (years) b to > Alcoholic a No Yes Smoker No Yes SD = standard deviation. a Mann-Whitney U test; b Kruskal-Wallis test s 633

5 Table 6. Comparison of PAT scores among clinical variables. Variables n Mean SD Median p-value Time of 2 to lesion a (years) 6 to Lesion size a 5 to (cm 2 ) 11 to to > Presence no of exudate b Yes * Presence no of odor b Yes * a Kruskal-Wallis test; b Mann-Whitney U test References 1 Carmo, S.S., Castro, C.D., Rios, V.S., Sarquis, M.G.A. Nursing care to the venous ulcer carrier news. Rev Eletr Enf. 2007; 9: Reichenberg, J., Davis, M. Venous Ulcers. Semin Cutan Med Surg. 2005; 24, Frade, M.A.C., Cursi, I.B., Andrade, F.F. et al. Leg ulcer: an observational study in Juiz de Fora, MG (Brazil) and region. An Bras Derm. 2005; 80, Tang, J.C., Vivas, A., Rey, A. et al. Atypical ulcers: wound biopsy results from a university wound pathology service. Ostomy Wound Manage. 2012; 58, Malaquias, S.G., Bachion, M.M., Sant ana, S.M. et al. People with vascular ulcers in outpatient nursing care: a study of sociodemographic and clinical variables. Rev Esc Enferm USP. 2012; 46, Salomé, G.M., Pellegrino, D.M.S., Vieira, T.F. et al. Sleep quality among patients with venous ulcers: a cross-sectional study in a health care setting in São Paulo, Brazil. Wounds. 2012; 24, Salomé, GM., Pellegrino, D.M.S., Blanes, L., Ferreira, L.M. Self-esteem in patients with diabetes mellitus and foot ulcers. J Tissue Viability. 2011; 20, Salomé, G.M., Blanes, L., Ferreira, L.M. Functional capability of patients with diabetes with foot ulceration. Acta Paul Enferm. 2009; 22, Bongiovanni, C.M., Hughes, M.D., Bomengen, R.W. Accelerated wound healing: multidisciplinary advances in the care of venous leg ulcers. Angiology. 2006; 57, Salomé, G.M., Espósito, V.H. Nursing students experiences while caring people with wounds. Rev Bras Enferm. 2008; 61, Braga, C.G., da Cruz, D.A. Powerlessness: differentiation from other diagnoses and concepts. Rev Esc Enferm USP. 2005; 39, Salomé, G.M., Blanes, L., Ferreira, L.M. Evaluation of depressive symptoms in patients with venous ulcers. Rev Bras Cir Plast. 2012; 27, Braga, C.G., da Cruz, D.A. Powerlessness assessment tool for adult patients. Rev Esc Enferm USP. 2009; 43, Palfreyman, S. Assessing the impact of venous ulceration on quality of life. Nurs Times. 2008; 104, Salome, G.M., Blanes, L., Ferreira, L.M. Assessment of This study emphasises the need to focus on other aspects of the health of patients with VLUs and the importance for health professionals in public health services, hospitals, outpatient clinics, and family health centres to identify feelings of powerlessness and the basic care needs of patients who live daily with this condition. It is also important to ensure that caregivers have the necessary information to deal with the difficulties faced by these patients. The small sample size of the study may limit the generalisation of the results. Additional studies with a larger number of patients with VLUs are necessary to assess quality of life, self-esteem, self-image, and feelings of powerlessness in this population and extend our results. Studies evaluating the effect of the size of VLUs on pain, presence of wound odour and exudate, patient mobility, and other factors associated with this condition are also necessary. Conclusion Data obtained from the PAT for adult patients revealed that the majority of patients with VLUs had strong feelings of powerlessness, which may adversely affect their quality of life. The assessment of feelings of powerlessness may contribute to the planning of interventions aimed at creating positive feelings and minimise the impact of venous ulcers on the daily life of these patients. n depressive symptoms in people with diabetes mellitus and foot ulcers. Rev Col Bras Cir. 2011; 38, Farinasso, A.L.C., Marques, S., Rodriques, R..AP., Haas, V.J. Functional capacity and referred morbidity of elderly in an area covered by the Family Health Program. Rev Gaúch Enferm. 2006; 27, Jones, J., Barr, W., Robinson, J., Carlisle, C. Depression in patients with chronic venous ulceration. Br J Nurs. 2006; 15, S Kean, J. The effects of smoking on the wound healing process. J Wound Care. 2010; 19, Thomsen, T., Tønnesen, H., Møller, A.M. Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. Br J Surg. 2009; 96, Lindström, D., Wladis, A., Pekkari, K. Thethioredoxin and glutaredoxin systems in smoking cessation and the possible relation to postoperative wound complications. Wounds. 2010; 1, Gottrup, F., Apelqvist, J., Price, P. Outcomes in controlled and comparative studies on non-healing wounds: recommendations to improve the quality of evidence in wound management. J Wound Care. 2010; 19, Tobón, J. Complementary and alternative medicine for older adults with venous leg ulcer pain. J Gerontol Nurs. 2010; 36, Salomé, G.M., Ferreira, L.M. Impact of skin grafting of venous leg ulcers on functional status and pain. World J Surg. 2013; 37, Salomé, G.M., Pereira, V.R., Ferreira, L.M. Spirituality and subjective wellbeing of patients with lower-limb ulceration. J Wound Care. 2013; 22, Waidman, M.A.P., Rocha, S.C., Correa, J.L. et al. Daily routines for individuals with a chronic wound and their mental health. Texto Contexto Enferm. 2011; 20, Salomé, G.M., Alves, S.G., Costa, V.F, Pereira V.R. Feelings of powerlessness and hope for cure in patients with chronic lower-limb ulcers. J Wound Care. 2013; 22,