The relationship between stress and delayed healing is now firmly established. This evidenced relationship may be associated with a range of factors linked to wound care. For example, the novelty of certain treatments- negative pressure for example- or the pain associated with wound management. Given the range of factors that are associated with wound related stress it is important that the health care professional understands the nature and model of stress, how best to assess it in practice and how any stress can be managed. These will be the foci of this particular chapter. Stress may be a consequence of several wound related factors: most particularly pain and wound management pain in particular. Preventing stress, and stress related to pain, is important not just for the relationship with delayed wound healing, but importantly, to understand that this may be an ongoing deleterious cyclical relationship. Increased wound related pain leads to increased stress which leads to delayed healing, which can lead to more pain. It is this cycle that this chapter addresses and suggests methods to break this damaging predicament.

The physiological model of stress- the General Adaption Syndrome (GAS) was proposed by Selye (1956). When a patient is experiencing stress there are usually a number of common bodily responses that can be identified, including; increased respiration, blood pressure or heart rate. These responses are all part of the ‘fight or flight’ syndrome that prepares the body and which are mediated through the nervous and endocrine system. The GAS describes three stages that are evident within the stress process, consisting of: (1) Alarm stage; (2) Resistance stage; (3) Exhaustion stage:

The GAS was one of the first models of stress, being underpinned by the classic work of Cannon (1932): revealing that when an individual is stressed, physiological systems are activated in order to prepare for ‘fight of flight’ (Kemeny 2003). Although this process is beneficial to the individual in the short term, it can become highly maladaptive if the stressor becomes long term. Selye (1956), on the basis of the ‘fight or flight’ response, observed a number of animals and their reaction to stressful situations, discovering that this reaction was the beginning of a series of responses made by the body and ultimately physiological collapse, or exhaustion (see Fig. 3.2).

This prolonged experience of stress can significantly lower the immune functioning and the lower levels of various inflammatory cytokines and enzymes that are influential in tissue repair (Upton 2011a, b), and in the case of wound care, delayed wound healing. Such changes in cytokine and enzyme levels could explain the relationship between reduced wound healing and stress (Marucha et al. 1998). Physiologically, prolonged stress can lead to raised levels of the hormone cortisol. Although stress isn’t the only reason that cortisol is secreted into the bloodstream, it has been termed “the stress hormone” because it is secreted in higher levels during the body’s ‘fight or flight’ response to stress (Ebrecht et al. 2004). Higher and more prolonged levels of cortisol in the bloodstream have been shown to have negative effects on the body including, increased heart rate, higher blood pressure and lowered immunity and inflammatory responses in the body.

Psychologically, stress can increase the likelihood of patients making cognitive errors or negative appraisals, for example perceiving a dressing removal as an unpleasant experience, which can result in detrimental effects to the wound healing process and/or avoidance of treatment. Thus negative emotional responses affect biological and behavioural responses which feed back to further negatively affect the emotional response to pain, producing a continuous cycle (Adams et al. 2006) with delayed wound healing as a consequence. It is important for clinicians to recognise that pain and stress are both comprised of complex interactions between physiological, psychological and social factors (see Table 3.1).

Although the GAS model provided an insight into the physiological stress process, it regards the individual as responding to a stressor, with stress being a linear stimulus-response framework. In doing so it ignores the role of psychological factors and individual differences. Hence, Lazarus and Folkman (1984, 1987) developed an alternative model that integrated the potential for psychological variables: the interactional model of stress.

Within the interactional model of stress, Lazarus and Folkman (1984, 1987) posited that stress and stress perception was based upon a transaction between an individual and their external world/environment. Hence, a stressful event would only elicit a stress response if the individual actually perceived the event to be stressful. In doing so, this model accounts for the individual differences that may be evident in perceiving an event stressful (E.g. while one patient may perceive a dressing change to be highly stressful, another may perceive it as a usual occurrence; see Fig. 3.3).

As can be seen in Fig. 3.3, this model proposes two types of appraisal; primary and secondary. The primary appraisal, whereby the event is appraised as to whether it is a threat or not (see Rovira et al. 2010a, b; Schlotz et al. 2011), is the initial response to a particular demand. From this, then two possible outcomes are available: either a threat or not (and the latter may either be positive, or neutral). If an individual perceives the situation to be threatening, secondary appraisal occurs; where the individual’s ability to cope and the resources available are assessed (see Prati et al. 2010) and put into action. The available choices from this assessment reflects the control that the patient may have; taking control of the situation themself, gaining help from another, or avoiding the situation (this can be particularly influential when considering patient’s treatment concordance, discussed later in this book). When an individual believes that, given their secondary appraisal, they have limited resources to cope with the situation, they will experience some form of stress and ultimately negative physiological consequences.

From this description of the model, a number of considerations for the wound care clinician can be noted. Firstly, clinicians cannot simply characterise a situation as stressful or not. Due to the differences in stress perception it may be that while one patient perceives a routine visit from the tissue viability nurse as stressful, another may perceive it as benign (or indeed, positive). Similarly, although the nurse may consider the dressing change as routine, normal and hence benign, the patient may not share this view. Furthermore, a patient whom may have experienced a previous painful experience during dressing removal may become highly stressed and anxious: their appraisal is based on learnt behaviour. Therefore, it is necessary for clinicians to be aware of such situations and consider patients on an individual basis.

Something which the clinician may view as routine clinical practice may be considered highly stressful by a patient (Upton 2011a, b). Secondly, the interactional model is based upon cognitive appraisal and is influenced by other psychological factors. Hence, it is possible for a patient to interpret the same situation in a number of differing ways depending on their mood- their cognitive appraisal is modified by their emotional state. Finally, it is important to remember that a patient can experience a stressful response irrespective of whether the event was experienced, anticipated or imagined. Within this model, the mere thought of having a dressing change itself can be stressful for the patient (Upton 2011a, b).

Lazarus and Folkman (1984) suggested two predominant functions of coping; the alteration of the situation (problem-focused coping), or regulation of emotional responses to the situation (emotional-focused coping). Briefly, problem-focused coping aims to reduce the stressful demands of expanding resources associated with dealing with that demand (e.g. this could include avoidance of dressing changes due to the stress perceived beforehand and during the procedure, or adopting a distraction strategy in order to help deal with the perceived stress). Alternatively, emotional-focused coping aims to regulate the emotional response through behavioural coping or cognitive coping strategies. For example, trying to stay calm throughout the treatment and reducing their own stress or worry.

It is well documented that psychological stress can result in delayed wound healing (Broadbent et al. 2003; Ebrecht et al. 2004; Francis and Pennebaker 1992; Gouin et al. 2008; Jones et al. 2006; Marucha et al. 1998; Weinman et al. 2008). Also, as highlighted previously in this chapter, stress can result in distorted cognition and subsequent increased pain. Hence, it is essential for wound care professionals to assess patient’s psychological stress throughout the treatment regime. Self-report or physiological measures should be used to assess patient’s stress in addition to an awareness of patient’s behavioural (see Table 3.2) indicators of stress.

In order for clinicians to assess levels of stress and pain in patients with chronic wounds, it is important to recognise that both stress and pain are biopsychosocial concepts (i.e. both stress and pain are comprised of complex interactions between biological, psychological and social components) and hence both physiological and psychological measures are required.

Effective psychological measures of stress focus upon the emotional responses obtained through self-report methods (see Table 3.3 for brief overview). Self-report methods of measuring stress are common in investigating patients’ response to illness/injury (e.g. chronic wounds) and can range from a simple “stress-thermometer” (for example, see Fig. 3.4) to more formal psychometric measures. For example, the PSS allows clinicians to assess a patient’s psychological appraisal of stress, whereas a measurement of increased heart rate or blood pressure would show a physiological outcome of stress. Accurate assessments of this nature allow us to determine the impact of interventions on psychological stress and anxiety in such situations. An overview of some of the more popular psychological measures of stress is presented here.