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Stewart, Ann, Edwards, Helen, & Finlayson, Kathleen(2018)Reflection on the cause and avoidance of recurrent venous leg ulcers: aninterpretive descriptive approach.Journal of Clinical Nursing, 27 (5-6), pp. 931-939.
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https://doi.org/10.1111/jocn.13994
1
REFLECTION ON THE CAUSE AND AVOIDANCE OF RECURRENT VENOUS LEG
ULCERS: AN INTERPRETIVE DESCRIPTIVE APPROACH
TITLE PAGE
Short title: Reflection on Recurrences
Ann STEWART RN MN (Hons) Clinical Nurse Consultant Community Nursing The Sutherland
Hospital Sydney, PhD Candidate Queensland University of Technology, Wound Management
Innovation Cooperative Research Centre
Address: 26 Kareena Rd Miranda NSW 2228 Australia
Business phone: 61295407076 Mobile: 61409417782 Fax: 61295407855
Email: [email protected] Corresponding author
Professor Helen EDWARDS RN PhD OAM Assistant Dean (International and Engagement) Institute
of Health and Biomedical Innovation Faculty of Health Deans Office Queensland University of
Technology
Address: Victoria Park Rd Kelvin Grove Kelvin Grove QLD 4059 Australia
Business phone: 61731384523 Fax: 61731384523
Email: [email protected]
Dr Kathleen FINLAYSON RN PhD Research Fellow Institute of Health and Biomedical Innovation
Faculty of Health School of Nursing Queensland University of Technology
Address: 60 Musk Ave Kelvin Grove
Business phone: 61731386105 Fax: 61731386030
Email: [email protected]
Funding Statement: This work was supported by the Wound Management Innovation CRC
established and supported under the Australian Government’s Cooperative Research Centres Program.
It was also supported by South Eastern Sydney Local Health District.
There is no conflict of interest
2
REFLECTION ON THE CAUSE AND AVOIDANCE OF RECURRENT VENOUS LEG
ULCERS: AN INTERPRETIVE DESCRIPTIVE APPROACH
ABSTRACT
Aims and objectives: To gain insight into the experience of recurrent venous leg ulcers from the
individual’s perspective and provide knowledge on potential risks of recurrence not previously
investigated.
Background: Venous leg ulcers are a consequence of chronic venous disease and frequently recur.
They are costly and can impact on physical and psychological health. Despite research suggesting the
risk can be reduced through compression and lifestyle changes, recurrence rates are often high. This
study provides an insight into individual’s perceptions of the cause of their ulcers and how they try to
avoid them.
Design: A qualitative design guided by the Chronic Illness Trajectory Model and Social Cognitive
Theory
Method: A purposive sample of three males and four females were recruited from a community
nursing clinic. Participants were ulcer free, had experienced at least two previous venous leg ulcers
and could speak and comprehend English. An interpretive descriptive approach was taken using semi-
structured interviews and thematic analysis.
Results: Three themes each containing three categories emerged: The Increasing Influence of the
Recurring Wound on Mind and Body, Reflection on Past Experiences and Optimism in the Face of
Adversity. Most participants reported traumatic injury and lower leg surgery triggered ulcer
recurrence. Failure to replace compression stockings was also deemed a cause. Compression was
reported essential but some participants were unaware of the level they were wearing and how often it
should be replaced. Other preventive activities included avoiding injury and securing immediate
assistance if wounding occurred.
3
Conclusion: Clinicians need to be aware that lower leg surgery may trigger recurrent venous
ulceration and that individuals require ongoing emotional, physical and financial support throughout
the trajectory of venous disease. The continued use of old compression stockings should be avoided
and recurrence prevented by adoption of evidence based practice rather than reflection on past
experiences.
Key Words: Nursing, recurrence, venous leg ulcer, qualitative research, chronic disease
What does this paper contribute to the wider global clinical
community?
This research alerts clinicians of the possibility that
lower leg surgery could trigger recurrence of venous
ulceration
Compression stockings are not always replaced due to
the expense and raise the risk of recurrent venous leg
ulceration resulting in a financial and social impact on
the individual and the community.
Ongoing education and support for individuals with
venous disease will assist in the provision of evidenced
based management rather than dependence on past
experiences.
4
REFLECTION ON THE CAUSE AND AVOIDANCE OF RECURRENT VENOUS LEG
ULCERS: AN INTERPRETIVE DESCRIPTIVE APPROACH
INTRODUCTION
A distressing characteristic of venous disease is a recurring leg ulcer, where the episodes of ulceration
frequently increase in intensity and length. It has been estimated that about 1% of the adult population
has experienced venous leg ulceration (Fowkes, Evans, & Lee, 2001). Recurrence rates are high and
reports in the literature inconsistent (Reeder, Eggen, Maessen-Visch, de Roos, & Martino Neumann,
2013).Venous leg ulcers can affect physical and psychological health, reduce quality of life
(González-Consuegra & Verdú, 2011; Green, Jester, McKinley, & Pooler, 2013) and are costly for the
individual and the community. This qualitative study gained information about the perceived causes
and prevention of recurrence from the individuals’ perspectives through an interpretive descriptive
approach guided by the integration of the Chronic Illness Trajectory Model and Social Cognitive
Theory. All participants had experienced recurrent venous leg ulcers and were ulcer free at time of
interview.
BACKGROUND
Venous leg ulcers are a consequence of primary or secondary venous disease. The two aetiologies
have different time trajectories and consequences. Primary venous disease generally develops over
many years commencing in the superficial venous system and gradually extending into the deep
venous system (Labropoulos, Gasparis, Pefanis, Leon, & Tassiopoulos, 2009; Marston, 2010).
Conversely secondary venous disease has a more rapid onset and is often initiated by deep venous
thrombosis. Superficial venous thrombosis has also been implicated as it has been found to sometimes
extend into the deep venous system (Décousus et al., 2011; Milio et al., 2008). Both aetiologies result
in venous reflux however the secondary condition also has outflow obstruction and is associated with
a higher incidence of recurrence (Labropoulos, et al., 2009; Bradbury, 2010; de Souza, Yoshida, de
Melo, Aragão, & de Oliveira, 2013). Ulceration is precipitated by underlying venous insufficiency or
5
by a break in the integrity of the skin and wound healing is impaired by venous disease. Treatment
and or lifestyle changes may be required to break the cycle of recurring ulceration.
Surgery or endovascular procedures are sometimes warranted to treat venous disorders (Mosti, 2012)
and compression therapy (Nelson & Bell-Syer, 2014), found to significantly reduce the likelihood of
ulceration but concordance is often difficult to achieve (Harding, 2016; Moffatt, Kommala, Dourdin,
& Choe, 2009). Despite the discomfort and difficulty with application and removal there is often
interplay of more complex issues. High levels of self-efficacy and social support have been identified
as the catalyst in making positive lifestyle changes (Finlayson, Edwards, & Courtney, 2011) and
depression found to inhibit the use of compression therapy (Finlayson, Edwards, & Courtney, 2010).
Shannon, Hawk, Navaroli and Serena (2013) found increased body weight to be associated with
recurrence and not lack of compression therapy. In another study lifestyle changes were not
considered by participants who believed their initial ulcers were an acute skin problem which would
resolve with healing (Van Hecke, Beeckman, Grypdonck, Meuleneire, Hermie & Verhaeghe, 2013).
Some lifestyle changes have been achieved through therapeutic social groups such as the Lively Legs
Program (Heinen et al., 2012) and Leg Clubs (Lindsay & Tyndale-Biscoe, 2011) but attendance at
these is yet to demonstrate a reduction in recurrence rates.
Qualitative research has provided some insight into management and experience of venous disease
post-healing. Education pre-healing and an understanding of the chronic condition were reported as
key factors in making positive lifestyle changes (Kapp & Miller, 2015). In an earlier study knowledge
of the underlying disease and an understanding of the rationale behind treatment also predicted the
individual’s ability to manage their condition (Flaherty, 2005). However, despite the use of
compression and the belief that it was beneficial most participants experienced ulcers caused by
trauma and a recurrence whilst wearing compression stockings. Protecting the legs from injury
became an important preventive activity.
6
The association of these issues with recurrence suggests the need for a further in-depth study
focussing on the individuals’ perception of the cause of their recurring ulcers and how they attempt to
avoid them.
The aim of the study was to provide knowledge on other potential risks of recurrence that have not
been previously investigated. The research question: What are participants’ perceptions of the cause
of their recurrence and how do they manage avoidance?
METHODS
Design
A qualitative design using semi-structured interviews was chosen for the study. Interpretive
description (Thorne, Kirkham, & MacDonald-Emes, 1997) methodology enabled participants to
reflect on their previous leg ulcers and provide insights into what they believed were the cause and
how they tried to avoid subsequent ulceration. Interpretive description is an appropriate method to
gain information for clinical issues (Thorn 2008).
The study was guided by the integration of the Chronic Illness Trajectory Model (Corbin, 1998;
Corbin & Strauss, 1991) and Social Cognitive Theory (Bandura, 1986). The Chronic Illness
Trajectory Model asserts a chronic disease passes through a sequence of events which can be
manipulated or controlled with effective management. Social Cognitive Theory implies that an
awareness of the benefits and risks of health behaviours is a prerequisite to behavioural change.
Change depends on the individual’s perceived self-efficacy, their personal goals, outcome
expectations and any impediments that prevent action (Bandura 2004). This combination addresses
the physical cause of recurrence and the psychological issues which are a barrier to behavioural
change.
Purposive sampling facilitated the selection of participants with a varied leg ulcer history. Theoretical
sampling was employed as the research progressed to ensure the inclusion of participants whose
wounds had recently healed and those who were experiencing a long period of remission. Participants
7
were selected from the data base of the Community Nurses’ Clinic at a metropolitan hospital. Clients
receiving treatment for recurrent venous leg ulcers were informed about the study and were
approached by the researcher if they expressed interest in participating. Others who had not presented
at the clinic for some time were contacted by the researcher and invited to participate. Participants
were required to speak and understand English, have had at least two previous leg ulcers of primarily
venous aetiology and have an ankle brachial pressure of > 0.8 and < 1.3. All participants were ulcer
free at time of interview. Wound healing was defined as complete epithelialisation for a minimum of
two weeks. The sample comprised seven participants whose previous venous leg ulcer aetiology had
been diagnosed by their vascular surgeon or general practitioner. The researcher did not have access
to the medical officers’ records and therefore details of their previous investigations and surgical
history were unknown and it was unclear if their ulceration was a consequence of primary or
secondary venous disease. However, two participants had experienced a deep venous thrombosis in
their effected leg and one participant reported having a congenital abnormality in the vein in her leg.
Two females had been diagnosed with factor 5 Leiden. Pseudonyms are used to protect confidentiality
(see Table 1).
Ethical approval was gained from the local health district Human Research Ethics Committee (HREC)
and the university (HREC). Participants were informed about the study prior to giving written
consent. Confidentiality was ensured by giving participants a pseudonym and removal of identifying
information from the data.
Data Collection
Data were collected by the researcher between November 2014 and May 2015. Face to face semi-
structured interviews were conducted in a quiet room in the community health department at the
hospital. Interviews were audio-recorded and lasted between 20 and 30 minutes. Interview length was
related to participants’ knowledge of their venous disease and the complexity of their physical health
problems. Field notes were written after the interview and data were promptly transcribed by a
professional transcriber. A journal was kept by the researcher throughout the study.
8
Data Analysis
Data collection and analysis were carried out concurrently and the methodological guidelines
provided by Colaizzi (1978) guided data analysis. Recordings were played and the narratives read
numerous times during analysis. Participants’ non language verbalisations, pauses and the
researcher’s notations from the field notes and journal assisted with interpretation of the data.
Significant statements were selected from the transcripts and assigned to an analysis table (Graneheim
& Lundman, 2004). Clustering of similar statements assisted with recognition of patterns. These
statements were further condensed and labelled codes which led to the identification of a common
thread or category. A deeper understanding of the data was then sought resulting in the identification
of themes. A final preferred step used in interpretive description of confirming observations and
tentative interpretations of the data (Thorne 2008) was carried out with participants, a wound care
clinician and a wound care expert.
Trustworthiness of the research was assured by attention to credibility, transferability, dependability
and conformability as suggested by Lincoln & Guba (1985). Rapport was established with
participants prior to the interview to prolong the engagement and encourage an open and honest
contribution. Member checks were carried out which gave participants opportunity to check their
contribution. The research process and method of analysis were clearly articulated and field notes and
subjective reflections considered in data analysis. Additional requirements for interpretive description
(Thorne 2008) ensured interpretation of findings consistent with the research question and appropriate
selection of participants.
RESULTS
Seven participants whose age ranged from 54-84 years, with a varied experience of recurrence
provided insights into the cause and prevention of their venous leg ulcers (see Table 1). Three themes
each containing three categories emerged from the data (see Table 2).
Participants provided information on what they believed caused their recurrent venous leg ulcers and
how they endeavoured to avoid them. They valued the opportunity to talk about the issue and found
9
the experience cathartic. They reflected on the trajectory of their disease, pondered on past
experiences and provided predictions about the likelihood of remaining ulcer free. Information
distilled from their accounts is reported under three themes: The Increasing Influence of the Recurring
Wound on Mind and Body, Reflection on Past Experiences, and Optimism in the Face of Adversity.
The Increasing Influence of the Recurring Wound on Mind and Body
Participants reported how recurrences had impacted on their physical and emotional health. Healing
of initial ulcers had been usually straight forward but more recent episodes of ulceration were often
complicated by wound infections, hospitalisations or cellulitis. Almost all the sample had experienced
cellulitis and this had frequently occurred in the absence of ulceration. One participant reported:
I had cellulitis. Well the doctors think it was caused by the ulcer even though I thought it had
healed but there must be some underlying infection to make it flare up. It was quite a serious
infection I was in hospital for six weeks (Pam).
The trajectory of venous disease was generally not well understood as exemplified by the above
excerpt from the narrative. The absence of an active ulcer had given rise to an assumption that the
problems with the leg had been alleviated. Lack of knowledge about the condition left participants
surprised at the severity of complications of venous disease.
All participants believed their ulcers were caused by problems with veins in the legs but they had
generally been provided with little information about the extent of their problem and the repercussions
on their health if it was not addressed. One participant was informed of his “vein trouble” following
surgery and recounted the doctor’s words:
When I had a triple arthrodesis done the surgeon at the time said “You’ll have vein trouble
after this and you’ll need to get something done about it somewhere along the track”
(sometime in the future) (Bernie).
This participant did not understand the significance of his “vein trouble” until after he had his
Achilles tendon repaired and the surgical site became ulcerated. He describes how the area of
10
ulceration increased and the subsequent course of events as clinicians attempted to promote wound
healing:
I first went to the doctor because I had an ulcer behind my ankle (on the surgical site). Then
another started and it blew the thing open (the whole surgical site became ulcerated). They
tried a skin graft. It didn’t work. I went back into hospital and they stitched it. The stitches
pulled out. That didn’t work. Then the doctor suggested that I have five veins done (stripped)
in my leg which he did. Then we went onto the vacuum pump (topical negative pressure
wound therapy) for twelve weeks (Bernie).
The above quotation captures the participant’s frustration and confusion about his post-surgical
experience. The integrity of the skin on the previously healed surgical site had become impaired and
all attempts to promote healing were failing. Finally topical negative pressure wound therapy was
initiated. This misunderstanding and failure to treat the underlying venous disease had resulted in
lifestyle disruption, hospital admission, morbidity and expense.
The recurrence experience generated a sense of anxiety about protecting the skin. Wounds were often
not considered healed and the possibility of the wound breaking out again was predicted. Measures
taken to minimise this risk included application of a dry non-adherent dressing to the wound site and
or a delay in the use of a compression stocking. Some participants used a tubular elastic bandage in
the interim. The following excerpt was taken from a narrative where the participant’s wound was
deemed healed and the compression bandaging ceased by the clinician.
Oh it’s still very tender and I haven’t really had it (left) undressed… until today…We’re
doing the tubing (applying tubular elastic bandage) and I moisturise as much as I can to try
and toughen the skin up. Hopefully that works…Once the tubing has gone and the skin has
sort of hardened up we’ll use a compression stocking probably for the rest of my life (Mary).
The above quotation describes how the participant had nurtured the skin her leg following wound
healing. The heightened concern about prevention of recurrence had inadvertently resulted in
11
prioritising skin care over circulation. It was unclear how long these measures were intended to be
used before application of the compression stocking.
Reflection on Past Experiences
Participants reflected on what they believed initiated their previous ulcers and described their
subsequent actions and lifestyle changes post-healing in an attempt to avoid a recurrence. These
narratives portrayed their determination as they described how they had pieced together events
leading up to recurrences.
On a number of occasions recurrences occurred despite wearing compression stockings. Participants
believed the stockings in use at the time had not delivered appropriate compression and blamed
themselves. One participant recalled:
I couldn’t afford to buy new stockings because they were so expensive and the stockings that
I had, were not really giving me good compression and my legs broke down (re-ulcerated)
(Colleen).
This quote exemplifies the possible dilemma individuals are confronted with when new compression
stockings are required. The expense of the garments led to risk taking and the use of stockings which
did not deliver appropriate compression. The problem was not always failure to purchase new
stockings but also failure to discard worn out stockings as reported in the following excerpt:
I used to just buy a pair of compression stockings and when I felt they had just about had it
(were almost worn out) I’d go and buy another pair and then I’d get them mixed up and
wouldn’t know which was the new one and which one was an old one (Michael).
The deteriorating strength of compression in the old stockings had gone unnoticed providing a false
sense of security and increasing the likelihood of a recurrence.
On numerous occasions participants were able to recall traumatic injuries that resulted in ulceration as
demonstrated in the following excerpt from a narrative:
12
I believe it was something that bit me in the garden. I felt a sting…I took my shoes and socks
off and I couldn’t see anything but it was terribly itchy for a long time. So I just washed it and
cleansed it and a couple of days later after that that area broke out in a blister. Then a week
later the ulcer appeared (Pam).
Despite numerous events preceding ulceration the participant believed it was the sting that caused the
ulcer.
A number of recurrences were deemed to have been triggered by surgical procedures that failed to
heal and were associated with considerable morbidity. These included excision of lesions, joint
surgery and skin grafts. One participant explained her post-surgical ordeal:
I had a knee replacement. At one stage it (the wound) covered almost the whole front of my
leg… The plastic surgeon took the skin graft from the inside of the lower leg…and put it on
the other side of the leg. Well then the area they took the skin from became septic so I
virtually ended up with two sides of my leg ulcerated (Mary).
This participant describes how a small surgical wound on her lower leg failed to heal and increased in
area and how the integrity of the skin on her leg was further impaired through attempts to promote
wound healing through a skin graft where the donor site was taken from the same lower leg. The
quotation illustrates the possible morbidity following lower leg surgery when there is underlying
venous disease.
There were some reports of recurrences where triggers were unable to be identified. These ulcers
often developed in the same vicinity as previous ulcers as explained in the following narratives:
It was a strange thing it seemed to heal and then break down again (Pam).
Now the third one came up where the second one had been, like in the same space (Sandra).
13
These excerpts suggest that these recurrences were triggered by the underlying venous insufficiency
and not by an external event implying a different pathophysiology to that of ulcers triggered by
trauma.
Wearing compression stockings was the principal lifestyle change participants had made to avoid a
recurrence. They all acknowledged that this was important and attempted to tolerate what they
believed was adequate compression as described by one participant:
It’s just the one (the stocking) I buy at the chemist… it is very firm around the ankle section
around the lower part of the leg but not real tight at the top which helps (Fred).
The above quotation suggests comfort was a factor in the participant’s choice of compression
stocking.
Less than half the sample wore class II or Class III stockings. The remainder chose to wear
compression that was comfortable and few participants chose to make lifestyle changes such as
regular exercise and leg elevation. Leg elevation above the heart was only performed by two
participants. One participant reported:
I love to elevate my legs…every afternoon if I get the chance, but sometimes four times a
week, five times a week…for a couple of hours (Sandra).
Leg elevation was carried out by participants who were aware of the benefits. However, the majority
of the sample had little interest in this activity or found it difficult due to their decreased mobility.
Optimism in the Face of Adversity
An air of optimism prevailed following wound healing but this was accompanied with an underlying
uncertainty about avoiding a recurrence. Participants were generally hopeful about remaining ulcer
free as they had recognised what they believed had caused their previous ulcers. Despite this
positivity there was often some doubt detected in the narratives.
14
I elevate my legs I do the compression… I don’t think they’re going to come back. As I said
I’ve got no vein, I won’t get any more venous ulcers (Sandra).
This participant had made lifestyle changes and had veins stripped in her leg, which she believed
would prevent a recurrence. Her hesitation was clarified in her following quotation:
I have asthma. Sometimes I get really short of breath I concentrate more on the top half of
my body (Sandra).
Despite the self-assurance that the cause of the ulcers had been removed, management of a life
threatening co-morbidity took precedence over lifestyle changes that would further reduce the
likelihood of recurrence. Most participants had co-morbidities that needed attention periodically and
therefore managing preventive activities during these acute episodes might not be a priority.
A life-long commitment to lifestyle changes was generally recognised as essential for prevention of
recurrence but this became a daunting thought when inevitable age related changes in the body were
envisaged. One participant expressed his concerns:
I’ve got to admit as I get older I sometimes wonder how I’m going to get them (the
compression stockings) on and off because at this stage of my life I do get my wife to take
them off sometimes (Michael).
This excerpt from the narrative provides insight into the effort required to apply and remove
compression stockings and the need for social support and adequate levels of self-efficacy that would
enable the ongoing management of these activities.
Concerns about preventing injury to the legs heightened vigilance post-healing and situations likely to
pose a risk were avoided as explained in the following quotation:
I’m super careful that I don’t cut myself or damage my foot in any way or break the skin… I
get something done really quickly if it happens (Bernie).
15
Risks were minimised and cuts and abrasions treated immediately. Ulcers that recurred on the
malleolar or Achilles area were often described as being on the foot and in these instances there was
little concern expressed about the remainder of the leg.
A couple of participants were striving to lose weight. Colleen narrated her experience:
I’ve been losing weight for the last 18 months or so. The less weight I have to carry around
the less stress on my whole system and my legs (Colleen).
The above citation illustrates an understanding of a lifestyle change that would have a positive impact
on the health of the legs.
A number of changes in the legs, which signalled the progression of venous disease, were reported.
However, participants were not always aware of the significance of the changes. One participant
expressed his concerns:
My left leg has gone black. It does have me concerned at times. I have asked the doctor about
it and he’s mentioned that he is going to send me to a vascular surgeon (Fred).
The above account from the participant describes his concerns about venous staining and raises the
issue of early identification and treatment of venous disease. In this instance a referral to a vascular
specialist was made late in the trajectory of the condition.
DISCUSSION
This study has reinforced previous research and gained additional insight into the cause and avoidance
of recurrent venous leg ulcers from individuals who have experienced these wounds. Information
integral to patient care has been captured throughout the themes and if addressed could possibly
reduce the morbidity related to the disease.
Theme one describes the increasing severity and complexity of each recurrence and the subsequent
impact on participants’ physical and emotional wellbeing. They reported loss of mobility over time
and a sense of anxiety about developing another ulcer. It is unknown if these issues were related or
16
influenced by the ongoing use of compression bandages or by an exacerbation of comorbidities.
Feelings of anxiety surrounding recurrence have not been previously examined through research and
could impact on the individual’s ability to interpret their educational advice and manage their
condition. There were no reports of current feelings of depression, an emotion previously associated
with the underuse of compression therapy (Finlayson, et al., 2010).
It is not surprising most participants experienced cellulitis, as chronic venous disease has been
identified as a risk factor for recurrent cellulitis (Tay et al., 2015). However, on occasion there were
reports of episodes of cellulitis in the absence of an ulcer. This is uncommon as cellulitis does not
usually occur when the integrity of the skin is intact (Raju, Tackett, & Neglen, 2008). Therefore it is
possible other factors such as unnoticed dry cracked skin or tinea could have initiated the infection.
There were also reports of severe wound infections and subsequent hospitalisations. This increasing
morbidity with each recurrence suggests a corresponding increasing impact on health care costs.
Theme two portrays how participants reflected on their past experiences and retrieved information
that guided management of their venous disease. A dry dressing was frequently worn over the healed
wound to protect the fragile skin until it had strengthened. This activity was reported in another study
where participants were at risk of developing further diabetic foot ulcers (Beattie, Campbell, &
Vedhara, 2014). The majority of participants reported their venous ulceration was initiated by trauma
or surgery to the lower leg but other participants were unclear about what triggered their leg ulcers.
On occasion their wounds recurred spontaneously suggesting a different wound pathophysiology than
the traumatic wounds. Shai and Halevy (2005) found numerous triggers to ulceration in their study
and argue the development of venous ulcers should not be attributed solely to underlying venous
insufficiency. It was concerning that some ulcers in the current study were reported to result from
lower leg surgery including failed skin grafts causing significant distress and ongoing disability. Little
attention has been previously paid to iatrogenic triggered venous leg ulcers. A Cochrane review
suggests bilayer artificial skin grafts and compression bandaging will increase the healing of venous
leg ulcers compared to simple dressings and compression but found insufficient evidence to establish
a relationship with other grafts and the healing of venous leg ulcers (Jones, Nelson, & Al-Hity, 2013).
17
Nevertheless if a graft or surgery is carried out on the lower leg, assessment and management of
venous disease should also be considered.
Prevention of recurrence was generally attempted through wearing compression stockings and this is
supported by evidence (Nelson & Bell-Syer, 2014). Participants also avoided known triggers where
possible and immediately treated a leg wound and or sought help if a leg injury was sustained.
However, knowledge deficits about the issue were evident. Despite narrating wearing compression
stockings would prevent recurrence, less than half the sample was able to articulate the level of
compression they used and how often the stockings needed to be replaced. A number of participants
reported their compression stockings needed to be comfortable. Few participants were aware of
benefits to be gained from lifestyle changes such as elevation of the legs and physical activity
(Finlayson, Edwards, & Courtney, 2009). In the current study when these strategies were included
using some compression a longer period of respite from ulceration was reported.
Ulcers have been noted to develop despite the use of compression stockings (Flaherty 2005).
Participants in the current study also reported this experience and believed their stockings had not
provided adequate compression as they had not been replaced or disposed of when new garments
were purchased due to expense. This resulted in confusion and the continued use of loose stockings.
The expense of compression stockings for prevention of recurrence was cited as a barrier to
replacement in another study where the issue was linked to the non-existence of a government subsidy
(Kapp & Miller, 2015). Confusion with old and new stockings has however shed new light on the
issue and could possibly be addressed through a stocking exchange program where the old garment
can be replaced at a reduced cost.
Participants were generally self-caring and mobile but in some incidences reported assistance from
partners. It is interesting that on occasion “we” was used instead of “I” in accounts of their
experiences. This could possibly indicate a shared responsibility and might be a key to assisting
concordance. Concerns were raised about ongoing self-management of preventive activities in the
light of age related changes and the possible lack of social support. Social support combined with high
18
levels of self-efficacy has previously been recognised as an important element in prevention of
recurrence (Finlayson, et al., 2011).
Theme three provides insight into the scenario facing participants following wound healing and
exposes some knowledge deficits regarding the understanding of the trajectory of venous disease.
Their optimism about remaining ulcer free was shrouded in uncertainty as they envisaged a lifelong
commitment to lifestyle changes and the possible impediments to carrying out these activities. Some
participants had become aware of changes in their legs which signalled the progression of the disease
but they did not understand the significance of the changes. It was not surprising the management of a
life threatening co-morbidity was prioritised over prevention of an ulcer as most participants had
numerous comorbidities competing for attention.
Limitations
The findings from this study were generated from interviews with seven participants therefore are
unable to be generalised. All participants were ulcer free at time of interview. Therefore it is unknown
if similar themes would unfold in a similar sample with active ulcers. Some participants were
dependent on assistance from partners with management of their venous disease. Exclusion of
partners from the interviews may have resulted in loss of valuable information.
CONCLUSION
This study echoes the results of previous research and has shed light on additional issues which could
contribute to the recurrence of venous leg ulcers. The main trigger of recurrence for most participants
was trauma and lower leg surgery. Preventive strategies were mostly concerned with the use of
compression, avoidance of traumatic injury and securing immediate treatment if the integrity of the
skin was impaired. Little attention has been previously made to iatrogenic triggered venous leg ulcers
and it is therefore unknown if it is an extensive problem and should be further investigated. There was
recognition of the value of social support and concerns raised about management of preventive
19
strategies if this was not available. The expense of compression garments was reported a barrier to
renewal and a cause of recurrence. This is not a new issue and will continue to impact on the
treatment of venous disease until the cost of the garments is reduced and or government subsidies
implemented for individuals with healed venous leg ulcers. This may not occur until this chronic
condition is recognised as a significant but treatable disease which currently consumes a large portion
of the health care budget. This study highlights the need for an increased awareness about venous leg
ulcer triggers and ongoing emotional, physical and financial support for individuals post-healing. This
should promote evidence-based self-management of the condition rather than dependence on
experiences of previous episodes of ulceration. Such an approach should assist in providing a longer
period of respite from ulceration for individuals with venous disease.
RELEVANCE TO CLINICAL PRACTICE
The findings of this research provide clinicians with insight into how some individuals with venous
disease manage this chronic condition. Some participants in this study lacked fundamental
information necessary to reduce the risk of recurrent venous leg ulcers. Therefore their understanding
of the disease and the information provided to them on prevention of recurrence should be
established. Any barriers to carrying out these activities should be ascertained and attempts made to
overcome them. Inclusion of carers in the educational process would be advantageous. Ongoing skin
care should be encouraged to reduce the possibility of cellulitis and disposal of loose stockings
advised.
Word Count: 5134
20
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Table 1: Participants
Name Gender Age Number of Previous Ulcers
Michael Male 54 8 or 9
Fred Male 76 2
Bernie Male 84 3
Colleen Female 60 3
Pam Female 84 numerous
Sandra Female 66 3
Mary Female 78 3
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Table 2: Themes and Categories
Theme Categories
The Increasing Influence of the Recurring Wound on Mind and Body Increasing Effect
Inevitability
Anticipatory Measures
Reflection on Past Experiences Self-Blame
Triggers
Lifestyle Changes
Optimism in the Face of Adversity Vigilance
Hopefulness
Awareness of the chronic
Condition
