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Adherence to compression therapy in patients with venous leg ulcers

Adherence to compression therapy in patients with venous leg ulcers

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An essay for the 2011 Undergraduate Awards Competition by Meagan Healy. Originally submitted for NU4037 Wound Management at University College Cork, with lecturer Irene Hartigan in the category of Nursing & Midwifery
An essay for the 2011 Undergraduate Awards Competition by Meagan Healy. Originally submitted for NU4037 Wound Management at University College Cork, with lecturer Irene Hartigan in the category of Nursing & Midwifery

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Published by: Undergraduate Awards on Aug 29, 2012
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Adherence to compression therapy for patients with venous leg ulcers

Table of Contents: Introduction 1.1 Trusting and Information with regards to adherence to compression therapy 1.2 Discomfort and non adherence to compression therapy 1.3 Conclusion References: 1 4 6 8



Venous leg ulcers are chronic non-healing wounds, generally causing symptoms of lower limb swelling, burning or itching sensation and discolouration of the skin. This type of ulcer can occur at any age, however they are more prevalent in older people (Templeton and Telford, 2010). The physical burden of venous leg ulcers impacts on the individuals’ activities of daily living and reduces their health related quality of life (Gonzalez-Consuegra and Verdu, 2011). Venous leg ulcers constitute 80-85% of all leg ulcers (Simon, Dix and McCollum, 2004; CONUEL, 2009) and are caused by venous insufficiency. It is estimated that 70% of venous leg ulcers reoccur after healing (Finlayson, Edwards and Courtney, 2010). Venous leg insufficiency is associated with deep vein thrombosis, congenital venous malformation and calf muscle failure (Lewis, Heitkemper, Dirksen, O’ Brien and Bucher, 2007). The focus of this assignment review is to explore the reasons for non-adherence in response to compression therapy in individuals diagnosed venous leg ulcers.

Compression therapy changes the effects of venous hypertension and is vital for management and prevention of venous leg ulcers (Hopkins and Worboys, 2005; Lewis et al., 2007; Van Hecke, Verhaeghe, Grypdonck, Beele, and Defloor, 2010). Compression bandaging is the optimum treatment for venous leg ulcers (Annells, O’ Neill and Flowers, 2008, Callum, Nelson, Fletcher and Sheldon, 2001) however leg exercises and leg elevation also contribute to reducing the risk of venous leg ulcers. Numerous compression systems are available for leg ulcer treatment, these include compression stockings (e.g. U-Stocking), elastic tubular support bandages, multi-layer bandage systems (e.g. Profore). Venous leg ulcers can have the following 2

consequences for the patient; pain, restricted mobility and social isolation (Annells et al., 2008). The application of compression bandaging is a complex skill as it requires the nurse to be knowledgeable of the adequate levels of sustained graduated compression necessary. As well as to be cognisant of the circumference and shape of the limb, as this is also thought to have an influence on the pressure produced beneath a compression bandage. It is important to apply bandaging correctly to prevent damage and promote patient comfort. Therefore nurses need to be competent in theory and practice for correct application of compression bandaging to ensure patient safety (Beldom, 2008). Patients need to adhere to compression bandages over a long period of time, if not forever, to achieve the benefits of the therapy and prevent recurrence (Moffatt et al., 2004). Nonetheless, some patients fail to comply with instructions regarding treatment. Non-adherence to compression therapy is a very common occurrence due to many factors, such as, pain and discomfort, lack of knowledge or understanding, aesthetics and hygiene (Moffatt, Kommala, Dourdin and Choe, 2009). The nurse needs to address these barriers to combat the high recurrence rate of venous leg ulcers in patients (Finlayson, Edwards and Courtney, 2008).

To investigate this topic further, this assignment explored pertinent literature. The electronic database namely Cumulative Index of Nursing and Allied Health Literature (Cinahl), PubMed and ScienceDirect were searched using the following Boolean/phrase ‘venous leg ulcer’ and ‘compression therapy’. This yielded a large number of citations which was narrowed to include; recently published articles (within the last 6 years), both qualitative and quantitative research designs and explored patients’ adherence to compression therapy. Two common themes emerged from this literature regarding adherence to compression therapy. Firstly trust and 3

information with regards to adherence to compression therapy was evident and secondly, discomfort and non adherence to compression therapy.

1.1 Trusting and Information with regards to adherence to compression therapy A qualitative, phenomenological, descriptive study was conducted by Van Hecke, Verhaeghe, Grypdonck, Beele and Defloor (2010) to explore the processes underlying adherent behaviour among patients with venous leg ulcers. This study was conducted in Belgium and introduced an intervention programme to improve adherence to leg ulcer advice. Participants (n=25) were predominantly female (n=15) age range was 71-85 years and had a long history of recurring leg ulceration (n=9). The intervention progaramme was led by tissue viability nurses (TVN) and was conducted over a 12 week period. This study collected data on the patients experience and viewpoints of living with venous leg ulcers and examined their knowledge. Pain severity was recorded and patients utilized hosiery aids as well as specific leg exercises to treat venous leg ulcers in the intervention group.

Results of this study showed a strong correlation between adherence to leg ulcer treatment and trust in the nurse-patient relationship. The patients reported being confident in the information they received from the TVNs to manage their ulcers. The TVNs were spending meaningful time understanding the patient in a holistic manner, not just focusing on the wound. This trusting relationship initiated adherence, as patients were inclined to follow the TVN’s advice even if they did not entirely understand why, but solely due to the trusting nurse-patient relationship. However, when improvement was seen, patients were further convinced of the benefits of the 4

advice given to them by TVN. Some patients did not reap the benefits of the intervention, a number of patient had a negative attitude and doubted the therapy’s effectiveness. Others reported side-effects such as a ‘pulling sensation’ when conducting leg exercises and as a result discontinued the therapy. Despite this, one participant continued the therapy, but only due to the trust they conveyed in the nurse. The knowledge and understanding of the theory supporting the need for compression therapy may enhance a greater adherence (Van Hecke et al., 2010). Data was collected using semi-structured interviews with open-ended questions. This further created a trusting relationship and allowed the patient to express their experience openly. Akin to this, the study was carried out in participants homes, using this environment permitted participants to be more relaxed during the interview and helped build on the trusting relationship (Polit and Beck, 2006). As patients were attending the assessment each week as part of the intervention programme, this built on the trusting relationship with the nurses. This was also evident in the study results by Van Hecke et al., (2010) where trust acted as a mechanism for patient adherence. However, it is important to note that as the TVNs’ designed the intervention programme, the interpretation of the results may be affected by biased opinion.

In a review conducted in Canada by Moffatt, Kommala, Dourdin and Choe (2009) reasons for non-adherence to leg ulcer treatment were found to include patients not clearly understanding their condition or the prescribed therapy. Thereby patients felt that wearing of compression stockings was unnecessary. Similarly, Annells, O’ Neill and Flowers (2008) set out to describe and explore the reasons for use or non-use of compression bandages by district nurses. The research employed a qualitative, descriptive design with use of interviews. The authors found that knowledge was an 5

important factor affecting district nurses use of compression bandaging; namely their ability to identify venous leg ulcers and application of appropriate bandaging. However, the most dominant finding was that patients were not adhering compression therapy. The non-adherence of patients to compression bandaging was explored, and where non-adherence occurred the nurse educated and encouraged the patient to comply with treatment. Also in this study, findings reported a link between adherence and advice given by the nurse, when patients accepted education and trusted in the nurses advice adherence to therapy improved. The above three studies conveys the correlation of the trusting nurse-patient relationship and educational information, to patient adherence to compression therapy.

1.2 Discomfort and non adherence to compression therapy

Mudge, Iris, Simmonds and Price (2007) conducted research in Cardiff, which investigated adherence and comfort associated with using a particular compression therapy: a 2-layer compression system, over a 6 week period with patients who had a history of non-adherence to other compression therapies. The authors used an exploratory, descriptive approach to conduct the study in a community setting. The study required 30 participants with a history of non-adherence to previous compression therapies. Assessments of the intervention were performed at the end of every week. It is important to note that 17 of the participants reported having previous ulcers at the same location as present ones, hence, emphasizing the non-adherence to previous leg ulcer treatments and highlighting the complications of non-adherence. The first week’s assessment is the only one in which data from all original 30 participants was recorded, as after this, patients began to withdraw due to early wound 6

healing, signifying the benefits of the compression therapy. However, the lack of knowledge regarding length of therapy time needed, was not known by the patients. It should be noted also that this could perhaps be a reason for adherence from the remaining participants (seeing direct results). Comfort, along with bulkiness and satisfaction was among the reasons for non-adherence to previous compression bandages. A 5-point Likert Scale was employed to gauge levels of comfort, portraying that 14.8% of participants found the compression uncomfortable. Moffatt et al.’s study (2009) also found pain to be a contributing factor for non-adherence. Therefore, it is important to take note of pain when assessing compression therapy. The conclusion of Mudge et al., (2007) study, 17 patients were still using the therapy, and 76% wished to continue it. This conveys the success of the 2-way bandage system due to it being less bulky, more comfortable and more satisfying, as reported by 67% of participants. This could be due to the continued contact of the nurse to keep updating the patient on information and inquiring about their level of comfort with the bandage. Similarly, the findings by Annell et al., (2008) was that patients were often not willing to comply or were reluctant to use compression due to pain and discomfort.

Junger, Wollina, Kohnen and Rabe (2004) set out to investigate the efficacy of an ulcer compression stocking (U-Stocking) compared with a below the knee compression bandage. The quantitative study consisted of patients (n=121) who had to apply either the U-Stocking or bandages for 8-12 hours per day, for 12 weeks. The findings of this studied found one participant refusing and withdrawing from participation in the study once they had realized that they would be put in the ‘bandages’ group via random selection. This signifies the participant’s previous dissatisfaction of compression bandaging. Adherence was seen by the nursing staff 7

involved in 97% of the U-Stocking group in comparison to 85% of the bandages group. Results also showed that less pain and discomfort was reported among the Ustocking group. It should be noted that patients received instruction and a written information leaflet on how to fit the U-Stocking, as well as correct and accurate leg measurement from trained professionals. The U-Stocking was easier to apply, only one participant receiving help with U-Stocking compared to five with the bandages. Nursing staff also agreed that more participants preferred the U-Stocking over the bandages due to less discomfort, as well as better effects and satisfaction. Both the compression treatments had a high level of adherence, however the U-Stocking caused less pain and discomfort. The above reviewed literature demonstrated the strong correlation between discomfort and pain and non- adherence to compression therapy. 1.3 Conclusion

Ultimately, on reviewing the above literature, many conclusions about adherence to compression therapy can be drawn. For instance the primary reasons for adherence to treatment were evident in the findings of Van Hecke et al., (2010) and Moffatt et al., (2009). These were trust between the nurse and patient and, informational needs of the patient. The primary reasons for non-adherence was discomfort and pain along with dissatisfaction, bulkiness of dressing and difficulty applying. It was coherent throughout that in order for compression therapy to be adhered to; it is both the responsibility of the nurse and the patient to be actively involved. The skill of the nurse, as well as relevant knowledge and information is essential for accurate application of compression therapies, so as, to avoid what causes non-adherence, such 8

as discomfort and pain, and promote comfort. It is also vital for the nurse to convey their knowledge to the patient in order to reiterate this. Pain assessment was not an aspect that was appropriately discussed with regards patient discomfort. Pain assessment in concordance to wound and patient assessment is something that warrants future research. Venous leg ulcer education and understanding that patients need to receive is also notable, as it was proven to be linked with adherence to compression to therapy.


References: Annells, M., O’Neill, J. and Flowers, C. (2008) Compression bandaging for venous leg ulcers: the essentialness of a willing patient. Journal of Clinical Nursing 17:35050 Belsom, P. (2008) Compression Bandaging: avoiding pressure damage. Wound Care S6-S14 CONUEL (2009) Conferencia Nacional de Consenso en Ulceras de Extremidad Inferior. EdikaMed, SL, Spain. Cullum, N. Nelson, EA. Fletcher AW and Sheldon, TA. (2001) Compression for venous leg ulcers. The Cochrane Database of Systematic Reviews. 2. The Cochrane Collobration. Finlayson, K., Edwards, H. and Courtney, M. (2008) Factors associated with recurrence of venous leg ulcers: A survey and retrospective chart review. International Journal of Nursing Studies 46: 1071-78 Finlayson, K., Edwards, H. and Courtney, M. (2010) The impact of psychosocial factors on adherence to compression therapy to prevent recurrence of venous leg ulcers. Journal of Clinical Nursing. 19;1289-97. Gonzalez-Consuegra, R.V. and Verdu, J. (2011) Quality of life in people with venous leg ulcers: an integrative review. Journal of Advanced Nursing 67(5), 926-944. Heinen, M., Van der Vleuten, C., de Rooij, J. M., Uden, J. C., Evers, W. A. and Achterberg, T. (2007) Physical Activity and Adherence to Compression Therapy in Patients With Venous Leg Ulcers American Medical Association 143(10):1283-88 Hopkins, A. and Worboys, F. (2005) Understanding compression therapy to achieve tolerance. Wounds UK 1(3): 26-34 Junger, M., Wollina, U., Kihnen, R. and Rabe, E. (2004) Efficacy and tolerability of an ulcer compression stocking for therapy of chronic venous ulcer compared with a below-knee compression bandage: results from a prospective, randomized meta centre trial. Current Medical Research and Opinions 20(10)1613-23 Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P. and Bucher, L. (2007), 7th Ed., Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Mosby Elsevier, Missouri. Moffatt, C. J., (2004) Factors that affect concordance with compression therapy. Journal of Wound Care 13 (7): 291-94 Moffatt, C., Kommala, D., Dourdin, N. and Choe, Y. (2009) Venous leg ulcers: patient concordance with compression therapy and its impact on healing and prevention of 10

recurrence. International Wound Journal 6(5): 386-93 Mudge, E. Ivins, N., Wendy, S and Price, P. (2007). Adherence to a 2 layer compression system for chronic venous ulceration. British Journal of Nursing 16(20) s4-12. Polit, F. D. and Beck T. C. (2006) The Essentials Nursing Research: Methods, Appraisal and Utilization 6th Ed., Lippincott Williams and Wilkins. Simon, D. A., Dix, F. P. and McCollum, D. C. (2004) Management of venous leg ulcers. British Medical Journal 328: 1358-62. Templeton, S. and Telford, K. (2010) Diagnosis and management of venous leg ulcers: a nurse’s role? Wound Practice and Research 18(2) 72-79. Van Hecke, A., Verhaeghe S., Grypdonck, M., Beele, H. and Defloor, T. (2010) Processes underlying adherence to leg ulcer treatment: A qualitative field study. International Journal of Nursing Studies 48:145-55


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