Nursing Interventions Aimed at Persons with Venous Ulcers: an Integrative Review*

Johana Enyd Cifuentes Rodríguez; Sandra Guerrero Gamboa

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ABSTRACT

Objectives: This work sought to identify and describe the theoretical foundations, components, duration, delivery mode, and results of the nursing interventions aimed at persons with venous ulcers as available in the literature.

Materials and method: Integrative review between 2000 and 2018 in the Pubmed, Ovidnursing, and EBSCOhost electronic databases.

Results: This review includes 16 articles. Most of the interventions were of educational nature; three were developed in the community (through the Leg Club model) and the other ones were delivered by a nursing professional, face to face. The minimum time of duration for these was eight weeks, with telephone follow up. The most-common result variables were venous ulcer healing and reduction of the wound area.

Conclusions: Diversity existed in relation with the components of the interventions and the results expected. Report of the interventions must be reinforced, along with the use of nursing theories that support their design.

KEYWORDS (Source DeCS): Varicose ulcer, leg ulcer, nursing care, controlled before-after studies, practical nursing.

RESUMEN

Objetivos: identificar y describir los fundamentos teóricos, los componentes, la duración, el modo de entrega y los resultados de las intervenciones de enfermería dirigidas a personas con úlceras venosas disponibles en la literatura.

Materiales y método: revisión integrativa entre los años 2000 y 2018 en las bases de datos electrónicas Pubmed, Ovidnursing y EBSCOhost.

Resultados: esta revisión incluye dieciséis artículos. En su mayoría, las intervenciones fueron de carácter educativo, tres se desarrollaron en la comunidad (bajo el modelo Leg Club) y el resto de intervenciones fueron entregadas personalmente, cara a cara, por una enfermera profesional. El tiempo mínimo de duración de aquellas fue de ocho semanas, con seguimientos telefónicos. Las variables de resultados más comunes fueron la cicatrización de la úlcera venosa y la reducción del área de la herida.

Conclusiones: hubo diversidad en relación con los componentes de las intervenciones y los resultados esperados. Se debe reforzar el reporte de las intervenciones y el uso de teorías de enfermería que respalden su diseño.

PALABRAS CLAVE (Fuente DeCS): Úlcera varicosa, úlcera de la pierna, atención de enfermería, estudios controlados antes y después, enfermería práctica.

RESUMO

Objetivos: identificar e descrever os fundamentos teóricos, os componentes, a duração, o modo de entrega e os resultados das intervenções de Enfermagem dirigidas a pessoas com úlceras varicosas disponíveis na literatura.

Materiais e método: revisão integrativa entre 2000 e 2018 nas bases de dados eletrônicas PubMed, Ovidnursing e EBSCOhost.

Resultados: esta revisão inclui 16 artigos. Em sua maioria, as intervenções foram de caráter educativo; três foram desenvolvidas na comunidade (com o modelo Leg Club) e o restante foi entregue pessoalmente por uma enfermeira profissional. O tempo mínimo de duração foi de oito semanas, com seguimento telefônico. As variáveis de resultados mais comuns foram a cicatrização da úlcera varicosa e a redução da área da ferida.

Conclusões: houve diversidade quanto aos componentes das intervenções e dos resultados esperados. Deve-se salientar o relato das intervenções e o uso de teorias de Enfermagem que apoiem seu desenho.

PALAVRAS-CHAVE (Fonte DeCS): Úlcera varicosa, úlcera da perna, cuidados de enfermagem, estudos controlados antes e depois, enfermagem prática.

Carátula del artículo

Articles

Nursing Interventions Aimed at Persons with Venous Ulcers: an Integrative Review*

Intervenciones de enfermería dirigidas a las personas con úlceras venosas: una revisión integrativa*

Intervenções de Enfermagem dirigidas às pessoas com úlceras varicosas: uma revisão integrativa*

Johana Enyd Cifuentes Rodríguez jecifuentesr@unal.edu.co

Universidad Nacional de Colombia, Colombia

Sandra Guerrero Gamboa nsguerrerog@unal.edu.co

Universidad Nacional de Colombia, Colombia

Aquichan, vol. 20, no. 1, e2017, 2020
Universidad de La Sabana

Received: 10 August 2019

Revised document received: 11 December 2019

Accepted: 18 December 2019

DOI: https://doi.org/10.5294/aqui.2020.20.1.7

Introduction

Venous ulcers (VU), also known as varicose ulcers, are open cutaneous lesions that, generally, occur on the medial side of the lower leg, between the ankle and knee, as a result of chronic venous insufficiency and ambulatory venous hypertension. Its healing can take between four and six weeks, after their initial onset ¹.

Between 75 % and 80 % of all lower limb ulcers is of venous etiology, their prevalence ranges between 0.5 % and 2.7 %, and increase with age ²^,³. It has been estimated that active VU have a mean age of 210 days, with periods of < 1 to > 67 years and up to 70 % recurrence rate within three months after wound closure ⁴^-⁶. These aspects turn them into a complex chronic condition, not only for patients and their families, but also to health systems.

The role the nursing discipline has played in caring for these patients has been fundamental to now understand the complexity of living with VU in lower limbs and its negative impact in all the dimensions of the quality of life of the people. The common problems confronted by patients with VU include pain, exudate, odor, limitations in mobility, depression, anxiety, social isolation, sense of sadness, and sleep disorders ⁷^-⁹. Venous ulcers, like any other chronic condition, demand long-term nursing care, significant changes in lifestyle, and adherence to therapeutic regimes by the patients. These call for using compression therapy for life (the gold standard for caring and managing VU) and prevention and maintenance strategies to avoid recurrence, like leg elevation, weight control, physical activity, skin care, and protection against lesions, among others ¹⁰^,¹¹.

Due to the aforementioned, recently, nurses have begun to design interventions to investigate if such could contribute in healing, diminished recurrence, or improved quality of life of patients with VU, besides other physical and psychosocial variables. Identifying in the literature nursing interventions available for patients with VU permits knowing the elements that compose them and how these produce beneficial results. Hence, the objective of this review is to identify and describe the theoretical foundations, components, duration, delivery mode, and results of nursing interventions aimed at persons with VU as available in the literature.

Materials and Methods

Integrative literature review based on the method proposed by Whittemore and Knafl ¹², which includes the following stages:

1. Definition of the purpose of the review: identify and describe the theoretical foundations, components, duration, delivery mode, and results of nursing interventions aimed at persons with VU as available in the literature.
2. Literature search: a search was conducted of articles in the Pubmed, Ovidnursing, and EBSCOhost electronic databases, between 2000 and 2018, given the limited research in the area prior to this time frame. The keywords were venous leg ulcer or varicose ulcer, nursing, interventions, and wound healing in English, Portuguese, and Spanish. Combinations were made with the Boolean operators (AND, OR). The search took place between 01 January and 31 April 2018, and was updated in February 2019. The inclusion criteria were: 1) articles published in indexed journals; 2) descriptive, experimental, and quasi-experimental studies developed exclusively by nursing; and 3) articles clearly presenting the development or implementation of the intervention. The work included reviews, Masters and PhD theses, unpublished articles, as well as studies centered on diagnostic methods or intervention studies with laboratory products or pharmaceutical companies.
3. Data assessment: during this stage, seeking to estimate their methodological quality, the critical reading was made of the articles selected, under criteria proposed by the Joanna Briggs Institute ¹³. Consequently, the reviewers examined the titles independently, in function of the abstract, excluding irrelevant studies; thereafter, they selected the articles according to the inclusion criteria and examined each of the articles independently.
4. Data analysis: a work instrument was designed to extract the principal characteristics of the studies included in the analysis. The instrument was composed of the following sections: 1) identification data of the study, author, year, and country; 2) study objective; 3) study design and sample; 4) description of the intervention: type of intervention, theoretical foundation, components, duration and delivery mode; and 5) intervention result variables. For their classification according to their level of evidence, the work followed the criteria proposed by the Joanna Briggs Institute ¹³. The final stage of the review describes the findings through the synthesis of the information and is presented hereinafter.

Results

According to their content, 207 studies were found, of which 42 were discarded due to duplication in the databases; then, the titles and abstracts of the remaining articles were revised, according to the inclusion and exclusion criteria; finally, three reviewers, through consensus, kept 16 articles in the review.

In this review, 16 articles fulfilled the search criteria and were included. Of these, 50 % ⁸ were carried out in countries in Oceania; 25 % ⁴ in Europe; 12.5 % ² in North America; 6.25 % ¹ in Asia; and 6.25 % ¹ in South America (Table 1).

According with their design, the studies were: quantitative, randomized clinical trial type ¹⁰; pre and post-test with a single group ³; quasi-experimental ¹; prospective with control group ¹; and comparative ¹. Levels of evidence prevailed in levels I and II (Table 1).

The 16 articles included 1249 patients from different community nursing care centers, outpatient injury and dermatology clinics, and care services to patients with tissue disturbance in university hospitals. Among the participants, female sex had the highest prevalence, and age ranged between 54 and 80 years.

Figure 1
Study selection process
Source: Own elaboration.

Target population

Herein, 100 % of the interventions were aimed at patients with VU; their relatives or caregivers were not considered.

Type of intervention and theoretical foundation

Of the 16 interventions found in the studies, 11 were educational ¹⁴^-²⁴; among these, four promoted the development of progressive resistance exercises ¹⁴^,¹⁸^,¹⁹^,²¹; two, of clinical characteristics, evaluated change in the quality of life of patients receiving a system of four-layer and short stretch compression bandage; and three were community type ²⁵^,²⁶.

The cognitive social theory by Bandura supported four educational interventions ¹⁴^,¹⁸^,²²^,²⁴. Two studies added elements from the goal setting theory by Locke, besides using the motivational interview by Miller and Rollnick as technique to facilitate behavioral change among participants during their meetings ²²^,²⁴.

The three community interventions proposed were based on the so-called Leg Club care model, which proposes that wound care take place in an informal setting (nonclinical), owned by the community (like community halls), which promote social interaction, support among peers, information exchange, health promotion, education, and continuous care for all age groups with problems related with their legs ²⁷^-²⁹ (Table 1).

Components of the interventions

Of the interventions identified, 87.5 % (14/16) mentioned an educational component in their development ¹⁴^-²⁴^,²⁷^-²⁹; while 12.5 % (2/16) did not conduct any type of education, given that change in VU healing rate was only observed as response to using four-layer short stretch compression systems ²⁵^,²⁶. Among the education themes, the review found lifestyles, causes, development, progress and prevention of VU, importance of compression bandages, adherence, self-care activities, and exercise. The last is the aspect imparted most frequently by nurses, at 62.5 % (10/16) ¹⁴^-¹⁹^,²¹^-²⁴.

The community interventions ⁽²⁷^-²⁹ included assessing the health status, measuring the ankle-arm index, treating the VU, applying a short stretch compression bandage system, counseling and support regarding VU, follow up and attendance to the community’s Leg Club. All the interventions considered an essential clinical element, which was the clinical evaluation of the wound area (Table 1).

Delivery mode and duration

All the interventions took place face to face; however, 13 were delivered individually, and three collectively ²⁷^-²⁹. Four studies had telephone follow up with the participants ¹⁴^,¹⁷^,¹⁸^,²⁰. The first made six calls from 10 to 15 minutes to reinforce development of resistance exercises ⁽¹⁴; the second indicated regular telephone follow up during the first, fourth, and last week, without stipulating the time ⁽¹⁶; the third made calls only when the patient required it ⁽¹⁸; and the fourth indicated that the two monitoring were of 30 minutes ⁽²⁰.

In relation with the material used to deliver the intervention, 43.7 % (7/16) of the studies was supported by booklets and brochures ¹⁴^,¹⁵^,¹⁷^,¹⁸^,²⁰^,²¹^,²⁴; while 31.5 % (5/16) did not describe this aspect ¹⁹^,²²^,²⁷^,²⁸. The minimum time for the interventions was of eight weeks, and the maximum lasted 72 (18 months). Nevertheless, 50 % (8/16) of the interventions lasted 12 weeks ¹⁴^,¹⁶^-¹⁹^,²⁸^,²⁹. With respect to the follow up, only one study did not monitor the participants ²³; the rest showed diversity regarding its time and purpose, which ranged between weekly, biweekly, and monthly. On the time dedicated to each session with the patient, it varied from 20 to 60 minutes for the first session; the rest lasted between 10 and 30 minutes ¹⁴^,¹⁷^,²⁰^-²³. Of all the interventions, 62.2 % (10/16) were delivered in clinical contexts; 18.7 % (3/16) in the patients’ homes; and 18.7 % (3/16) in the community’s Leg Club (Table 1).

Table 1
Description of the nursing interventions aimed at persons with venous ulcers

*RCT: randomized clinical trial; †n: sample; ‡ CG: control group; § IG: intervention group. Source: elaborated by the authors.

Result variables

Among the result variables evaluated with highest frequency, it was found: 1) measurement of the wound area (11/16) ¹⁴^,¹⁶^-¹⁹^,²²^,²⁴^-²⁶^,²⁸; 2) assessment of the healing process with the scale denominated The Pressure Ulcer Scale for Healing, through aspects of wound area, amount of exudate, and type of tissue (6/16); 3) pain (7/16) ¹⁶^,¹⁷^,²¹^,²⁴^,²⁶^-²⁸; and 4) quality of life (5/16) ⁽¹⁴^,¹⁷^,²⁵^-²⁷. Regarding the instruments used to assess the results mentioned, only four studies reported the corresponding psychometric properties ²¹^,²⁵^-²⁷.

Based on this integrative literature review, the recommendation is to strengthen the design and report of the interventions in this specific area of nursing knowledge. For this, entities exist, like the Medical Research Council, which offers guidelines for their construction, or the Template for intervention description and replication (TIDieR) checklist and guide ³⁰, among others.

Discussion

The objective of this review was to identify and describe the theoretical foundations, components, duration, delivery mode, and results of nursing interventions aimed at persons with VU available in the literature. The findings described confirm the variety of nursing interventions seeking to improve care and potentiate care aimed at this population.

Although most of the interventions were educational, few mentioned the theory, concepts or proposals that guided their construction. The use of conceptual models and nursing theories facilitate understanding common problems in the practice from a unique perspective. This permits testing disciplinary knowledge, demonstrating positive results in the health of individuals, and acquiring autonomy and jurisdiction in the practice ⁽³¹. As reported with the use of the nursing care model for patients with VU in Australia, denominated Leg Club, this model is based on the community; patients are treated collectively while operating without prior schedules, and incorporating a well leg regime, a preventive education and counseling program, once the ulcer heals. Its objective is to empower patients and turn them into participants in their treatment, through modification of behaviors that diminish the recurrence of VU ⁽³²^-³⁴. It has been recognized as a viable, replicable, and profitable model in The United Kingdom, Australia, and other European countries ³⁵.

In terms of the components of the interventions, the promotion of physical activity and exercise was the central theme of the studies where it was prescribed and patients were motivated to walk and elevate their legs. Evidence exists that demonstrates the positive effect of exercise in improving the calf muscle pump function and its subsequent effects on healing VU, besides their use as complementary therapy to compression systems that, until now, are considered the gold standard in treating these types of chronic wounds ³⁶^-⁴⁰. More than 50 % of the authors considered wound assessment an essential component and a positive effect of their interventions ¹⁴^-¹⁹^,²¹^,²²^,²⁶^-²⁹.

The delivery mode was face to face; 15 studies conducted follow up, but only four specified that it was via telephone, and its objective was to reinforce the education taught ¹⁴^,¹⁶^,¹⁷^,²⁰. Systematic literature reviews have validated the efficacy of telephone support in interventions developed by different health professionals and have reported positive results in patients, like quality of life and reduced rates of hospitalization and costs in health systems ⁽⁴¹^,⁴². Consequently, the telephone calls could be a useful tool and more effective than other communication devices to offer care to patients with VU, considering that mobility impairment is one of the most common negative effects in this population.

The time invested in delivering the interventions is paramount in identifying cost-effective nursing practices. Notwithstanding, few mentioned the specific time invested in each session with patients and their follow ups. With regards to the support material, only one study used multimedia presentation ²³. Probably, the use of digital media results problematic for elderly patients, who often lack the knowledge and skills needed to use electronic resources ⁴³. However, eHealth literacy interventions could offer an opportunity to the elderly with VU, by permitting access to resources, like electronic health records, on-line support groups, and self-management tools that guide patients to solve habitual problems, make informed decisions, and communicate with health providers ⁴⁴^,⁴⁵. Likewise, involving relatives and caregivers would contribute to the identification, follow up, and timely control of complications related with the venous ulcer ⁴⁶.

With respect to the result variables, two aspects are highlighted; the first has to do with the psychometric properties of the instruments used to measure the result variables proposed, given that only four studies did so, and most of the scales used were not specific for patients with VU. This could be explained by the limited number of specific instruments available for patients with VU. Concretely, six instruments have been identified for this type of population, but such have demonstrated poor criterion and construct validity. Additionally, generic questionnaires, like the EQ-5D and the SF-36 of quality of life evidenced weak response capacity, or did not support their use in patients with VU ⁴⁷. These aspects would have important repercussions on the validity of the data reported. Secondly, the fact that clinical aspects prevail, like wound healing and the healing process against other variables. Empirical evidence exists that holds that wound healing processes are complex, and these affect physical, psychological, and even sociological factors, in favorable or unfavorable manner ⁵^,⁴⁸^-⁵³. With this, it must be stated that, although the clinical-type variables as objectives are important, including behavioral variables is also important. It is likely, in many cases, to achieve significant behavioral changes, but not clinical in the short term.

In consequence, it is not possible to rule that a nursing intervention is effective if it did not manage to get patients with VU to heal their wounds in a given time, but it is possible perhaps if it contributed to improving they experience and cope with this chronic health condition. Thus, the question would be if it is pertinent to establish as results only clinical variables in this type of population.

Limitations

The articles included were published only in English, so that studies in other languages and contexts could ratify or contradict the way the interventions are developed and the results expected. The lack of specific instruments for patients with VU and the use of other generic questionnaires without satisfactory validity tests could limit the interpretation of the results. This review did not include in its search interventions aimed at caregivers or relatives of patients with VU.

Conclusions

The findings presented in this integrative review permit identifying the existence of few nursing interventions aimed at persons with VU, although it is a chronic condition that tends to increase its incidence and prevalence. Unfortunately, less than half of the studies mentioned the theoretical foundation supporting the intervention, and those which did so did not expose which concepts or propositions were selected as guides in their development. Diversity existed regarding the delivery time of the intervention and the dynamics of the face-to-face meetings, as well as the follow up carried out. Few studies reported the thematic content of their interventions, a fact that limits understanding if these generate impact or not on the primary results established, with the priority being the venous ulcer healing. It is considered necessary to rethink the approach of nursing interventions in this area of knowledge, given the prevalence of people as holistic beings, and the object of nursing is that of caring for the human health experience.

Supplementary material

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Notes

* This work is derived from the doctoral research proyect named: "M.A.T.E.O. viabilidad y efecto de una intervención de automanejo para pacientes con úlceras venosas".

* Artículo derivado del proyecto de investigación doctoral titulado: "M.A.T.E.O. viabilidad y efecto de una intervención de automanejo para pacientes con úlceras venosas".

* Artigo derivado do projeto de pesquisa de doutorado chamado "M.A.T.E.O. viabilidad y efecto de una intervención de automanejo para pacientes con úlceras venosas".

Theme: Evidence-based practice.

Contribution to the discipline: Identifying the elements that shaped nursing interventions in other cultures and the foundations underlying them, permits knowing progress in the area, as well as strengths and weaknesses in their development and execution. In turn, testing nursing interventions in keeping with our context, that is, those addressing human beings with their needs, doubts, and fears - through viable learning and mutual construction settings favor positive care experiences. Providing quality and cost-effective care requires viable, effective, easily replicable nursing interventions with important social impact, which transform the nursing practice and demonstrate their autonomy and jurisdiction.

Conflict of interests: none declared.

Acknowledgements: Johana Cifuentes thanks the Academic Direction at Universidad Nacional de Colombia for the scholarship granted to conduct her PhD studies.

Para citar este artículo / To reference this article / Para citar este artigo: Cifuentes JE, Guerrero S. Nursing Interventions Aimed at Persons with Venous Ulcers: an Integrative Review. Aquichan. 2020;20(1):e2017. DOI: https://doi.org/10.5294/aqui.2020.20.1.7

Figure 1
Study selection process
Source: Own elaboration.

Table 1
Description of the nursing interventions aimed at persons with venous ulcers

*RCT: randomized clinical trial; †n: sample; ‡ CG: control group; § IG: intervention group. Source: elaborated by the authors.