Accepted Manuscript Feelings of powerlessness in individuals with either venous or diabetic foot ulcers Sergio Aguinaldo de Almeida , RN, Specialist in Auditing Geraldo Magela Salomé , RN, PhD, Adjunct Professor Rosimar Aparecida Alves Dutra , RN, MS Student Lydia Masako Ferreira , MD, PhD, Full Professor PII:
S0965-206X(14)00032-1
DOI:
10.1016/j.jtv.2014.04.005
Reference:
JTV 146
To appear in:
Journal of Tissue Viability
Received Date: 6 December 2012 Revised Date:
28 March 2014
Accepted Date: 29 April 2014
Please cite this article as: de Almeida SA, Salomé GM, Dutra RAA, Ferreira LM, Feelings of powerlessness in individuals with either venous or diabetic foot ulcers, Journal of Tissue Viability (2014), doi: 10.1016/j.jtv.2014.04.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Highlights The difficulty or inability to perform activities of daily life affects the psychological and emotional well-being of individuals, increasing their feelings of powerlessness.
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Patients with venous and diabetic foot ulcers had very strong feelings of powerlessness, but these feelings were significantly stronger in patients with foot ulcerations.
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and reduced feelings of powerlessness.
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Patient’s participation in health care activities has been linked to better health outcomes
ACCEPTED MANUSCRIPT
Feelings of powerlessness in individuals with either venous or diabetic foot ulcers
Lydia Masako Ferreira4
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Sergio Aguinaldo de Almeida,1 Geraldo Magela Salomé,2 Rosimar Aparecida Alves Dutra,3
RN, Specialist in Auditing, Private Practice, São Paulo, SP, Brazil
2
RN, PhD, Adjunct Professor, Professional Master’s degree Program in Sciences Applied to
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1
Health, Sapucaí Valley University (UNIVÁS), Pouso Alegre, MG, Brazil
RN, MS Student, Professional Master’s degree Program in Sciences Applied to Health, UNIVÁS, Pouso Alegre, MG, Brazil
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3
MD, PhD, Full Professor, Division of Plastic Surgery, Federal University of São Paulo
Corresponding author:
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Geraldo Magela Salomé
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(UNIFESP), São Paulo, SP, Brazil.
Av. Francisco de Paula Quintanilha Ribeiro 280, apt. 134
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CEP 04330-020 São Paulo, SP, Brazil Email: [email protected]
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Feelings of powerlessness in individuals with either venous or diabetic foot ulcers
Abstract
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Aim: To assess feelings of powerlessness in patients with either venous or diabetic foot ulcers. Methods: This was an exploratory, descriptive, cross-sectional study conducted from May 2010 to August 2012. Two hundred adult patients with either venous leg ulcers (n = 100) or diabetic
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foot ulcers (n = 100) were consecutively recruited from an outpatient wound-care clinic of a university hospital in the city of São Paulo (Brazil). Eligibility criteria included patients with
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type 1 and 2 diabetes and foot ulcers, and those with venous leg ulcers and ankle-arm index between 0.8-1.0. Patients unable to respond to a questionnaire due to physical or cognitive deficit were excluded. Two instruments were used for data collection: a questionnaire assessing sociodemographic and clinical characteristics, and the Powerlessness Assessment Tool (PAT)
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for adult patients. Results: Most patients were women, aged 60 to 70 years, and smokers. Fiftyseven (57%) patients with diabetes had had foot ulcers for 3-6 years and 55 (55%) patients had had venous ulcers for 7-10 years. Wound odor and exudate were present in most ulcers. The
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total PAT score was significantly higher (P = 0.002) for patients with foot ulcers (mean, 57.10) than for patients with venous ulcers (mean, 55.12). The highest mean scores for patients with
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venous and diabetic foot ulcers were 58.09 and 58.10, respectively, on the “self-perception of decision-making capacity” domain. Conclusion: Patients with venous and diabetic foot ulcers had very strong feelings of powerlessness, but these feelings were significantly stronger in those with foot ulcerations.
Keywords: Feelings; Self-concept; Quality of life; Leg ulcer; Varicose ulcer; Diabetic foot.
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ACCEPTED MANUSCRIPT Feelings of powerlessness in individuals with either venous or diabetic foot ulcers
1. Introduction Problems in the lower limbs represent one of the most important chronic
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complications in individuals with vascular disease and diabetes mellitus. In industrialized countries, ulceration is the most common cause of non-traumatic lower-limb amputations, and has been shown to be a great public health problem worldwide. Therefore, due the high
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incidence, prevalence and complications, the socioeconomic impact on the quality of life of these individuals is considered important. It is known that the majority of leg ulcers (60-
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70%) result from vascular causes.1,2 The prevalence of venous ulcers is from 0.6 to 3.6% in the general population.1-3
Foot ulcers and amputations are the main consequences associated with morbidity among persons with diabetes mellitus,4 and it is estimated that 15% of diabetic patients are at
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risk for foot ulceration.2 Studies have shown that the annual population-based incidence may range between 1% and 4.1% and prevalence from 4% to 10%.5 Ulcers cause pain, alteration in sleep patterns and loss of functional mobility,
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affecting the individuals' capacity to work and compromising their daily life and leisure activities. Associated with these factors, expenditure on treatment has a negative impact on
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the quality of life of persons and their family members.6,7 All of these aspects make patients feel frustrated, dissatisfied, insecure, fearful, powerless and out of control. Individuals with wounds feel incapable of performing daily activities, and frequently consider themselves incapable of and impotent to play their role in society.8-10 The feeling of powerlessness may be seen as a loss; the loss of control of running one's own life.11 NANDA-I defined the feeling of powerlessness as “the perception that one's
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own action would not significantly affect a result; a lack of control perceived about a current situation or an immediate happening”.12 Professionals in the field of health have technical and human skills to provide care for people with lower-limb ulcers and must be able to identify feelings of powerlessness and the
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basic care needs of this population. The assessment of feelings of powerlessness may contribute to the planning of interventions aimed at creating positive feelings and minimize the impact of lower-limb ulcers on the daily life of these patients.
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The aim of this study was to assess feelings of powerlessness in patients with venous leg ulcers and compare with that of patients with diabetic foot ulcers to provide supportive
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evidence for improving quality of care for this population, directing interventions more satisfactorily toward the individual needs of the patient with a wound.
2. Methods
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This is an exploratory, descriptive, cross-sectional study. The sample comprised 100 patients with diabetes mellitus and foot ulceration, and 100 individuals with venous leg ulcers. All received care at the Wound Unit in the Plastic Surgery Outpatient Clinic of the
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Federal University of São Paulo and in an outpatient wound care clinic of a hospital complex
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in interior São Paulo.
Two groups of patients were included: with Type 1 or Type 2 diabetes and foot ulcer
and with venous ulcer, persons over the age of 18 years. Patients without physical and mental conditions to answer the questions in the questionnaire were excluded from the study. Data were collected in the period comprising May 2010 to August 2012, after approval from the Research Ethics Committee of the Federal University of São Paulo, (Protocol No.0383/10). Written informed consent was obtained from all patients prior to their inclusion in the study.
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Two instruments were used for data collection: a questionnaire assessing sociodemographic and clinical characteristics, and the Powerlessness Assessment Tool (PAT) for adult patients. Because most participants had a low education level, the questionnaires were administered as a structured interview by the researchers.
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The PAT was developed in Brazil and tested in a population sample of 210 adult patients from medical-surgical wards for item selection, reliability and validity.11,13 It shows good internal consistency (Cronbach’s alpha coefficient of 0.80) and test-retest reliability (p
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> 0.05).11,13 The instrument consists of a 12-item measure of powerlessness rated on a 5-point Likert-type scale ranging from “never” (1) to “always” (5). The total PAT score range from
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12-60, with higher scores corresponding to stronger feelings of powerlessness. Based on the total PAT score, feelings of powerlessness can be rated as absent (12), mild (13-24), moderate (25-36), strong (37-48), and very strong (49-60). The 12 items are grouped into three domains: 1) “capacity to perform behavior” or perceived behavioral control, which
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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
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perceived control”, which assesses the patients’ feelings regarding their perceived loss of
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control over aspects of their life (Table 1).11,13 The Statistical Package for the Social Sciences (SPSS) 15.0 for Windows (SPSS Inc.,
Chicago, IL, USA) and Microsoft Office Excel software (Microsoft Corp., Redmond, WA, USA) were used for data analysis. The chi-square test was used to compare the frequency distribution of categorical variables between groups. The Kruskal-Wallis test and the Spearman correlation coefficient were also used in the statistical analysis. All statistical tests were performed at a significance level of 0.05 (P < 0.05).
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3. Results Most patients in both groups were women, aged 60 to 70 years, and smokers, with significant differences between groups for all variables (Table 2).
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Fifty-seven (57%) patients with diabetes had had foot ulcers for 3-6 years and 55 (55%) patients had had the venous ulcers for 7-10 years. Wound odor and exudate were present in most ulcers (Table 3).
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Eighty-seven (87%) patients with diabetic foot ulcers and 71 (71%) patients with venous leg ulcers reported very strong feelings of powerlessness (Table 4).
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The mean total PAT score was 55.12 for patients with venous ulcers and 57.10 for patients with foot ulcers, with a significant difference between groups (P = 0.002). This shows that patients with diabetic foot ulcers had stronger feelings of powerlessness than those with venous leg ulcers. Both groups of patients had high scores on all PAT domains.
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The highest mean PAT scores reported by patients with venous and diabetic foot ulcers were
(Table 5).
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4. Discussion
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58.09 and 58.10, respectively, on the “self-perception of decision-making capacity” domain
Feelings of powerlessness were assessed in 200 adult patients with either venous or
diabetic foot ulcers. Most patients (diabetic foot ulcers, 87%; venous leg ulcers, 71%) had very strong feelings of powerlessness. Total PAT score was significantly higher for patients with foot ulcers than for patients with venous leg ulcers. Venous and diabetic foot ulcers are characterized by a chronic, painful process, with a negative impact on the quality of life because they affect mobility, the emotional state and
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functional capacity of these patients. Lower-limb ulcers require proper local and systemic treatment performed by a multidisciplinary team. The individuals most affected by this condition are women and those aged 60 years and over,1,6,7,14-17 which is in agreement with our results. Various studies have indicated that
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the predominant age-group affected by leg ulcers ranges from 51 to 70 years.1,2,5,7,18-22
The studied sample had a low education level, with over half of the participants being illiterate. Low education level may negatively affect the quality of information collected
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using self-administered questionnaires, and therefore the instruments were administered as a structured interview. In Brazil, the illiteracy rate is high and over half of persons with venous
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problems has incomplete primary education.23 The low education level may negatively affect the patient’s ability to understand and follow self-care instructions and the treatment regimen, such as daily evaluation of the feet, use of prescribed medications and appropriate dressings.26-28
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Lower-limb ulcers cause great impact on patients, leading to changes in lifestyle, chronic pain, low self-esteem, and possibly depression.24 To live with the condition of having a chronic wound, which frequently is associated with odor, exudation, edema and pain, may
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result in a series of changes in the lives of patients and their families.25 These individuals feel
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uncomfortable, discouraged and powerless in the face of losing control of their own lives. The lesion may remove the patient from work and be the reason for early retirement of an individual who is still in the productive stage, due to the incapacitating nature of the disease.1,19,22,27,29,30 The majority of the participants in this study were retired. Various studies conducted in patients with chronic wounds have shown that over half of participants are retired or laid-off workers.23,26,29 Lower-limb wounds negatively interfere in the quality of life of these individuals, leading to mobility limitation associated with decreased functional
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status, thus affecting activities of daily living and intensifying the dependency needs of these patients, and consequently increasing their feelings of powerlessness.19,31 A previous study reported strong feelings of powerlessness (mean total PAT score, 47.83; range, 51-60) in patients with venous ulcers.9 Similarly, in this study, the majority of
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participants with venous and diabetic foot ulcers had very strong feelings of powerlessness (Table 5). Other study assessing feelings of powerlessness and hope in patients with either chronic venous ulcers or diabetic foot ulcers found that those with diabetic foot ulcers had
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stronger feelings of powerlessness and less hope for cure than patients with venous leg ulcers, which is agreement with our results.10
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A study assessed the level of psychosocial adjustment was assessed in 50 patients with venous ulcers using the Roy Adaptation model in a university hospital in Brazil.32 It was found that 82% of patients reported maladaptation in the role-function mode (leisure, pain, social, educational and transportation restrictions) and interdependence mode (support in
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treatment).32 These factors may diminish the ability of these persons to deal with situations, resulting in feelings of powerlessness.
Individuals with chronic wounds must be helped to understand that the lesion is a new
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condition to which they have to adapt and not a restriction on social and sexual life.
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Considering how difficult it is to live under this circumstance, the aid of a professional is required so that the patient feels supported and motivated to seek help. Patient’s participation in health care activities has been linked to better health outcomes.11 Patients should be motivated to perform self-care and activities of daily living, since feelings of powerlessness may interfere with treatment adherence and self-care, affecting recovery.7,11 The results of this study highlight the need to focus on other aspects of the health of patients with lower-limb ulcers and the importance for health professionals to identify
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feelings of powerlessness and the basic care needs of patients who live daily with this condition. In view of the needs that have arisen during the last few decades as a result of the increasing incidence of chronic diseases associated with the aging of the population in many
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countries, it is equally necessary to redirect the academic training and qualification of health professionals, valuing not only the technical aspects of care, but also the humanization of care. Actions that include factors associated with chronic diseases and mental health will
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certainly contribute to the well-being and quality of life of individuals with chronic ulcers,
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especially in the elderly population.
5. Conclusion
Our results indicated that patients with venous and diabetic foot ulcers had very strong feelings of powerlessness in the face of living with an ulcer, but these feelings were
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significantly stronger in those with foot ulcerations.
The results also provide supportive evidence for improving quality of care for this population, and may contribute to direct interventions more satisfactorily toward the
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individual needs of the patient with a lower-limb ulcer.
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ACCEPTED MANUSCRIPT 6. Conflict of interest statement
The authors have no conflict of interest, financial interest or commercial association with any
7. Role of the funding source
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There was no external funding for this study.
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of the subject matter or products mentioned in the manuscript.
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ACCEPTED MANUSCRIPT 8. References
1. Abbade LPF, Lastória S. Management of patients with venous leg ulcer. An Bras Dermatol 2006;81:509-22. 2. Bakker K, Schaper NC. The development of global consensus guidelines on the
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management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev 2012;28:116-8.
3. Salomé GM, Pellegrino DMS, Vieira TF, Blanes L, Ferreira LM. Sleep quality among
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patients with venous ulcers: a cross-sectional study in a health care setting in São Paulo, Brazil. Wounds 2012;24:124-31.
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4. Genuth S, Eastman R, Kahn R, et al. Implications of the United Kingdom prospective diabetes study. Diabetes Care 2003;26:S28-32.
5. Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999;22:157-62.
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6. Bongiovanni CM, Hughes MD, Bomengen RW. Accelerated wound healing: multidisciplinary advances in the care of venous leg ulcers. Angiology 2006;57:139- 44. 7. Salomé GM, Pellegrino DM, Blanes L, Ferreira LM. Self-esteem in patients with diabetes
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mellitus and foot ulcers. J Tissue Viability 2011;20:100-6.
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8. Salomé GM, Blanes L, Ferreira LM. The impact of skin grafting on the quality of life and self-esteem of patients with venous leg ulcers. World J Surg 2014;38:233-40. 9. Salomé GM, Openheimer DG, de Almeida SA, Bueno ML, Dutra RA, Ferreira LM. Feelings of powerlessness in patients with venous leg ulcers. J Wound Care 2013;22:6284. 10. Salomé GM, Alves SG, Costa VF, Pereira VR, Ferreira LM. Feelings of powerlessness and hope for cure in patients with chronic lower-limb ulcers. J Wound Care 2013;22:3004.
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11. Braga CG, Cruz DALM. Powerlessness: differentiation from other diagnoses and concepts. Rev Esc Enferm USP 2005;39:350-7. 12. North American Nursing Diagnosis Association International. Nursing diagnoses: Definitions and classification 2007-2008. Porto Alegre: Artmed, 2008.
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13. Braga CG, Cruz DALM. Powerlessness assessment tool for adult patients. Rev Esc Enferm USP 2009;43:1063-70.
14. L de Lima E, Salomé GM, de Brito Rocha MJ, Ferreira LM. The impact of compression
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therapy with Unna's boot on the functional status of VLU patients. J Wound Care 2013;22:558-61.
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15. Salomé GM, Ferreira LM. Quality of life in patients with venous ulcers treated with Unna's boot compressive therapy. Rev Bras Cir Plást 2012;27:466-71. 16. de Almeida, SA, Silveira MM, Santo PFE, Pereira RC, Salomé GM. Assessment of the quality of life of patients with diabetes mellitus and foot ulcers. Rev Bras Cir Plást
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2013;28:142-46.
17. Frade MAC, Cursi IB, Andrade FF, et al. Leg ulcer: an observational study in Juiz de Fora, MG (Brazil) and region. An Bras Derm 2005;80:41-6.
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18. Malaquias SG, Bachion MM, Sant'ana SM, Dallarmi CC, Lino Junior Rde S, Ferreira PS.
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People with vascular ulcers in outpatient nursing care: a study of sociodemographic and clinical variables. Rev Esc Enferm USP 2012;46:302-10. 19. Nottingham IC, Victor JF, Brito CKD, Feitoza SMS, Monteiro LS, Balbino AC. Assessment of biopsychosocial aspects of patients with venous ulcers. Rev Enferm UFPE on line 2012;6:1582-8. 20. Angélico RCP, Oliveira AKA, Silva DDN, Vasconcelos QLDAQ, Costa IKF, Torres GV. Socio-demographic profile, clinical and health of people with venous ulcers treated at a university hospital. Rev Enferm UFPE on line 2012;6:62-8.
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21. Viswanathan V, Kesavan R, Kavitha KV, Kumpatla S. A pilot study on the effects of a polyherbal formulation cream on diabetic foot ulcers. Indian J Med Res 2011;134:168-73. 22. Parsa HN, Zangivand AA, Hajimaghsoudi L. The effect of pentoxifylline on chronic venous ulcers. Wounds 2012;24:190-94.
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23. Macêdo EAB, Silva DDN, Oliveira AKA, Vasconcelos QLDAQ, Costa IKF, Torres GV. Characterization of the care to patients with venous ulcers in 10 weeks using conventional therapy. Rev Enferm UFPE on line 2011;5:2129-35.
venous ulcers. Rev Bras Cir Plást 2012;27:124-29.
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24. Salomé GM, Blanes L, Ferreira LM. Evaluation of depressive symptoms in patients with
ulcer. Cienc Enferm 2008;14:43-52.
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25. Lucas LS, Martins JT, Robazzi MLCC. Life quality of people with lower limb ulcers - leg
26. Santos RFFN, Porfírio GJM, Pitta GBB. Differences in the quality of life of patients with mild and severe chronic venous disease. J Vasc Bras 2009;8:143-7.
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27. Salomé GM, Blanes L, Ferreira LM. Assessment of depressive symptoms in people with diabetes mellitus and foot ulcers. Rev Col Bras Cir 2011;38:327-33. 28. Spentzouris G, Labropoulos N. The evaluation of lower-extremity ulcers. Semin Intervent
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Radiol 2009;26:286-95.
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29. Salomé GM, Blanes L, Ferreira LM. Functional capability of patients with diabetes with foot ulceration. Acta Paul Enferm 2009;22:412-16. 30. Silva FAA, Freitas CHA, Jorge MSB, Moreira TMM, Alcântara MCM. Nursing in stomatherapy: clinical care for the patient with varicose ulcer: review. Rev Bras Enferm 2009;62:889-93. 31. Salomé GM, Ferreira LM. Impact of skin grafting of venous leg ulcers on functional status and pain. World J Surg 2013;37:1438-45.
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32. Costa IKF, Nóbrega WG, Costa IKF, et al. People with venous ulcers: a study of the
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psychosocial aspects of the Roy Adaptation Model. Rev Gaucha Enferm 2011;32:561-8.
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ACCEPTED MANUSCRIPT TABLES Table 1. Powerlessness Assessment Tool (PAT)13 No.
Items Capacity to Perform Behavior The things I do can help in my recovery.
2
I feel I am capable of achieving my goal.
3
I feel I have the disposition to participative in my care.
4
I feel my opinions can contribute in the decisions about my health.
5
I feel capable of looking after myself.
6
My body still obeys my command.
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1
Self-perception of Decision Making Capacity
My health conditions avoid me from making decisions about my treatment.
8
Nothing I do can change the situation I am in.
9
I feel I am not capable of making any decisions.
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7
Emotional Responses to Perceived Control I feel sad that I can’t control my body functioning as I did before.
11
I feel sad when I think I need someone to help me.
12
I feel there is nothing I can to make the place I am in more pleasant.
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2
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DF (N =100)
VL (N = 100)
N
%
N
%
P-value*
66
66
74
74
0.035
< 60
41
41
28
60-70
58
58
68
>70
1
1
4
67
67
76
Women
28
68
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DF, diabetic foot ulcer patients; VL, venous leg ulcer patients
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* Chi-square test of independence (P < 0.05)
0.033
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Smokers
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Age Group (years)
76
0.041
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DF (N =100)
VL (N = 100)
N
%
N
%
≤2
16
16
10
10
3-6
57
57
27
7-10
15
15
55
> 10 years
12
12
8
Exudate
67
67
Odor
67
67
P-value*
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Age of the wound (years)
27
0.015
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0.023
62
62
0.029
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8
70
DF, diabetic foot ulcer patients; VL, venous leg ulcer patients * Chi-square test of independence (P < 0.05)
55
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VL (N = 100)
N
%
N
%
≤ 30
2
2
4
4
31-40
4
4
8
8
41-50
7
7
17
17
51-60
87
87
71
71
P-value*
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Total PAT score
0.013
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DF, diabetic foot ulcer patients; VL, venous leg ulcer patients
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* Kruskal-Wallis test and Spearman correlation coefficient (P < 0.05)
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ACCEPTED MANUSCRIPT Table 5. Mean total and subscale PAT scores of patients with venous and diabetic foot ulcers. PAT domains
DF (N =100)
VL (N = 100)
SD
55.1
7.301
53.09 7.209
Self-perception of decision making capacity 56.78
6.980
56.09
Emotional responses to perceived control
58.10
7.578
58.09 7.523
Total PAT score
57.109
8.578
55.12 7.974
SD
6.03
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Capacity to perform behavior
Mean
P-value *
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Mean
0.002
0.002
DF, diabetic foot ulcer patients; VL, venous leg ulcer patients; SD, standard deviation
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* Kruskal-Wallis test and Spearman correlation coefficient (P < 0.05)
S0965-206X(14)00032-1
DOI:
10.1016/j.jtv.2014.04.005
Reference:
JTV 146
To appear in:
Journal of Tissue Viability
Received Date: 6 December 2012 Revised Date:
28 March 2014
Accepted Date: 29 April 2014
Please cite this article as: de Almeida SA, Salomé GM, Dutra RAA, Ferreira LM, Feelings of powerlessness in individuals with either venous or diabetic foot ulcers, Journal of Tissue Viability (2014), doi: 10.1016/j.jtv.2014.04.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Highlights The difficulty or inability to perform activities of daily life affects the psychological and emotional well-being of individuals, increasing their feelings of powerlessness.
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Patients with venous and diabetic foot ulcers had very strong feelings of powerlessness, but these feelings were significantly stronger in patients with foot ulcerations.
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EP
TE D
M AN U
and reduced feelings of powerlessness.
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Patient’s participation in health care activities has been linked to better health outcomes
ACCEPTED MANUSCRIPT
Feelings of powerlessness in individuals with either venous or diabetic foot ulcers
Lydia Masako Ferreira4
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Sergio Aguinaldo de Almeida,1 Geraldo Magela Salomé,2 Rosimar Aparecida Alves Dutra,3
RN, Specialist in Auditing, Private Practice, São Paulo, SP, Brazil
2
RN, PhD, Adjunct Professor, Professional Master’s degree Program in Sciences Applied to
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1
Health, Sapucaí Valley University (UNIVÁS), Pouso Alegre, MG, Brazil
RN, MS Student, Professional Master’s degree Program in Sciences Applied to Health, UNIVÁS, Pouso Alegre, MG, Brazil
4
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3
MD, PhD, Full Professor, Division of Plastic Surgery, Federal University of São Paulo
Corresponding author:
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Geraldo Magela Salomé
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(UNIFESP), São Paulo, SP, Brazil.
Av. Francisco de Paula Quintanilha Ribeiro 280, apt. 134
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CEP 04330-020 São Paulo, SP, Brazil Email: [email protected]
ACCEPTED MANUSCRIPT
Feelings of powerlessness in individuals with either venous or diabetic foot ulcers
Abstract
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Aim: To assess feelings of powerlessness in patients with either venous or diabetic foot ulcers. Methods: This was an exploratory, descriptive, cross-sectional study conducted from May 2010 to August 2012. Two hundred adult patients with either venous leg ulcers (n = 100) or diabetic
SC
foot ulcers (n = 100) were consecutively recruited from an outpatient wound-care clinic of a university hospital in the city of São Paulo (Brazil). Eligibility criteria included patients with
M AN U
type 1 and 2 diabetes and foot ulcers, and those with venous leg ulcers and ankle-arm index between 0.8-1.0. Patients unable to respond to a questionnaire due to physical or cognitive deficit were excluded. Two instruments were used for data collection: a questionnaire assessing sociodemographic and clinical characteristics, and the Powerlessness Assessment Tool (PAT)
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for adult patients. Results: Most patients were women, aged 60 to 70 years, and smokers. Fiftyseven (57%) patients with diabetes had had foot ulcers for 3-6 years and 55 (55%) patients had had venous ulcers for 7-10 years. Wound odor and exudate were present in most ulcers. The
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total PAT score was significantly higher (P = 0.002) for patients with foot ulcers (mean, 57.10) than for patients with venous ulcers (mean, 55.12). The highest mean scores for patients with
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venous and diabetic foot ulcers were 58.09 and 58.10, respectively, on the “self-perception of decision-making capacity” domain. Conclusion: Patients with venous and diabetic foot ulcers had very strong feelings of powerlessness, but these feelings were significantly stronger in those with foot ulcerations.
Keywords: Feelings; Self-concept; Quality of life; Leg ulcer; Varicose ulcer; Diabetic foot.
1
ACCEPTED MANUSCRIPT Feelings of powerlessness in individuals with either venous or diabetic foot ulcers
1. Introduction Problems in the lower limbs represent one of the most important chronic
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complications in individuals with vascular disease and diabetes mellitus. In industrialized countries, ulceration is the most common cause of non-traumatic lower-limb amputations, and has been shown to be a great public health problem worldwide. Therefore, due the high
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incidence, prevalence and complications, the socioeconomic impact on the quality of life of these individuals is considered important. It is known that the majority of leg ulcers (60-
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70%) result from vascular causes.1,2 The prevalence of venous ulcers is from 0.6 to 3.6% in the general population.1-3
Foot ulcers and amputations are the main consequences associated with morbidity among persons with diabetes mellitus,4 and it is estimated that 15% of diabetic patients are at
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risk for foot ulceration.2 Studies have shown that the annual population-based incidence may range between 1% and 4.1% and prevalence from 4% to 10%.5 Ulcers cause pain, alteration in sleep patterns and loss of functional mobility,
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affecting the individuals' capacity to work and compromising their daily life and leisure activities. Associated with these factors, expenditure on treatment has a negative impact on
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the quality of life of persons and their family members.6,7 All of these aspects make patients feel frustrated, dissatisfied, insecure, fearful, powerless and out of control. Individuals with wounds feel incapable of performing daily activities, and frequently consider themselves incapable of and impotent to play their role in society.8-10 The feeling of powerlessness may be seen as a loss; the loss of control of running one's own life.11 NANDA-I defined the feeling of powerlessness as “the perception that one's
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own action would not significantly affect a result; a lack of control perceived about a current situation or an immediate happening”.12 Professionals in the field of health have technical and human skills to provide care for people with lower-limb ulcers and must be able to identify feelings of powerlessness and the
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basic care needs of this population. The assessment of feelings of powerlessness may contribute to the planning of interventions aimed at creating positive feelings and minimize the impact of lower-limb ulcers on the daily life of these patients.
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The aim of this study was to assess feelings of powerlessness in patients with venous leg ulcers and compare with that of patients with diabetic foot ulcers to provide supportive
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evidence for improving quality of care for this population, directing interventions more satisfactorily toward the individual needs of the patient with a wound.
2. Methods
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This is an exploratory, descriptive, cross-sectional study. The sample comprised 100 patients with diabetes mellitus and foot ulceration, and 100 individuals with venous leg ulcers. All received care at the Wound Unit in the Plastic Surgery Outpatient Clinic of the
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Federal University of São Paulo and in an outpatient wound care clinic of a hospital complex
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in interior São Paulo.
Two groups of patients were included: with Type 1 or Type 2 diabetes and foot ulcer
and with venous ulcer, persons over the age of 18 years. Patients without physical and mental conditions to answer the questions in the questionnaire were excluded from the study. Data were collected in the period comprising May 2010 to August 2012, after approval from the Research Ethics Committee of the Federal University of São Paulo, (Protocol No.0383/10). Written informed consent was obtained from all patients prior to their inclusion in the study.
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Two instruments were used for data collection: a questionnaire assessing sociodemographic and clinical characteristics, and the Powerlessness Assessment Tool (PAT) for adult patients. Because most participants had a low education level, the questionnaires were administered as a structured interview by the researchers.
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The PAT was developed in Brazil and tested in a population sample of 210 adult patients from medical-surgical wards for item selection, reliability and validity.11,13 It shows good internal consistency (Cronbach’s alpha coefficient of 0.80) and test-retest reliability (p
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> 0.05).11,13 The instrument consists of a 12-item measure of powerlessness rated on a 5-point Likert-type scale ranging from “never” (1) to “always” (5). The total PAT score range from
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12-60, with higher scores corresponding to stronger feelings of powerlessness. Based on the total PAT score, feelings of powerlessness can be rated as absent (12), mild (13-24), moderate (25-36), strong (37-48), and very strong (49-60). The 12 items are grouped into three domains: 1) “capacity to perform behavior” or perceived behavioral control, which
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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
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perceived control”, which assesses the patients’ feelings regarding their perceived loss of
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control over aspects of their life (Table 1).11,13 The Statistical Package for the Social Sciences (SPSS) 15.0 for Windows (SPSS Inc.,
Chicago, IL, USA) and Microsoft Office Excel software (Microsoft Corp., Redmond, WA, USA) were used for data analysis. The chi-square test was used to compare the frequency distribution of categorical variables between groups. The Kruskal-Wallis test and the Spearman correlation coefficient were also used in the statistical analysis. All statistical tests were performed at a significance level of 0.05 (P < 0.05).
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3. Results Most patients in both groups were women, aged 60 to 70 years, and smokers, with significant differences between groups for all variables (Table 2).
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Fifty-seven (57%) patients with diabetes had had foot ulcers for 3-6 years and 55 (55%) patients had had the venous ulcers for 7-10 years. Wound odor and exudate were present in most ulcers (Table 3).
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Eighty-seven (87%) patients with diabetic foot ulcers and 71 (71%) patients with venous leg ulcers reported very strong feelings of powerlessness (Table 4).
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The mean total PAT score was 55.12 for patients with venous ulcers and 57.10 for patients with foot ulcers, with a significant difference between groups (P = 0.002). This shows that patients with diabetic foot ulcers had stronger feelings of powerlessness than those with venous leg ulcers. Both groups of patients had high scores on all PAT domains.
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The highest mean PAT scores reported by patients with venous and diabetic foot ulcers were
(Table 5).
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4. Discussion
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58.09 and 58.10, respectively, on the “self-perception of decision-making capacity” domain
Feelings of powerlessness were assessed in 200 adult patients with either venous or
diabetic foot ulcers. Most patients (diabetic foot ulcers, 87%; venous leg ulcers, 71%) had very strong feelings of powerlessness. Total PAT score was significantly higher for patients with foot ulcers than for patients with venous leg ulcers. Venous and diabetic foot ulcers are characterized by a chronic, painful process, with a negative impact on the quality of life because they affect mobility, the emotional state and
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functional capacity of these patients. Lower-limb ulcers require proper local and systemic treatment performed by a multidisciplinary team. The individuals most affected by this condition are women and those aged 60 years and over,1,6,7,14-17 which is in agreement with our results. Various studies have indicated that
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the predominant age-group affected by leg ulcers ranges from 51 to 70 years.1,2,5,7,18-22
The studied sample had a low education level, with over half of the participants being illiterate. Low education level may negatively affect the quality of information collected
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using self-administered questionnaires, and therefore the instruments were administered as a structured interview. In Brazil, the illiteracy rate is high and over half of persons with venous
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problems has incomplete primary education.23 The low education level may negatively affect the patient’s ability to understand and follow self-care instructions and the treatment regimen, such as daily evaluation of the feet, use of prescribed medications and appropriate dressings.26-28
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Lower-limb ulcers cause great impact on patients, leading to changes in lifestyle, chronic pain, low self-esteem, and possibly depression.24 To live with the condition of having a chronic wound, which frequently is associated with odor, exudation, edema and pain, may
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result in a series of changes in the lives of patients and their families.25 These individuals feel
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uncomfortable, discouraged and powerless in the face of losing control of their own lives. The lesion may remove the patient from work and be the reason for early retirement of an individual who is still in the productive stage, due to the incapacitating nature of the disease.1,19,22,27,29,30 The majority of the participants in this study were retired. Various studies conducted in patients with chronic wounds have shown that over half of participants are retired or laid-off workers.23,26,29 Lower-limb wounds negatively interfere in the quality of life of these individuals, leading to mobility limitation associated with decreased functional
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status, thus affecting activities of daily living and intensifying the dependency needs of these patients, and consequently increasing their feelings of powerlessness.19,31 A previous study reported strong feelings of powerlessness (mean total PAT score, 47.83; range, 51-60) in patients with venous ulcers.9 Similarly, in this study, the majority of
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participants with venous and diabetic foot ulcers had very strong feelings of powerlessness (Table 5). Other study assessing feelings of powerlessness and hope in patients with either chronic venous ulcers or diabetic foot ulcers found that those with diabetic foot ulcers had
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stronger feelings of powerlessness and less hope for cure than patients with venous leg ulcers, which is agreement with our results.10
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A study assessed the level of psychosocial adjustment was assessed in 50 patients with venous ulcers using the Roy Adaptation model in a university hospital in Brazil.32 It was found that 82% of patients reported maladaptation in the role-function mode (leisure, pain, social, educational and transportation restrictions) and interdependence mode (support in
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treatment).32 These factors may diminish the ability of these persons to deal with situations, resulting in feelings of powerlessness.
Individuals with chronic wounds must be helped to understand that the lesion is a new
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condition to which they have to adapt and not a restriction on social and sexual life.
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Considering how difficult it is to live under this circumstance, the aid of a professional is required so that the patient feels supported and motivated to seek help. Patient’s participation in health care activities has been linked to better health outcomes.11 Patients should be motivated to perform self-care and activities of daily living, since feelings of powerlessness may interfere with treatment adherence and self-care, affecting recovery.7,11 The results of this study highlight the need to focus on other aspects of the health of patients with lower-limb ulcers and the importance for health professionals to identify
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feelings of powerlessness and the basic care needs of patients who live daily with this condition. In view of the needs that have arisen during the last few decades as a result of the increasing incidence of chronic diseases associated with the aging of the population in many
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countries, it is equally necessary to redirect the academic training and qualification of health professionals, valuing not only the technical aspects of care, but also the humanization of care. Actions that include factors associated with chronic diseases and mental health will
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certainly contribute to the well-being and quality of life of individuals with chronic ulcers,
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especially in the elderly population.
5. Conclusion
Our results indicated that patients with venous and diabetic foot ulcers had very strong feelings of powerlessness in the face of living with an ulcer, but these feelings were
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significantly stronger in those with foot ulcerations.
The results also provide supportive evidence for improving quality of care for this population, and may contribute to direct interventions more satisfactorily toward the
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individual needs of the patient with a lower-limb ulcer.
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ACCEPTED MANUSCRIPT 6. Conflict of interest statement
The authors have no conflict of interest, financial interest or commercial association with any
7. Role of the funding source
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There was no external funding for this study.
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of the subject matter or products mentioned in the manuscript.
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ACCEPTED MANUSCRIPT 8. References
1. Abbade LPF, Lastória S. Management of patients with venous leg ulcer. An Bras Dermatol 2006;81:509-22. 2. Bakker K, Schaper NC. The development of global consensus guidelines on the
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management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev 2012;28:116-8.
3. Salomé GM, Pellegrino DMS, Vieira TF, Blanes L, Ferreira LM. Sleep quality among
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patients with venous ulcers: a cross-sectional study in a health care setting in São Paulo, Brazil. Wounds 2012;24:124-31.
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4. Genuth S, Eastman R, Kahn R, et al. Implications of the United Kingdom prospective diabetes study. Diabetes Care 2003;26:S28-32.
5. Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999;22:157-62.
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6. Bongiovanni CM, Hughes MD, Bomengen RW. Accelerated wound healing: multidisciplinary advances in the care of venous leg ulcers. Angiology 2006;57:139- 44. 7. Salomé GM, Pellegrino DM, Blanes L, Ferreira LM. Self-esteem in patients with diabetes
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mellitus and foot ulcers. J Tissue Viability 2011;20:100-6.
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8. Salomé GM, Blanes L, Ferreira LM. The impact of skin grafting on the quality of life and self-esteem of patients with venous leg ulcers. World J Surg 2014;38:233-40. 9. Salomé GM, Openheimer DG, de Almeida SA, Bueno ML, Dutra RA, Ferreira LM. Feelings of powerlessness in patients with venous leg ulcers. J Wound Care 2013;22:6284. 10. Salomé GM, Alves SG, Costa VF, Pereira VR, Ferreira LM. Feelings of powerlessness and hope for cure in patients with chronic lower-limb ulcers. J Wound Care 2013;22:3004.
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11. Braga CG, Cruz DALM. Powerlessness: differentiation from other diagnoses and concepts. Rev Esc Enferm USP 2005;39:350-7. 12. North American Nursing Diagnosis Association International. Nursing diagnoses: Definitions and classification 2007-2008. Porto Alegre: Artmed, 2008.
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13. Braga CG, Cruz DALM. Powerlessness assessment tool for adult patients. Rev Esc Enferm USP 2009;43:1063-70.
14. L de Lima E, Salomé GM, de Brito Rocha MJ, Ferreira LM. The impact of compression
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therapy with Unna's boot on the functional status of VLU patients. J Wound Care 2013;22:558-61.
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15. Salomé GM, Ferreira LM. Quality of life in patients with venous ulcers treated with Unna's boot compressive therapy. Rev Bras Cir Plást 2012;27:466-71. 16. de Almeida, SA, Silveira MM, Santo PFE, Pereira RC, Salomé GM. Assessment of the quality of life of patients with diabetes mellitus and foot ulcers. Rev Bras Cir Plást
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17. Frade MAC, Cursi IB, Andrade FF, et al. Leg ulcer: an observational study in Juiz de Fora, MG (Brazil) and region. An Bras Derm 2005;80:41-6.
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18. Malaquias SG, Bachion MM, Sant'ana SM, Dallarmi CC, Lino Junior Rde S, Ferreira PS.
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People with vascular ulcers in outpatient nursing care: a study of sociodemographic and clinical variables. Rev Esc Enferm USP 2012;46:302-10. 19. Nottingham IC, Victor JF, Brito CKD, Feitoza SMS, Monteiro LS, Balbino AC. Assessment of biopsychosocial aspects of patients with venous ulcers. Rev Enferm UFPE on line 2012;6:1582-8. 20. Angélico RCP, Oliveira AKA, Silva DDN, Vasconcelos QLDAQ, Costa IKF, Torres GV. Socio-demographic profile, clinical and health of people with venous ulcers treated at a university hospital. Rev Enferm UFPE on line 2012;6:62-8.
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21. Viswanathan V, Kesavan R, Kavitha KV, Kumpatla S. A pilot study on the effects of a polyherbal formulation cream on diabetic foot ulcers. Indian J Med Res 2011;134:168-73. 22. Parsa HN, Zangivand AA, Hajimaghsoudi L. The effect of pentoxifylline on chronic venous ulcers. Wounds 2012;24:190-94.
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23. Macêdo EAB, Silva DDN, Oliveira AKA, Vasconcelos QLDAQ, Costa IKF, Torres GV. Characterization of the care to patients with venous ulcers in 10 weeks using conventional therapy. Rev Enferm UFPE on line 2011;5:2129-35.
venous ulcers. Rev Bras Cir Plást 2012;27:124-29.
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24. Salomé GM, Blanes L, Ferreira LM. Evaluation of depressive symptoms in patients with
ulcer. Cienc Enferm 2008;14:43-52.
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25. Lucas LS, Martins JT, Robazzi MLCC. Life quality of people with lower limb ulcers - leg
26. Santos RFFN, Porfírio GJM, Pitta GBB. Differences in the quality of life of patients with mild and severe chronic venous disease. J Vasc Bras 2009;8:143-7.
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27. Salomé GM, Blanes L, Ferreira LM. Assessment of depressive symptoms in people with diabetes mellitus and foot ulcers. Rev Col Bras Cir 2011;38:327-33. 28. Spentzouris G, Labropoulos N. The evaluation of lower-extremity ulcers. Semin Intervent
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Radiol 2009;26:286-95.
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29. Salomé GM, Blanes L, Ferreira LM. Functional capability of patients with diabetes with foot ulceration. Acta Paul Enferm 2009;22:412-16. 30. Silva FAA, Freitas CHA, Jorge MSB, Moreira TMM, Alcântara MCM. Nursing in stomatherapy: clinical care for the patient with varicose ulcer: review. Rev Bras Enferm 2009;62:889-93. 31. Salomé GM, Ferreira LM. Impact of skin grafting of venous leg ulcers on functional status and pain. World J Surg 2013;37:1438-45.
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32. Costa IKF, Nóbrega WG, Costa IKF, et al. People with venous ulcers: a study of the
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psychosocial aspects of the Roy Adaptation Model. Rev Gaucha Enferm 2011;32:561-8.
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ACCEPTED MANUSCRIPT TABLES Table 1. Powerlessness Assessment Tool (PAT)13 No.
Items Capacity to Perform Behavior The things I do can help in my recovery.
2
I feel I am capable of achieving my goal.
3
I feel I have the disposition to participative in my care.
4
I feel my opinions can contribute in the decisions about my health.
5
I feel capable of looking after myself.
6
My body still obeys my command.
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Self-perception of Decision Making Capacity
My health conditions avoid me from making decisions about my treatment.
8
Nothing I do can change the situation I am in.
9
I feel I am not capable of making any decisions.
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7
Emotional Responses to Perceived Control I feel sad that I can’t control my body functioning as I did before.
11
I feel sad when I think I need someone to help me.
12
I feel there is nothing I can to make the place I am in more pleasant.
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ACCEPTED MANUSCRIPT Table 2. Sociodemographic characteristics of patients with venous and diabetic foot ulcers VARIABLES
DF (N =100)
VL (N = 100)
N
%
N
%
P-value*
66
66
74
74
0.035
< 60
41
41
28
60-70
58
58
68
>70
1
1
4
67
67
76
Women
28
68
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DF, diabetic foot ulcer patients; VL, venous leg ulcer patients
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* Chi-square test of independence (P < 0.05)
0.033
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Smokers
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Age Group (years)
76
0.041
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DF (N =100)
VL (N = 100)
N
%
N
%
≤2
16
16
10
10
3-6
57
57
27
7-10
15
15
55
> 10 years
12
12
8
Exudate
67
67
Odor
67
67
P-value*
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Age of the wound (years)
27
0.015
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0.023
62
62
0.029
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8
70
DF, diabetic foot ulcer patients; VL, venous leg ulcer patients * Chi-square test of independence (P < 0.05)
55
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VL (N = 100)
N
%
N
%
≤ 30
2
2
4
4
31-40
4
4
8
8
41-50
7
7
17
17
51-60
87
87
71
71
P-value*
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Total PAT score
0.013
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DF, diabetic foot ulcer patients; VL, venous leg ulcer patients
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* Kruskal-Wallis test and Spearman correlation coefficient (P < 0.05)
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ACCEPTED MANUSCRIPT Table 5. Mean total and subscale PAT scores of patients with venous and diabetic foot ulcers. PAT domains
DF (N =100)
VL (N = 100)
SD
55.1
7.301
53.09 7.209
Self-perception of decision making capacity 56.78
6.980
56.09
Emotional responses to perceived control
58.10
7.578
58.09 7.523
Total PAT score
57.109
8.578
55.12 7.974
SD
6.03
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Capacity to perform behavior
Mean
P-value *
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Mean
0.002
0.002
DF, diabetic foot ulcer patients; VL, venous leg ulcer patients; SD, standard deviation
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* Kruskal-Wallis test and Spearman correlation coefficient (P < 0.05)
