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Psycho social issues of patients with malignant wounds nursing essay

This article was originally published in the Journal of Tissue Viability and is reprinted in World Wide Wounds by kind permission of the publishers. Abstract At present, recognition of the importance of psychological factors in the care of individuals with diabetes is still in its infancy. Understanding of the specific psychological factors relating diabetic foot ulceration is embryonic.

The study reported in this paper begins to raise awareness of psychosocial quality of life issues for patients living with diabetic foot ulceration, as narrated by the patients themselves. Findings revealed a range of restrictions on daily life that profoundly affected the individual's sense of self.

These findings have implications for patients' adherence to treatment. Implications of these findings for health promotion are also reported. Introduction A growing awareness of the importance of psychological and social influences on health and illness has led to the development of a biopsychosocial framework [1] for research and psycho social issues of patients with malignant wounds nursing essay.

This integrative mode [1] has served as a basic framework for academic and clinical research in many areas, including assessment of patients' health-related quality of life HRQoLas the inseparable nature of physical, psychological and social factors are taken into account [2]. Despite the recent burgeoning of methods for assessing HRQoL [3][4] most studies still represent a largely clinical perspective, although many originate from patients' concerns.

Self-reported perceptions of health and HRQoL have frequently been viewed as poor data compared to the 'hard' evidence provided by biochemical, physiological and psychological tests [5]. It has further been argued [6][7] that the data collected have led to a confusion of two distinct forms of information - objective and subjective data - with all data becoming subsumed within a common measure.

This in turn has led to the negation of the importance of the patients' subjective experiences and appraisal of their own wellbeing. This factor is of particular concern since health professionals have been shown to rate patients' HRQoL very differently from the patients themselves [8]. One of the consequences of health professionals' dominance in patient care and issues relating to patients' HRQoL has been that interpretation of patients' needs has been within a climate of professionalisation within medical discourse.

As a consequence, the emphasis has been on addressing largely physiological issues.

  1. The issues raised by participants in the study were reported to the clinicians at the hospital by the research team and some minor changes in care were instigated immediately. A process of interpretative phenomenological analysis refined the raw data [29].
  2. Experiencing discredited definitions of self Most of the participants in the study reported experiencing discredited definitions of their sense of self as a direct result of foot ulceration.
  3. I talk to people about sexually transmitted diseases and any of these things can lead to discussing sex.

Research has demonstrated that doctors who are still largely trained in the medical model [9] are often unwilling and unable to adopt a biopsychosocial approach to patient care [10]. Perhaps if greater voice were given to patients' own perspectives then more attention would be given to psychological and social issues alongside the biological factors. Research in individuals with diabetes has suggested that HRQoL is affected by a range of factors including effective metabolic control and positive mental health [11][12].

However, given the confusion concerning collection and interpretation of data within studies [6][7] it can be argued that these findings are limited. The research is further limited because application of the biopsychosocial framework to the care of individuals with diabetes, including factors related to HRQoL, has mainly emphasised the management of physical symptoms. This negation of psychological and social factors is despite the increasing recognition by those involved in the health care of people with diabetes that many patients experience major, long-term psychological and social difficulties.

Currently in the UK, psychological care following referral is available only for those with 'severe problems' [13].

It has been argued [3] that this is a serious omission in care, having also major implications for health promotion for these individuals. Holistic patient care requires attention to physical, psychological and social areas of life, a premise which formed the foundations of the biopsychosocial model [1]. In this way the difficulties and traumas of living with diabetes - at all levels - are addressed.

If these interrelated issues are not taken into account, this limits not only immediate intervention, but also the effectiveness of health-promoting practices and long-term care, since biological, psychological and social areas of an individual's life are interconnected and reciprocally influential.

Indeed, while biological elements of care are clearly important, research has suggested that psychological and social factors are highly influential in determining patients' health-related behaviour [14].

Foot ulceration in diabetes Foot ulcers are defined as major erosions of the epithelium that extend into the dermis and deeper tissues and are associated with reduced healing capacity [15]. In the UK, there are over 1. A study by Young et al showed 10. Symmetrical distal psycho social issues of patients with malignant wounds nursing essay that encompasses motor, sensory and autonomic involvement is important in the pathogenesis of foot ulceration.

Foot infections are the most common reason for admission to hospital among people with diabetes [15][20][21]. Additionally, many people with diabetes who proceed to amputation have previously experienced foot ulceration. It is clear that foot ulceration is a major complication of diabetes for many patients and from an economic perspective the impact of foot ulceration on this patient group is well recognised [15][22][23].

However, there is a paucity of research into the specific effects of foot ulceration on the psychosocial HRQoL of patients. Further, although studies have reported psychosocial concerns experienced by patients with diabetes [24][25] and the complications of lower extremity ulcers [26]there is little qualitative research which outlines patients' perspectives of living with foot ulceration. Given that foot ulceration is a common complication of a chronic condition, this void in research is important, particularly in the context of the studies presented above.

Additionally, work with patients with chronic illnesses [27] suggests that many patients experience major psychological and social difficulties specific to their condition, which impact upon their HRQoL. Qualitative research which emphasises meaning and understanding [28] is the appropriate methodology for exploring these issues. Aim of the study This study aimed to address the lack of research relating to both psychosocial HRQoL issues for patients living with diabetic foot ulceration and also the limited number of studies that reflect patients' perspectives.

Method A phenomenological approach using semi-structured, conversational interviews was used to enable participants to record their own experiences within this aim. Each interview was tape-recorded, transcribed in full and given a code to preserve the anonymity of the participants.

Every transcript was read line by line and summarised by the researchers in order to obtain a complete view of the interview and identify all the topics discussed. A process of interpretative phenomenological analysis refined the raw data [29]. The different professional and academic backgrounds of the researchers podiatry, nursing and psychology facilitated a multidisciplinary approach to analysis.

The use of multiple raters is relevant to phenomenological study [30] since it facilitates indication and eradication of any inconsistencies between the raw data and the researchers' interpretations. Ethical approval was obtained for the interviews from the research ethics committee in the NHS trust concerned and from the consultant and nursing staff in the foot clinic.

Sample A total of 47 people who met the criteria for inclusion aged 18 years or over, diagnosed with diabetes and foot ulceration and who attended a clinic for diabetics with foot problems were invited to participate in the study. None of the participants who declined to participate or who agreed initially but subsequently changed their minds wished to give the reason why. Twenty one interviews were recorded fully. The mean age of the female participants was 59.

Eight participants 4 male and 4 female had been diagnosed as having non-insulin-dependent diabetes mellitus NIDDM and the remaining participants 11 male and 2 female had been diagnosed as having insulin-dependent diabetes mellitus IDDM.

Two men were South Asian but were fluent in English and did not require an interpreter. One man was African-Caribbean. The remaining participants were Caucasian and did not volunteer any information pertaining to ethnicity. In addition to their foot ulcers, 15 participants were suffering from consequences of diabetes other than foot ulceration, including failing eyesight, heart disease and kidney disease. The presence of these complications raised concerns for the researchers about the extent to which the views and experiences of the participants were attributable to foot ulcers and how far they reflected the difficulties of living with diabetes as a condition.

For this reason all participants were prompted to talk specifically about the psychosocial effects of their foot ulceration on HRQoL. The researcher commenced each interview with a statement concerning the aim of the study to explore HRQoL issues relating to foot ulceration. Throughout each interview, prompts were repeatedly framed within a context of this aim such that the emphasis of the interview was consistently on how foot ulceration as a complication of diabetes was affecting HRQoL.

Findings Analysis of interviews revealed a number of themes which can be discussed within a context of 'loss'. Participants' narratives recorded a sense of psycho social issues of patients with malignant wounds nursing essay of the life they had experienced before the foot ulceration and also an associated loss of 'sense of self'. As a consequence, the data are discussed here within the Charmaz [31] framework of 'loss of self'.

Charmaz argued that individuals with chronic conditions become highly aware of previously assumed aspects of 'self' that are now lost.

  • Canadian Journal of Podiatric Medicine 1998; 33 2;
  • Diabetes 1991; 40 10;
  • Additionally, work with patients with chronic illnesses [27] suggests that many patients experience major psychological and social difficulties specific to their condition, which impact upon their HRQoL;
  • One influential prospective study of 279 men with early prostate cancer appeared to show greater sexual dysfunction and urinary incontinence in the year following radical prostatectomy than after radiotherapy [ 1 ].

She proposed that this loss of self is exacerbated by four psychological conditions: All four conditions were seen in the narratives of the participants. Findings in relation to each of these are discussed below.

'Loss of self': a psychosocial study of the quality of life of adults with diabetic ulceration

Living a restricted life Many participants reported that diabetic foot ulceration had had a major impact on their freedom to live life as they did before.

Restrictions resulting from reduced mobility, the need to attend clinic and ensuring that effective care is taken of the feet were reported by the majority of participants, as in the extract below: When you stop to think about it you could just get up and go and now you can't; you're restricted; you have to take care not to knock your leg; you have to be careful that you don't tread on anything that you know is on the ground.

For example, one female participant commented on the restrictions to her life as a grandparent, as she was unable to undertake activities associated with the role: I mean his other nan took him to feed the ducks and things. And it choked me because I thought, well, I should be doing that as well.


Other dysfunction was also reported, including psychological effects of restricted choice in all aspects of life and particular issues of lack of self-efficacy [32]. For example, one man who had been encouraged by professionals to rest his ulcerated foot, and thus remain immobile, reported that after 3.

He had begged, without success, for amputation and seriously considered doing the job himself because. And I was determined one way or another to get it off. In fact I contemplated going to the railway station which isn't very far from me and leaving it on the railway line, because I was getting desperate. Another man who was blind reported that although he was aware of the necessity for effective foot care, continuous and consistent attention restricted his life.

As a consequence, he determined to ignore the restrictions and wear the shoes he wished. Unfortunately the results of his action were severe: Next day she [his wife] looked at my feet and said there were blisters, very big blisters.

So it's my own mistake. He realised that such behaviour brought possible consequences, but felt that the risk taken was compensated for by the sense of freedom and release from the vigilance and restrictions of his life which were necessary to control his diabetic foot ulceration [33]. This decision and resultant behaviour is reflected in the research that suggests that many patients will actively psycho social issues of patients with malignant wounds nursing essay clinical advice which demands a reduction in QoL in return for reduced risk of long-term illness complications [34].

These findings have many important implications for health professionals, not only in terms of compliance with treatment, but also in the context of health promotion. They support the view that focussing on the physical realities of the condition to the detriment of the psychosocial features of HRQoL has important, limiting effects on patient care and strategies for intervention.

Existing in social isolation Most of the participants reported negative effects of foot ulceration on social roles and activities. Restricted mobility, pain and lack of employment all contributed to a growing sense of social isolation. Enforced unemployment impacts on the individual not only in financial terms, but also psychosocially. Social networks developed purposefully through shared work experience cease to have meaning or value and become increasingly problematic to maintain.

Relationships with former work colleagues were gradually eroded as the once shared experiences of the work environment were no longer relevant. Additionally, physical isolation caused by reduced mobility was reported by four male participants. For example, one man had experienced difficulties in accessing suitable toilet facilities as a wheelchair user and consequently found going out of the house stressful.

Another man spoke of being unable to leave his flat, even to go into the garden, unless two people were available to lift his chair up and down the steps either at the back or front of his house.

Sexuality and Cancer: Conversation Comfort Zone

This did not happen often and he therefore felt a deep sense of social isolation and psychological distress. Experiencing discredited definitions of self Most of the participants in the study reported experiencing discredited definitions of their sense of self as a direct result of foot ulceration.

  • These individuals highly valued conventional sexual intercourse;
  • Diabetes in the UK;
  • Other dysfunction was also reported, including psychological effects of restricted choice in all aspects of life and particular issues of lack of self-efficacy [32];
  • And it choked me because I thought, well, I should be doing that as well;
  • Psychotherapy and Psychosomatics 1990; 54;
  • Conclusion Although small, this qualitative study has highlighted individuals with diabetes' experiences of their psychosocial HRQoL as they live with diabetic foot ulceration.

Different reasons for this response were narrated, but a major if simple issue reported was the inability to bathe or shower.