Evaluating & Managing Behavioral Patterns in the Wound Care Population

  Proper wound care is associated with a number of positive outcomes but requires a complex set of self-management behaviors. Although engaging in healthy wound care behaviors benefits patients, these same people often have difficulty adhering to their providers’ treatment recommendations due to the impact of wounds on everyday life.   The Health Belief Model (HBM), developed in the 1950s by social psychologists at the US Public Health Service, is one of the most well-known and widely used theories in health behavior research and provides a useful framework for understanding health behavior change. Providers can use this framework, along with such principles as motivational interviewing, shared decision-making, patient-centered communication, agenda setting, active listening, asking open-ended questions, decisional balance exercise, and realistic goal setting to help their patients interact in a meaningful way in order to reach optimal wound care. This article provides background on health behavior change and practical strategies for incorporating techniques into everyday interactions with patients.

Health Behaviors in Wound Care

  Effective wound care reduces infection, number of home health and/or hospital visits, and both direct and indirect costs.^1,2 Proper wound care requires a complex set of behaviors ranging from appropriate medical care to nutrition and sufficient sleep.² Since the care of chronic wounds requires a different approach than acute wound care, it can be particularly challenging for patients to shift their mindset from acute to chronic care. While acute wound healing follows a predictable and time-limited series of stages, chronic wound healing can follow an unpredictable course and persist for a lengthy period of time, leaving the patient to question whether there is an end to be achieved.³ While patients may more easily tolerate the distress caused by an acute wound, living with a chronic wound can become burdensome and easily deplete the patient’s coping resources. To help patients manage both acute and chronic wounds (and to prevent future wounds or worsening of existing wounds), providers can facilitate a number of behaviors that are known to impact wound healing, including adequate sleep, healthy nutrition, reduced alcohol use, smoking cessation, increased exercise (when appropriate), more social contact, elevation of the affected area, compression, use of proper dressings (wearing and changing them), cleaning the wound, keeping the wound moist, and managing associated pain.^4,5 Nonhealing wounds have a number of consequences for patients from a quality-of-life standpoint, such as pain, decreased mobility, decreased appetite, poor sleep, fatigue, anxiety, depression, frustration/anger, altered body image, avoidance of socialization (ie, related to concerns about odor or oozing), stigma, low self-esteem, negative impact on employment, absenteeism, and increased dependency on others.⁶ Given this lengthy (and yet, incomplete) list of negative consequences associated with poor wound healing, providers may begin to question why patients are not better able to adhere to their treatment recommendations. Broadly speaking, the average nonadherence rate to medical recommendations is 24.8%, suggesting that it is expected that a significant proportion of patients will have difficulty adhering to wound care recommendations.⁷ Literature also shows that educational programs, particularly those that teach practical wound care skills through modeling and patient demonstration of understanding and uptake, can produce better outcomes when compared with usual care.^2,8-10 However, wound care providers do not always have access to such structured programs. Still, providers can enhance their interactions with patients to help treat their wounds more effectively and better manage health over the long term.

Models for Understanding Behavior & Communication

  The HBM is a useful framework for understanding how and why patients make behavior changes or stay with the status quo.¹¹ HBM suggests that patients will move toward behavior change if they believe: 1) that the health condition is serious; 2) that they are susceptible to consequences of the health condition if they don’t make a behavior change; 3) that the chosen behavior change will improve the health condition and will not cause more harm than good; and 4) that the perceived barriers to making the behavior change are manageable.¹² For example, in working with a patient who’s living with a chronic wound and who is smoking, the HBM suggests the patient must believe that a nonhealing wound is a serious health condition, that he/she is at risk for consequences (eg, pain, loss of time at work, etc.) related to the wound if he/she does not quit smoking, that quitting smoking will result in improved wound healing, that quitting smoking is not more aversive than dealing with the wound, and that the perceived barriers to quitting smoking (eg, weight gain, irritability) seem manageable. Of the four components of the HBM, perceived barriers have the strongest association with behavior change.¹³ Therefore, intervention should be focused on problem-solving how to address barriers to wound care. For example, in working with a patient who is smoking, it is important to understand why he/she is smoking (eg, stress management) and provide smoking cessation treatment with particular emphasis on learning alternate stress-management strategies.

  The use of evidence-based patient-centered communication strategies can assist providers in using the HBM to help their patients manage their wounds more effectively. Patient-centered communication includes provider behaviors such as eliciting patients’ questions and concerns, partnering with patients in decision-making, educating patients about self-management, supporting self-care, and helping patients feel understood and accepted.¹⁴ The TEACH¹⁵ program used by the US Department of Veterans Affairs’ Office of Health Promotion and Disease Prevention serves as a helpful tool for providers wanting to improve their ability to facilitate health behavior change in patients living with chronic wounds. Encompassing the five specific aspects of patient-centered communication listed in Table 1, the overall efficacy of TEACH has not been formally evaluated, but the specific skills taught in the modules have been associated with positive outcomes in a large body of research literature. For example, when speaking with providers who are perceived as having stronger listening skills (ie, “tuning into the patient”), patients are more engaged in discussions and medical encounters are more efficient.^16,17 Greater patient motivation and self-efficacy (ie, “assisting with behavior change”) have previously been associated with greater improvements in patient alcohol and tobacco use, diabetes management, diet, weight, and hypertension.^18-23 Importantly, patients are more satisfied when their providers utilize patient-centered communication techniques.^24,25

Applying Models To Practice

  It takes time to conceptualize patients’ wound care behaviors (or lack thereof) in terms of the HBM and to use the appropriate TEACH skills during interactions with patients. Table 2 shows providers which TEACH skills to focus on when trying to enhance each of the four precepts of the HBM model. The following clinical examples demonstrate how to integrate some of these skills into typical provider/patient interactions around proper wound care. Often, patients do not perceive the seriousness of a health condition (precept No. 1 of the HBM) or may not believe they are susceptible to the negative consequences of a health condition (precept No. 2). Providers can help enhance patient’s perceptions related to the need for change by using agenda setting, active listening, and information-sharing skills.

  Agenda Setting sets the stage for the remainder of the patient’s appointment. Involving the patient in this process allows the provider to balance an agenda with the patient’s needs and concerns. In the following example, the provider begins by letting the patient know what is expected during the appointment. The patient is given a chance to add any items to the agenda and provides useful information about psychosocial factors that appear to have impacted her self-care.

  Provider: We are here today to check on your leg ulcer. I’d also like to check in with you about your blood sugar and your smoking. Is there anything else you would like to discuss today?

  Patient: I’m really worried about my leg and I guess my sugars have been pretty out of control lately, too. My husband has been sick the last couple weeks, so I have been really stressed and have been eating a lot of junk and smoking up a storm!

  Provider: Sounds like you’ve had a lot on your plate. I’m sorry your husband has been sick. Looks like we might want to spend some time making sure you have everything you need so that it is easier to take care of yourself, and him, too!

  Active Listening involves listening to what patients say (and how they speak) and reflecting back the content, emotions, and meaning of their statements.

  Patient: I’d like to quit smoking, but last time I gained so much weight so I started smoking again. Then I just felt terrible about giving up.

Examples of different levels of reflection:
  Provider: So you were able to stop smoking before, but you gained weight and so you went back to it? (reflecting content)

  Provider: So you were discouraged when you gained weight and went back to smoking? (reflecting emotions)

  Provider: Sounds like you would like to quit smoking, but you don’t want to have another unsuccessful attempt and feel like a failure? (reflecting meaning)

  Active listening lets patients know they were heard, understood, and accepted. It also encourages them to say more through the use of open, as opposed to closed, questions.

  Provider: Did you know that poorly controlled blood sugar could affect your wound healing? (closed question)

  Patient: No.

  Provider: What is your understanding of the relationship between your diabetes control and your wound healing? (open question)

  Patient: I never really thought about it before. Maybe if my sugar is high then my wound won’t heal as well.

  Provider: Yes, that’s true. Can I share some information with you about how diabetes and wound healing go hand in hand? (asking before telling)

  The provider’s open-ended question resulted in the patient sharing more information about understanding the effect of high blood sugar on wound healing. Notice how the provider asked the patient if there was more information needed before providing additional content. "Asking before telling" is a useful strategy for involving patients in the education process and to avoid repeating information the patient has heard before.

  Summarizing and Key Questions allow the provider to check in with the patient to ensure information is understood. Summarizing can also be useful in moving the discussion forward when combined with the use of a key question, as shown in the dialog below.

  Provider: We’ve spent some time today talking about how your high blood sugars may be interfering with healing your leg ulcer. You have an appointment with the nutritionist next week to help you with your diet and your diabetes. We also talked about how your smoking habit could be slowing things down. You want to quit smoking, but you don’t want to have another failed quit attempt. Do I have that right?

  Patient: You sure do! I wish I could quit; it’s just so hard.

  Provider: You feel like you have a good plan to help with the diabetes, but not the smoking, though you know that both are probably making it harder for that leg ulcer to heal. So where does that leave us now? (key question)

  Patient: Well, I should probably take another stab at quitting. Is there anything I can do to keep from gaining all that weight again?

  Use of some classic motivational interviewing tools such as the decisional balance exercise or a confidence ruler²⁶ can be helpful when patients are experiencing barriers to making health behavior changes (precept No. 4 of the HBM) or feel that the health behavior change might not be effective in improving their wound care (precept No. 3). Use of goal setting may also enhance patients’ self-efficacy for making these changes.

  Decisional Balance is an exercise in which the provider assists the patient in exploring the pros and cons of both making the health behavior change and maintaining the status quo. For example, the provider in the scenario above may help the patient explore the benefits of quitting smoking, the drawbacks to quitting, the benefits of not quitting, and the drawbacks of not quitting. This provides a thorough exploration of the patient’s reasons for and against behavior change and may allow the patient to resolve any ambivalence about making a change.

  S.M.A.R.T. Goal Setting and Confidence Ruler encourage patients to set goals that are “specific, measurable, action-oriented, realistic, and time-bound” to complete.²⁷ Providers using this format may avoid common pitfalls (eg, goals that are too vague, too large, too difficult) when assisting patients in setting goals related to health behavior change. Assessing patients’ confidence in their ability to meet their goals is another good indicator of whether the goal is “S.M.A.R.T.” As demonstrated in the interaction below, if patients rate their confidence as lower than 7 or 8, the goal may need to be revised to be more achievable.

  Provider: What is a small step you think you can take this week towards your larger goal of quitting smoking?

  Patient: I think I can quit tomorrow, cold turkey.

  Provider: That’s great that you are so motivated to quit! How would you rate your confidence in your ability to quit cold turkey tomorrow on a scale of 1-10, where 1 is not at all confident and 10 is totally confident? (confidence ruler)

  Patient: I would give it a 3 or a 4. I am smoking more than I ever did before. I still don’t have my diet under control and I don’t want to gain a bunch of weight.

  Provider: I see. What might we be able to do to boost your confidence?

  Patient: Well, instead of quitting cold turkey, I could try cutting down my smoking by half this week. That’s how much I used to smoke before I got so stressed out. I have my nutritionist appointment too, so maybe I can talk there about tips to avoid gaining weight while quitting.

   Provider: That sounds like a good start. So, you plan to cut down from 2 packs per day to 1 pack per day by the end of the week. (SMART goal)

  Kathryn S. Connolly is a clinical psychologist for the telebehavioral pain management program, National Telemental Health Center, VA Connecticut Healthcare System, Willimantic Community-Based Outpatient Clinic. She may be reached at kathryn.connolly@va.gov. Kristina P. Schumann is on staff at Yale University School of Medicine.

References

1. Sturkey, EN, Linker, S, Keith, DD, Comeau, E. Improving wound care outcomes in the home setting. Journal of Nursing Care Quality. 2005;20:349-355.

2. London, F. Patient education: Teaching patients about wound care. Home Healthcare Nurse. 2007; 25:497-500.

3. Lazarus, GS, Cooper, DM, Knighton, DR, Margolis, DJ, Percoraro, RE, Rodeheaver, G, Robson, MC. Definitions and guidelines for assessment of wounds and evaluation of healing. Wound Repair and Regeneration. 1994;2:165-170.

4. Fonder, MA, Lazarus, GS, Cowan, DA, Aronson-Cook, B, Kohli, AR, Mamelak, AJ. Treating the chronic wound: A practical approach to the care of nonhealing wounds and wound care dressings. Journal of the American Academy of Dermatology. 2008; 58:185-206.

5. Guo, S, DiPietro, LA. Factors affecting wound healing. Journal of Dental Research. 2010; 89:219-229.

6. Brown, A. Implications of patient shared decision-making on wound care. Wound Care. 2013; 18:S26-S32.

7. DiMatteo, MR. Variations in patients’ adherence to medical recommendations: A quantitative review of 50 years of research. Medical Care. 2004; 42:200-209.

8. Van Hecke, A, Grypdonck, M, Defloor, T. Interventions to enhance patient compliance with leg ulcer treatment: A review of the literature. Journal of Clinical Nursing. 2007; 17(1);29-39.

9. Lo, SF Hayter, M, Hsu, M, Lin, SE, Lin, SI. The effectiveness of multimedia learning education programs on knowledge, anxiety and pressure garment compliance in patients undergoing burns rehabilitation in Taiwan: An experimental study. Journal of Clinical Nursing. 2010; 19:129-137.

10. Chen, YC, Wang, YC, Chen, WK, Smith, M, Huang, HM, Huang, LC. The effectiveness of a health education intervention on self-care of traumatic wounds. Journal of Clinical Nursing. 2012; 22:2499-2507.

11. Glanz, K, Rimer, BK, Lewis, FM(Eds.). Health Behavior and Health Education. 3rd ed. San Francisco: Jossey-Bass. 2002.

12. Hochbaum, GM. Public participation in medical screening programs: A socio-psychological study. Public Health Service Publication No. 572. Washington DC, Government Printing Office. 1958.

13. Janz, NK, Becker, MH. The Health Belief Model: A decade later. Health Education Quarterly. 1984;11:1-47.

14. Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Early evaluations of the medical home: building on a promising start. Am J Manag Care. 2012;18(2):105-16.

15. Office of Veterans Health Education and Information, VHA National Center for Health Promotion and Disease Prevention, & VA Employee Education System. Patient Education: TEACH for Success. Veterans Health Administration. 2010.

16. Mast, MS, Hall, JA Roter, DL. Caring and dominance affect participants’ perceptions and behaviors during a virtual medical visit. Journal of General Internal Medicine. 2008;23:523-527.

17. Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med. 2008;168(13):1387-95.

18. Ilgen, M, Tiet, Q, Finney, J, Moos, RH. Self-efficacy, therapeutic alliance, and alcohol-use disorder treatment outcomes. Journal of Studies in Alcohol. 2005; 67:465-472.

19. Williams, GC, Niemiec, CP, Patrick, H, Ryan, RM, Deci, EL. The importance of supporting autonomy and perceived competence in facilitating long-term tobacco abstinence. Annals of Behavioral Medicine. 2009;37: 315.

20. Channon SJ, Huws-Thomas MV, Rollnick S, Hood K, Cannings-John RL, Rogers C, Gregory JW. A multicenter randomized controlled trial of motivational interviewing in teenagers with diabetes. Diabetes Care. 2007; 30:1390-5.

21. Spahn JM, Reeves RS, Keim KS, Laquatra I, Kellogg M, Jortberg B, Clark NA: State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change. J Am Diet Assoc. 2010;110:879-91.

22. Scala, D, D’Avino, M, Cozzolino, S, Mancini, A, Andria, B, Caruso, G, Tajana, G, Caruso, D. Promotion of behavioural change in people with hypertension: An intervention study. Pharmacy World & Science. 2008;30:834-839.

23. Van Dorsten, B. The use of motivational interviewing in weight loss. Current Diabetes Reports. 2007;7:386-390.

24. Haskard, KB, Williams, SL, DiMatteo, MR, Rosenthal, R, White, MK, Goldstein, MG. Physician and patient communication training in primary care: effects on participation and satisfaction. Health Psychology. 2008; 27:513-522.

25. Roter, DD, Hall, JA. Doctors talking with patients/patients talking with doctors; improving communication in medical visits. 2nd ed. Westport, CT: Praeger; 2006.

26. Rollnick, S, Miller, WR, Butler, CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: The Guilford Press. 2007.

27. Doran, GT. There’s a S.M.A.R.T. way to write management’s goals and objectives. Management Review. 1981; 70(11):35-36.