CHAPTER 4 DISCUSSION 4. Discussion of the Major Findings 4.1.1 The nurses’ role in empowerment of patients with venous leg ulceration. The review indicated that nurses truly have a considerable role to play in the quest to support patients suffering venous lower leg ulceration . Bawden and Lindsay (2007) identified the areas in which such roles manifest in taking care of patients as including patients’ health promotion, empowerment and education as well as introduction on overall clinical practices. Empowerment and education of patients of venous lower leg ulceration have also been identified as a very important role, which nurses must play in providing support for them. For instance, Van-Hecke et al. (2009) rightly pointed out that, a successful treatment of people with venous leg ulceration cannot be possible without motivation, which can be delivered through empowerment programs. Similarly, Brown (2008) noted that, absolute compliance to nurses’ advices are very crucial for patients’ recovery from lower leg ulceration. The author specifically blames non-compliance to advices and educative directive of nurses as the major factors responsible for the manifestation of the consequences of the ailment such as; discouragement, presence of pain, unhealthy lifestyle and insufficient social support. Thus, unlike Van-Hecke et al. (2009) who focus mainly on motivation, Brown (2008) identified education of patients as being more crucial for successful treatment of leg ulcers. Scholarly publications also indicated that nurses’ roles in supporting patients with venous lower leg ulceration are not restricted to just patients’ health promotion, empowerment, education and specific clinical practices. Forssgren et al. (2008) recommended that nurses should obtain necessary information concerning patients’ life habits, profession, socio-cultural environment or context as well as pre-existing social support and its quality. According to the authors, such information help nurses to determine the exact treatment methods, support and advices to render to specific patients. However, Heinen et al. (2007) advocated for the use of a holistic approach in the management of patients. Their postulation is based on the assumed fact that; holistic approach takes all factors into full consideration. Thus, Heinen et al. (2007) in their observation believed nurses can fulfil their role in providing support for patients with venous lower leg ulceration by simply adopting a holistic approach in treating the patients and such approach obviously involve the promotion of social interaction among the people. Apart from Heinen et al. (2007), other studies reviewed so far were silent on the impact of the promotion of social interaction on healing of lower leg ulceration. In this case, Vowden (2010) specifically argued that promotion of social interaction between patients of leg ulceration and members of the public, as well as among the patients is a very important role, which nurses must undertake in the quest to control the ailment. His position was supported by Hjerppe et al. (2010) who requested that the promotion of social interaction among the patients be implemented alongside with other health care services as well as continuous medical follow up. Hjerppe et al. (2010) pointed out the benefit of following such approaches as including; pain reduction, a significant progress in healing, and improved quality of life, namely at work, mood, mobility, sleep pattern etc. Similarly, a publication by the Registered Nurses Association of Ontario indicated that, nurses have a very crucial role to play in the promotion of social interaction among patients, as such approach have a positive impact on patients’ level and consequently help to solve certain social-related consequences like social isolation, which provides efficient coping mechanisms to deal with the crisis pose by the disease. During the review already conducted, the findings of Kapp and Miller (2014) clearly indicated the immense roles which nurses must fulfil to make sure that patients have adequate understanding of the need to adopt self-management strategies for healing and recurrence prevention. This postulation is fully supported by Azoubel et al. (2010) who identified communication as an important instrument, which alongside with relevant education programs, behavioural, cognitive and affective features help to facilitate healing of leg ulceration. In another study, Fonseca et al. (2012) laid more emphasis on the attitude as well as the approach of the nurses. According to the authors, establishment of interpersonal relationships between nurses and patients is the surest way to ensure absolute trust. Additionally, the authors also pointed out that, such interpersonal relationship competencies in conjunction with the nurses’ good technical-scientific performance helps to generate positive process for healing. Consequently, it is highly recommended for nurses to facilitate the overall well-being of patients by establishing an empathetic relationship and adopting a holistic approach in the treatment of clients and also sustaining such relationship even after the patients’ leg ulcer have healed completely. By establishing the interpersonal relationship, patients will be able to make accountable and free choices in regarding to their autonomy as they now have increased trust on the company’s health care delivery. Through this way, their empowerment which was discussed by Bawden and Lindsay (2007) in the review is attained. Fonseca et al. (2012) also noted that nurses’ role in supporting patients with venous lower leg ulceration can be accomplished easily, when they operate as a multidisciplinary team. This position was also supported by O'Donnell et al. (2014), who pointed out the need for nurses taking care of patients of lower leg ulcerations to collectively generate objectives and strategies, specifically designed to fulfil the actual needs of the patients. In order to accomplish this, Fonseca et al. (2012:5) argued that “nurses must keep updated, and attend education and training in the area and maintain a good conversation with their peers, because taking care of this type of disease is more effective if the care is provided by a multidisciplinary team”. Furthermore, nurses cannot fulfil their respective role in supporting patients with venous lower leg ulceration without noting certain important information like patient's clinical history and ulcer's history. Through a careful evaluation of the characteristics of the wound, nurses are able to decide on the treatment always together with the client, so that common goals can be established. 4.1.2 The nurses’ role in pain management of venous lower leg ulceration The review identified pain as one of the common challenges encountered by patients that suffer from venous lower leg ulceration. Cwajda-Białasik et al. (2012) specifically noted that the pain usually becomes more intense during dressing changes, even though it is typically caused by various factors that include but not restricted to ischaemia, oedema etc. These prompted Heinen et al. (2007) to argue that, treatment of venous lower leg ulcers must focus on prevention of pain among others. In their own part, Taverner et al. (2011) argued that the accurate pain management of venous lower leg ulceration can be accomplished through careful selection of the specific dressings to be used as well as gentle handling of the limb. However, Hjerppe et al. (2010) argued that pain generally encountered by patients can be reduced by minimizing the incidence of oedema and providing adequate support for the limbs. This opinion is contradicted by Azoubel et al. (2010) who believed prescription of analgesia is the most suitable method for pain management of venous lower leg ulceration. The use of analgesics for pain management of venous lower leg ulceration is scantly reported in literature. O'Donnell et al. (2014) noted that even though pain is the commonest cause of functional limitation among patients of venous lower leg ulceration, pain killers are not actually prescribed to the entire patients that took part in the survey. The author attributed this fact to physicians’ underestimation of the pain, as chronic wounds are generally not seen as life threatening. Despite this reality, a study by O’Meara et al. (2015) identified the major drugs being used for pain management among patients suffering venous lower leg ulceration as: morphine-based analgesia and non-steroidal anti-inflammatory drugs. However, a study by Vowden et al. (2009) revealed that non-pharmacological practices for pain management are increasing being used among patients of venous lower leg ulceration. The authors listed some of such practise as; physiotherapeutic drugs, reposition of affected legs, dressing and massage. Nelson et al. (2009) argued that therapeutic method taken by nurses to take care of patients suffering venous lower leg ulceration is a major determinant of the exact method to employ in pain management of venous lower leg ulceration. For instance, the authors recommended the routine application of a high compression, multi component bandaging for the treatment of venous leg ulceration. However, Finlayson et al. (2015) believed compression therapy isn’t compatible with pain management of patients suffering venous lower leg ulceration. The authors identified pain, lack of valid lifestyle advice and discomfort as the major factors responsible for non-concordance/compliance with compression therapy. Several authors have come up with specific coping strategies for minimizing pain, which are also recognized as important pain management techniques for venous lower leg ulceration. Herbert et al. (2007) identify mild activity as one coping strategy for minimizing pain attributable to discomfort. The authors gave practical ways through which such pain can be relieved as, getting out of bed and walking around. However, Posnett et al. (2009) argued that partaking in distracting activities can help one to overcome unnecessary preoccupation of leg ulceration, thereby getting rid of situations that are capable of triggering intensifying pain. But for Van Hofn et al. (2010), patients suffering from venous lower leg ulceration minimize their pain by putting their legs in different positions or through simple massage. This postulation is partly supported by Neumann et al. (2014), who noted that, pains in some patients can be ameliorated, but remain unchanged for others. Nevertheless, the authors admit that, compression stockings, leg elevation and diuretic therapy are effective coping strategies for minimizing venous leg ulceration among patients. Indeed, pain is a very serious issue among patients of suffering from venous lower leg ulceration as many sufferers have admitted experiencing both acute and chronic form of pain. Moreover, lots of detrimental consequences ranging from increased rate of aging to overall discomfort have been linked directly to pain. Ineffective management of pain among patients may lead to intense pain, which may eventually force patients to amputate the affected leg. Unfortunately, even though pain management helps to protect the leg and acts as a mean of maintaining some control over its integrity, some of the strategies projected for pain management may ultimately lead to other deficits. Common examples of such deficits include avoiding crowded shopping areas, being afraid of having children on the knees, avoiding cats, and limiting mobility (Neumann et al., 2014). Such deficit will eventually cause the patient to become virtually housebound. Studies have also revealed that pain management of ulcerous patients can be achieved by employing traditional and herbal techniques. For instance, a study by Feng et al. (2009) indicated that, anti-inflammatory herbs are not only effective in reducing pain among patients of lower leg ulceration, but can also assist the wound to heal naturally. The author in his literature review identified examples of such herbs as Witch Hazel, Comfrey and Gotu Kola. This theory is in line with the findings of Jia et al. (2011) and Li and Zhang (2013) whose separate studies revealed that, some specific categories of therapies known as traditional Chinese medicine, gradual curative effect on venous ulcers. Consequently, the authors recommended this as cheaper, safer, and more effective treatment methods for patients. However, even though Li, Xiao, Ze, et al. (2015) acknowledged the curative effects of traditional Chinese medicine on venous ulcers, the authors argued that the potential benefits of such medicines for patients with venous ulcers, to justify either their recommendation or their clinical role, have not been evaluated. Wiederhold et al. (2014) came up with a relatively new concept that involved computer technology, a technique that has not been recommended by most scholars, include all the journal articles that have been reviewed so far. In this case, the authors investigated the applicability of virtual reality distraction techniques in the treatment of chronic pain as obtainable among patients suffering from lower leg ulceration. The method, which involves creation of virtual environments that are specifically designed to provide pleasurable and appealing experiences for patients, was found to have considerable positive effects on patients. According to the authors’ findings, “chronic pain patients demonstrated significant relief in subjective ratings of pain that corresponded to objective measurements in peripheral, non-invasive physiological measures (Wiederhold et al., 2014:5)”. Thus, virtual navigation is highly recommended as an effective technique, which nurses can use to manage the pains of their patients. However, Molton et al. (2007) argued that pain relieving measures employed in patients of venous lower leg ulceration cannot be effective without complementary measures. The authors identified, such complementary measures to include cognitive, behavioural, psycho-physiological and psychodynamic therapies which focus majorly on emotional, behavioural as well as cognitive aspects of the disease. This position was supported by Sibbald et al. (2007) who noted that, such approaches help to minimize stress and anxiety and enhance personal coping skills of patients. White (2008) also agreed with the authors and even added relaxation techniques as a very important method that can be used to manage pain among patients. Consequently, virtual reality, cognitive, behavioural, psycho-physiological and psychodynamic therapies are all recommended as strategies or techniques for effective management of pain among patients of lower leg ulceration. 4.1.3The nurses’ role in supporting psychological and social needs of patients suffering from venous lower leg ulceration. The review established very strong psychological and social consequences of venous lower leg ulceration among patients as well as the needs to support, psychological and social needs of patients (studies 8 and 9). For instance, the study by Parker (2012) established a positive correlation between mobility and pain, a situation that could eventually result to social isolation of the affected individuals. This hypothesis is confirmed by Herber et al. (2007) who noted a considerable increase in pain among patients suffering venous lower leg ulceration, which incidentally restrict them from partaking in more social functioning and consequently cause less vitality as well as limitation with respect to emotional roles compared to the respective controls. In the same vein, Isaac (2015) identified pain one of the most prominent factors that is responsible for restrictions in social interaction, recreation, work capacity, psychological well-being and various problems caused by treatment regimes. Qualitative studies have also linked venous lower leg ulceration to issues like, altered body image, frustrations, social isolation, pain, insomnia, fear, exudates and malodour, which several authors have identified as having negative impacts on patients’ psychological wellbeing (Byrne and Kelly, 2010, Green and Jester 2010, Finlayson et al., 2010, 2011, Edwards et al., 2014). However, Brown (2010) specifically pointed out that, nurses having the right skills and expertise can combat all the psychological and social consequences of venous lower leg ulceration. This notion is also supported by Upton et al. (2014), who noted that nurses can improve the psycho-social wellbeing of their patients by simply using specific approaches to improve patients’ perception. Similarly, Green, Jester and McKinley (2013) argued that the psychological and social consequences of venous lower leg ulceration become highly negligible whenever nurses with advanced skills and knowledge are employed as most patients naturally recognize such nurses and such recognition inevitably inspires confidence in their respective treatments. The authors also noted that, positive reinforcement and regular feedback are found to be highly supportive for the patients. However, Cullen and Phillips (2009) warned that non-healing and suspected patient non-compliance may lead to pessimism and frustrations among nurses, which may in turn facilitate those undesirable psychological and social consequences of venous lower leg ulceration. This reality also prompted Moffat, Kommala and Dourdin (2009) to point out the various reasons why nurses should never underestimate the influence of their attitudes under situation of pessimism and frustrations. Still on this notion Byrne and Kelly (2010) argued that such scenario can cause considerable deterioration of the nurse-patient relationship, which may even facilitate patients’ non-compliance. On their own part, Green et al. (2013) and Edwards et al. (2014) argued that such situation may promote depression and low mood among patients as well as their ability to comply with treatment and self-care guidelines. In a nutshell, the psychological and social consequences of venous lower leg ulceration among patients are determined to a great extent by the prevailing nature of existing nurse-patient relationship, which also influences patients’ compliance with recommended treatment (Palfreyman, 2008). Various literary publications have also revealed that; psychological and social consequences of venous lower leg ulceration are partly instigated by patients’ negative body image. For instance, Finlayson et al. (2010) and Green et al. (2013) observed that negative body image attributable to unpleasant bandages can have detrimental effects on patients’ ability to follow self-care regimens accurately. This has huge potential implications as clothing choices and body images are very important to patients of leg ulcerations. In their own study, Byrne and Kelly (2010) pointed out that; patients’ inability to dress correctly, can limit their social interactions as they have very limited choices when it comes to footwear that can conceal their bandages. This huge setback may force social isolation, which will then trigger huge psychosocial consequences. However, Upton et al. (2014) specifically identified leaking bandage as having the most prominent effects on patients’ body image. According to the authors, anxiety, distress, shame and embarrassment are among psychological issues that can be prompted by unexpected exudates and malodours. This hypothesis is supported by Jones et al. (2008) who established a positive correlation between exudates, malodour, poor social life and clinical depression. Byrne and Kelly (2010) also noted that the experiences of patients are not helped by other people, who naturally react fearfully to incidents of malodour and exudates. Thus, the authors specifically identified, such behaviours as major factors that prompt patients to avoid social situations, including family events. However, Upton et al. (2014) revealed that some patients do discourage themselves from participating in social activities. This was majorly attributed to their about harming or damaging the area affected by leg ulceration. This was also confirmed by Green et al. (2013) who noted that some patients tend to avoid certain social events or keep their legs, padded for the sole reason of preventing trauma. Unfortunately, such decision results in isolation as social gathering are usually crowded and disorderly. Finlayson et al. (2010) further noted that such isolation of patients triggers the numerous psychosocial consequences normally suffered by patients. Studies conducted by Brown (2010), Finlayson et al. (2010), Green et al. (2013) and Upton et al. (2014) all indicated that patients suffering from venous lower leg ulceration are overly anxious about their wellbeing to the extent that their possibility of being depressed is highly elevated. For instance, most participants in the studies checked their legs regularly throughout the entire duration of the day. Brown (2010) and Finlayson et al. (2010) elaborated that, high levels of such anxiety are associated with higher rates of ulcer recurrence, and people with multiple ulcers tend to become more anxious the more their ulcers recur. Green et al. (2013) further pointed out that patients may be forced to isolate themselves socially, if they are not satisfied with the healing progress of their leg ulceration. Unfortunately, such decision has huge implications on patients’ life, including their respective personal relationship. An instance, can be seen in the study conducted by Green et al. (2013), where patients found it extremely difficult to sustain intimate relationships. Finlayson et al. (2009) and Upton et al. (2014) blamed social isolation for being majorly responsible for most patients’ decision to rely exclusively on family members for badly needed care. Finlayson et al. (2009) specifically noted a positive correlation between poor personal relationships and unsuccessful treatments and self-care compliance. In other words, psychological factors are partly responsible for patients’ inability to follow self-care regimens judiciously while another found such approach to be socially limiting because of the time that is involved. Unlike all previous authors, Van Hecke et al. (2010) revealed that social isolation of patients can possibly be triggered unintentionally by nurses. For instance, nurses may have compelled patients to complete their dressing changes or attend leg ulcer clinics, while unknowingly imposing social constraints on them. Van Hecke et al. (2010) pointed out that patients’ dependency on nurses may eventually discourage them from practising self-care. However, patients’ dependency on nurses do have some positive effects as Green et al. (2013) in their own study argued that such scenario may eventually develop into full social interaction. In their separate studies, Van Hecke et al., (2008), Green and Jester (2010), Van Hecke et al. (2010) and Maddox (2012) all argued that support groups are very effecting in minimizing incidents of certain psychological and social consequences of venous lower leg ulceration. Van Hecke et al. (2010) and Maddox (2012) opinions were based on the fact that, support groups have the potentials of encouraging motivation and compliance among patients with self-care. However, Green and Jester (2010) noted that the positive impacts of support groups on certain psychological and social consequences of venous lower leg ulceration are based on their ability to alleviate financial pressures normally associated with patients suffering leg ulceration. In reality, such financial pressures are inevitable as patients lack gainful employment and are therefore incapable of fulfilling some of their financial obligations. 4.2. Recommendation The systemic review of literature generated lots of findings, which lead to generation numerous recommendations. First and foremost, this study identifies pain as a major psycho-social issue that affect patients that are afflicted with lower leg ulceration. Consequently, there is need for contemporary health institutions and workers to introduce pain management methods, which are specifically designed to obtain more positive results among patients of venous lower leg ulceration. In addition to this, the findings of this academic study revealed the need while every hospital facility must have wound care support and management facilities. Having effective facilities for adequate pain management and accurate wound care, support and management facilities can be very helpful in the quest to prevent social isolation of people suffering lower leg ulceration. Secondly, it is also recommended for nurses to develop and implement reliable social support system, which can enable patients to overcome negative feelings of social isolations. Such system should be designed to tackle embarrassments associated with certain physical symptoms of the illness and consequently. The findings of the study also indicated the need to care provision for patients that suffers lower leg ulceration, which must also include support groups and/or networks for patients. Lastly, the findings of this study showed that nurses have very crucial roles to play in assisting patients that suffer from venous lower leg ulceration. Thus, it has become very necessary for governmental health departments to boost investment in the management of venous leg ulceration. For instance, adequate communication ought to be included as part of any therapeutic relationship as it has the capability of promoting a sense of control and self-efficacy. Thus, it is very necessary to train nurses in this specific area so as to minimize the negative impacts of psychological and social consequences of lower leg ulceration. 4.3 Conclusion In conclusion, this academic study revealed that nurses have a huge role to play in supporting patients with lower leg ulceration. First and foremost, this study revealed that nurses have huge responsibilities in patient empowerment. However, it was revealed that for nurses to fulfil this huge obligation, they must obtain wound care information from reputable sources and undergo professional training. The review of the relevant literary publication conducted in this study revealed that, nurses can only fulfil their major roles of empowering their patients and encouraging them to embark on self-management of their disease if they have adequate and accurate of wound care knowledge. Additionally, this study, rightly identified pain as one of the common challenges encountered by patients that suffer from venous lower leg ulceration which prompted some authors to argue that, the treatment of venous lower leg ulcers must focus on prevention of pain among others. The proposed methods for pain management include: minimization of incidence of oedema, providing adequate support for the limb, prescription of analgesia and the adoption of specific coping strategies. Lastly, the study established very strong psychological and social consequences of venous lower leg ulceration among patients. Qualitative studies have also linked venous lower leg ulceration to issues like, altered body image, frustrations, social isolation, pain, insomnia, fear, exudates and malodour, which several authors have identified as having negative impacts on patients’ psychological and social wellbeing. Consequently, the ability to combat this consequence has been identified as one area which nurses must be highly skilful.