Inpatients felt that pressure ulcers had emotional, mental, physical, and social effects on quality of life because nurses did not adequately treat or manage their pain or discomfort
Q What are inpatients’ experiences of pressure ulcers, their treatment, and effects on health and quality of life?
Medical, elderly care, orthopaedic, and vascular surgery wards in 4 National Health Service hospitals in the UK.
Purposive sample of 23 hospital inpatients 33–92 years of age (median age 78 y, 78% women) who had pressure ulcers graded 2–5 (2 = partial thickness wound in the epidermis or dermis, 5 = black eschar) at various body sites (eg, heel, sacrum, buttock). Most were admitted to hospital for reasons other than a pressure ulcer, and most had a chronic condition (eg, diabetes, leg ulcer, stroke).
Patients participated in semistructured interviews and were asked questions about their general health, pressure ulcers (when they developed, duration, and treatment), and the effect of ulcers and treatments on physical health, functional ability, psychological well-being, and social relationships. Interviews were recorded, transcribed verbatim, coded, and analysed for themes.
Patients’ descriptions of their health and quality of life. Patients had varying levels of dependence on others (eg, family members or social services) for tasks such as activities of daily living. Patients’ living arrangements before hospital admission (eg, living alone) influenced their quality of life. Perceptions of impact of pressure ulcer. Most patients felt that pressure ulcers affected their lives emotionally, mentally, physically, and socially. Patients had varying levels of preoccupation with their ulcers. They described ulcers as “troublesome,” “annoying,” “disruptive,” or “inconvenient” and felt depressed or lacked confidence. Pressure ulcers affected patients’ positioning and comfort (eg, sitting or lying on the side), performance of everyday activities (eg, moving from bed to chair or showering), and infections that delayed healing or led to more health problems. Perceptions of cause of pressure ulcer. Many patients attributed pressure ulcer development to reduced mobility. The inability to move independently because of confinement to bed or chair led to “scuffing” or “rubbing” of the skin, which was already “like paper.” Patients attempting to move themselves because nurses did not reposition them often enough induced further damage to their ulcers. Some patients also blamed nurses for not prioritising care or delays in skin inspection; a few blamed nurses for directly causing the ulcer (eg, ill-fitting splint or improper use of a hoist) or delays in receiving preventive treatments (eg, pressure-relieving cushions in wheelchairs). Others blamed their chronic conditions, poor health, loss of appetite and weight, diabetes, poor hygiene, lack of knowledge, ignorance, or naivety. Descriptions of pressure ulcers. Patients described pain as “stabbing,” “jumping,” “niggling,” “red hot poker,” “carpet burn,” “tender,” and “raw.” The timing of pain was constant or varied daily, hourly, or became worse at night or with contact (eg, bed clothes). Patients described their ulcers by texture, dimensions, origin, first sensation, physical appearance, leakage, and smell. Many felt that nurses did not acknowledge nor adequately treat their pain, discomfort, and distress. Several patients could not see their ulcers and relied on nurses to describe them. However, nurses’ descriptions tended to focus on size and lacked information about the progress of healing. Experiences of pressure ulcer treatment, management, and care. Some patients reported pain with dressing changes because of the tenderness of the ulcer, technique used by nurses, allergy to dressings, adhesiveness of dressings, or problems with application (eg, ulcers leak and cause dressing to come off). Others experienced increased comfort and easing of pain. Some perceived dressing changes to be time consuming, whereas others felt inconvenienced by repeated hospital admissions to treat their ulcers. Patients’ comfort levels varied with use of pressure-relieving mattresses, although many reported limited availability of such resources. Patients depended on nurses for repositioning. Some felt that nurses had a negative attitude when patients requested help, whereas others were constantly repositioned, which disturbed their sleep.
Inpatients felt that pressure ulcers and their treatment affected their lives emotionally, mentally, physically, and socially. They depended on nurses to manage their ulcers but felt that their pain, discomfort, and distress were not acknowledged nor adequately treated.
- Lynne Esson, RN, BSN
The study by Spilsbury et al provides an important look at the complex issue of “quality of life” in patients admitted to hospital with pressure ulcers and other comorbidities. Other research findings have focused largely on the substantive theoretical and technical knowledge required to heal pressure ulcers1 or the experiences of specific patients. The study by Spilsbury et al offers a more holistic perspective by providing patients’ perceptions of the cause and impact of pressure ulcers on all aspects of their lives: social, emotional, mental, and physical. This portrait is enhanced by patients’ descriptions of the impact of treatment as well as their views of how health professionals manage pressure ulcer care.
Elucidating the effect of pressure ulcers and treatment (over and above other comorbidities) on patients’ perception of their quality of life is uniquely challenging. Nonetheless, this research provides important insights and guidance for nurses in the provision of care. Of particular interest is the suitability of language used by nurses to describe pressure ulcers and how such language was interpreted by patients. This cautions nurses to be sensitive in their communication and alert to the different meanings of language for patients and caregivers.
Clearly, more research is needed to identify specific interventions that nurses can use to support and maintain patients’ quality of life. The study by Spilsbury et al affirms that nurses require ongoing education in the management and care of wounds, communication skills, and pain management strategies in order to provide effective nursing care.
For correspondence: Dr K Spilsbury, University of York, York, UK.
Source of funding: NHS R&D Health Technology Assessment Programme.