Psychological stress, pain, negative emotions, malodour, high exudate levels, social isolation, sleep and mobility problems are just some of the negative consequences of living with a wound. The subsequent psychological effects can have a severe impact on an individual’s quality of life and their well-being. The evidence suggests that these psychological factors not only influence the occurrence of further wounds, but they also exacerbate the severity of a wound and affect its ability to heal, resulting in the individual having to endure further psychological problems as a consequence- a vicious circle that clinicians must be aware of when treating patients with wounds. This chapter explores some of the negative consequences of a wound and how some psychological resources can help both the clinician and, more importantly, the patient and their family. Summarizing the material presented elsewhere in this book and highlighting the clinical relevance, this chapter demonstrates the importance of psychology in both the experience of living with a wound and effective wound care.

As we have seen in Chap.​ 1, most researchers, clinicians and patients agree there are a host of psychosocial factors that can affect the individual patient of which the health care professional should be aware. These can include: lack of energy, limitations in work and leisure activities, worries and frustrations, a lack of self-esteem, frequency and regularity of dressing changes, which affect a patient’s daily routine, feeling of continued fatigue due to lack of adequate sleep, restricted mobility, persistent pain, exudate, odour and social isolation (Upton and South 2011). Mobility restrictions may effect every aspect of the patients life, limiting their availability to work or perform household tasks. Even attending to personal hygiene may become difficult, as previously independent patients become reliant on others and report loss of self-worth and role reversal within families. Social isolation may be exacerbated by the impact on self-esteem of the physical consequences of the wound- the odour, any strike-through or required dressing changes. These may increase anxiety and depression, embarrassment, negative body image and social isolation, which can all impact negatively on quality of life (Hareendran et al. 2005; Herber et al. 2007).

All of these factors may contribute to the psychological distress experienced by both the patient and their carer. Furthermore, some individuals may try different methods of coping with the physical manifestation of the wound. Such actions are often ineffective and, in some cases, can worsen the condition of the wound. For example, Lo et al. (2008) reported the experiences of cancer patients living with a malignant fungating wound. Findings suggest that some patients would attempt to cover wounds to avoid leakage, would drink less fluid in the hope of reducing the amount of exudate produced and would remove bandages to help exudate disperse. Patients often feel embarrassed about exudate leakage and malodour and have difficulty maintaining dignity and outward appearances (Walshe 1995; Hyde et al. 1999).

It is therefore essential that the clinician recognises and responds to these psychosocial issues: dealing with any self-esteem issues, any psychological distress or social isolation and importantly providing accurate information and education for the patient to reduce any misunderstanding or inappropriate coping mechanisms. In this way it should be possible to promote a positive approach to the patient’s situation and their treatment. This may involve information on self-management, self-care, and social integration (see Table 9.1).

In a systematic review of studies on the impact of leg ulcers on daily life Persoon et al. (2004) listed pain as the first and most dominant factor and this has been fully explored in Chap.​ 2. Jones et al. (2006) found prolonged pain (along with malodour) was the specific symptom associated with anxiety and depression. Given the numerous negative effects of pain, it is not surprising that healthcare practitioners unanimously believed that reducing chronic wound pain could improve patients’ psychological state significantly (Upton et al. 2012a, b, c). However, in an interactive wound care survey of 246 wound conference delegates only 35 % of NHS community staff and 44 % of NHS hospital staff considered that wound pain was being addressed sufficiently (Lloyd Jones et al. 2010). Given the over-riding significance of pain, the reported poor support provided and the potential impact that pain may have on treatment concordance, stress levels and ultimately wound healing it is the key issue that clinicians have to address in wound care through careful assessment and management. Along with the underlying wound aetiologies and local trauma that is exacerbated at dressing change (Woo and Sibbald 2008), a constellation of patient factors including emotions, personality structure and stress are integral to the comprehensive assessment and management of wound related pain. These can all be encapsulated under the P.A.I.N. (Preparation, Assessment, Intervention and Normalisation) model previously described (see Chap.​ 2).

There are many psychological therapies that can help the patient deal with their pain. For example, cognitive therapy that aims to modify attitudes, beliefs, and expectations has been shown to be successful in the management of both stress and pain. Furthermore, distraction techniques, imagery, relaxation or altering the significance of the pain to an individual can also be successful in reducing pain. Patients can also learn relaxation exercises to help reduce anxiety related tension in the muscle that contributes to pain. These techniques can be employed by the clinician, or referred on for more specialist interventions and can help not only pain but stress and other psychological disorders. Finally, support from others, whether those with a similar condition or from the family can help and should be actively encouraged by the clinician (see Table 9.1).

A systematic review and meta-analysis (Walburn et al. 2009) explored the relationship between stress on a variety of wound types in different contexts (for example, different types of acute and chronic wounds and experimentally created wounds such as punch biopsies). The findings demonstrated that the relationship between stress and wound healing is clinically relevant (Kiecolt-Glaser et al. 1995; Cole-King and Harding 2001). For example, in a study of 72 patients with burns, it was found that the greater the level of distress a person was under, the slower the wound healing process can be (Wilson et al. 2011). This study, along with many others and other clinically relevant reviews (e.g. Solowiej et al. 2010a, b; Solowiej et al. 2010; Solowiej and Upton 2010a, b; Upton and Solowiej 2011) presented in detail in Chap.​ 3 demonstrates the importance of minimising the stress of both living with a wound and the wound management regime.

Wound-related pain at dressing changes has also been shown to correlate positively with stress and anxiety (Solowiej et al. 2009, 2010a, b). The relationship between pain and anxiety could be due to the patient being more sensitive to pain due to increased anxiety and fear, particularly if this is based on a past experience (Mudge et al. 2008; Woo 2010). Alternatively, patients suffering higher pain levels are more likely to become stressed and anxious. This may, in turn, impact on their healing rate. Considerable evidence now exists demonstrating the link between stress and delayed healing and controlling pain more effectively can affect stress and should also impact upon healing rates (Cole-King and Harding 2001; Soon and Acton 2006; Woo 2010; Gouin and Kiecolt-Glaser 2011; Solowiej and Upton 2010a, b). Consequently this has considerable implications for practice. It may be that the continued stress of wound care change leads to chronic stress. In this way, stress has a cumulative impact- the “minor hassle” or relatively low levels of pain experienced at any one dressing change have a significant impact over time (see Fig. 9.1).

Practitioners have to appreciate this cumulative impact and minimise stress and pain at all wound changes. This may be related to dressing choice, relaxed and calm environments, effective communication with the patient, provision of appropriate support, or demonstrated psychological or physical therapies (see Table 9.1).

Although there have been a wealth of studies exploring the quality of life (QoL) of patients with wounds, many tend to focus on ‘health-related quality of life’ (HRQoL) or ‘health status’. Such measures are useful as outcome measures of treatment, yet they do not always tell us about important psychological factors and the impact of wounds on well-being; consequently, these issues are often overlooked (Upton et al. 2013a, b). Throughout this book we have attempted to address these psychological factors and put well-being at the centre of the discussions (see Fig. 9.2).