Coping Strategies Used By Patients With Chronic and/or Complex Wounds

Objective. The aim of this study was to investigate coping strategies used by patients with chronic and/or complex wounds treated in an outpatient wound clinic. Methods. Coping strategies were assessed using the Utrecht Coping List (UCL). The Mini-Mental State Examination (MMSE) was used to assess the patient’s cognitive functioning. Fifty patients were selected for this study. The wound etiologies studied were: diabetic foot ulcers, lower extremity ulcers, surgical wounds, trauma wounds, and pressure ulcers. Results. Scores on the coping measure for men and women differed significantly from the control groups. It was also found that each wound etiology showed a preference toward different coping strategies. Furthermore, 28% of the studied group had a lowered score on the MMSE, indicating possible cognitive impairments. Conclusions. There might be an association between wound etiology and the coping strategy that is preferred; this knowledge could be used to guide treatment strategies used by clinicians. Further research could focus on the effects of coping strategies on wound healing rates.

Have you ever noticed during a treatment session for a patient with a wound that little or no attention is paid to psychosocial factors such as coping, social situation, and the activities of daily life? If the answer is yes to at least one of these factors, keep reading!

The Rijnland Wound Clinic (Leiderdorp, The Netherlands) treats patients with chronic and/or complex wounds. Even though advanced techniques are used, some wounds still do not heal. It is not always clear why this occurs. Psychological, social, emotional, and cognitive factors play a significant role in the healing process^1–8 and influences a patient’s quality of life.^9–15 Nevertheless, in daily practice, it seems little attention is paid to these factors.¹ It is suggested that stress can delay the healing of a wound.^7,8 If a patient cannot cope with the situation, there might be more stress, and in turn, a delay in wound healing. Psychological care could be provided in such cases.¹⁶ One author suggests that a healthcare professional can influence a patient’s experience.¹⁴ Rich et al¹⁷ suggest that a patient needs a support network. Keeling et al¹⁸ report that there is a variation in the coping strategies used by elderly patients with chronic wounds, and that there was minimal social support.      

The quality of life for a patient with a wound has been researched; however, very few have focused on the coping aspect. Coping might have a big influence on the healing process and overall well being of the patient. An example of this is that if a patient is more able to cope with the situation, he or she might be more compliant to the prescribed therapy.⁶ It remains unclear whether patients with chronic and/or complex wounds use different coping strategies. Furthermore, it is unclear if patients with different wound etiologies use different coping strategies. If this is the case, knowledge of these differences might guide the clinician on how to approach these patients or improve the care that is given. As an example, perhaps some patients need written information while others need a verbal explanation.      

The aim of this study was to analyze which coping strategies are used by patients with chronic and/or complex wounds.

Patients
The data for this study was collected at the Rijnland Wound Clinic of the Rijnland Hospital (Leiderdorp, The Netherlands) from December 2007 until March 2008. Fifty outpatients (age 26–85 years) were included in the study. All patients gave informed consent. Each patient received instructions and was then asked to complete the Utrecht Coping List (UCL) questionnaire. After completing the UCL, the researcher (in all cases J. Vermieden) asked the MMSE questions. The age of the patient and the wound diagnosis (diabetic foot ulcer, trauma wound, lower extremity wound, surgical wound, or pressure ulcer) were registered.      

A nurse took part in this research and was responsible for handing out the questionnaire. This questionnaire did not ask any intimate information nor did it influence the treatment given, because the nurse did not have access to the treatment plan nor did she make decisions about the care plan. The questionnaires were reviewed retrospectively and compared to each patient’s medical status. Ethical approval was not necessary since intimate information, which might have influenced the treatment, was not required.      

Method
The UCL was used to study the coping strategies.¹⁹ This list comprises 47 items divided into 7 different scales (Table 1): active approach, palliative approach, avoidance, social support, passive response, expression of emotions, and reassuring thoughts.²⁰ The UCL defines coping as a personality trait. Each of the 47 items were scored using a 4-point system: rarely or never (1 point), sometimes (2 points), often (3 points), and very often (4 points). The total score of the scale is determined by tallying the scores per scale. On average, it takes about 5 minutes to complete the UCL questionnaire. The reliability and validity of the UCL has been studied; the control groups were created based on that research.¹⁹      

The patients were divided into the following groups so that group 1 and group 2 could be compared to the UCL control group: group 1 ages 19–49, group 2 ages 50–65, group 3 ages 66–75, and group 4 ages 76–99. 

The Mini-Mental State Examination (MMSE) was used to examine cognitive functioning. The MMSE consists of 11 questions, which test different components of cognitive functioning, including memory, orientation, and arithmetic skills.²¹ A score between 27 and 30 is normal. Scores of 20 to 26 show that cognitive impairment might be present. Scoring between 10 and 19 suggest moderate cognitive impairment, and scores below 10 suggest severe cognitive impairment. A low score does not necessarily mean that the patient has dementia, but could be an indication of a different mental disorder. The MMSE was divided into 4 groups according to the test results. In group 1 (scores below 10), group 2 (scores 10–19), group 3 (scores 20–26), and group 4 (scores 27–30).      

All data were entered using SPSS software. P values were obtained using Fisher’s exact test, which facilitated analysis of the small sample sizes.

Utrecht Coping List
The UCL control group is only valid for ages 19 to 65. This only allows us to compare patients ages 19–65 with the UCL control group. The remaining age groups however, were used for the rest of the analysis.      

Mini Mental State Examination
The highest score (between 27 and 30) was achieved by 35 patients (70% of the studied group). It appeared that patients with a high MMSE score (27–30) preferred the UCL’s “Active Approach” strategy, although this effect was only a trend (P = 0.57).      

Diabetic foot ulcers
On the UCL’s Active Approach scale, patients with a diabetic foot ulcer (n = 10) scored lower compared to patients with other diagnoses. They scored highest on the Passive Response Pattern with 12.4 points (P = 0.29) and lowest on the Expression of Emotions scale with 4.25 points (P = 0.06). Thirty percent (n = 3) of patients with a diabetic foot ulcer scored between 20 and 26 on the MMSE. The remaining 70% (n = 7) of the diabetic foot ulcer population scored between 27 and 30 (P = 0.65).      

Trauma wounds
Patients with a trauma wound (n = 8) scored high on the Active Approach scale with 17.3 points (P = 0.26) and the Palliative Approach scale with 17.25 points (P = 0.35). This group of patients scored lower on the Avoidance scale with 15.14 points (P = 0.11). A large group, 37.5% (n = 3), of the patients with trauma wounds scored between 20 and 26 on the MMSE. More than half the patients, 62.5% (n = 5), had a MMSE score between 27 and 30 (P = 0.45).      

Lower extremity wounds
Patient with lower extremity wounds (n = 11) scored lowest on the Active Approach scale with 15.09 points (P = 0.015). These patients had a high score on the Reassuring Thoughts scale with 14.67 points (P = 0.28). One patient had a score between 10 and 19. The remaining patients scored between 20 and 26 (n = 5) and 27 and 30 ([n = 5] P = 0.053).      

Surgical wounds (postoperative wound infections)
Patients with a postoperative wound infection after surgery (n = 19) scored high on the Active Approach scale with 17.67 points (P = 0.5) and the Social support scale with 12.76 points (P = 0.26). They scored lower on the Avoidance scale with 16.05 points (P = 0.45). Only 15.8% (n = 3) of the patients with a surgical wound had a MMSE score between 20–26. The remaining 84.2% (n = 16) scored between 27 and 30 (P = 0.078).      

Pressure ulcers
Not enough data was available to analyze this group (n = 2).      

Table 2 provides suggestions on how to approach treatment with these various patient groups.

The interpretation of the MMSE results found that 30% of the population might have cognitive problems (MMSE < 27). This is a relevant and important finding that indicates that cognitive problems are a serious problem when treating patients with chronic wounds. These outpatients could not realize or remember the instructions, which were given, or the treatment he or she had just received, hence, influencing the healing process. Perhaps, in addition to an oral explanation, written folders with information should be given that includes a clear instruction letter to the home care nurse. More knowledge regarding the wound healing process could help a patient understand the treatment he or she is receiving.      

Most of the effects observed in the present study were not statistically significant or were present only on a trend level. Only one effect was statistically significant: patients with lower extremity wounds scored lowest on the Active Approach scale. Globally, the following interesting points were found: a patient with a diabetic foot ulcer will probably try to avoid the situation or take a passive response approach and will most likely not express any emotion. A clinician should not expect a palliative approach. On the contrary, a patient with a trauma wound will probably take a palliative approach and express his or her emotions. One should not expect a patient with a trauma wound to avoid the situation or to seek social support. When looking at patients with lower extremity ulcers, the patient will most likely not take an active approach when dealing with a stressful situation. Alternatively, results show that this group of patients prefers to rely on reassuring thoughts when coping with a problem. Patients with surgical wounds tend to have a high preference for the Active Approach scale, meaning they try to resolve a given situation in a reasonable and calm manner. A clinician can also expect the need for social support in this group of patients. This knowledge might help the wound clinician gauge what type of behavior to expect from a patient, and how a patient might react to a situation. This could influence the approach a clinician uses during treatment. If a patient prefers using social support, the clinician could focus on involving the family in the treatment.

The ability to cope with a wound situation influences the healing process. An inability to cope with the situation might affect a patient’s quality of life. For example, a patient has had a wound for more than a year, which has prevented him from completing his daily activities. This could lead to increased stress and could influence the healing process. Helping a patient cope with the situation might help him get out of this cycle of thoughts and events, and therefore, have a positive influence on the wound healing process.      

One limitation of this study was that it only included 50 patients, and an insufficient number of patients were included in the pressure ulcer group, which warrants further study.      

Future studies will need to determine whether one coping strategy is more effective than another, and if different approaches by the caregiver will improve wound care.

Address correspondence to: J. Vermeiden, RN Afd. Wondcentrum Simon Smitweg 1 2353 GA Leiderdorp The Netherlands Phone: +31 715 828513 Email: jorivermeiden@gmail.com