As noted in other chapters, chronic wounds may cause financial, emotional and psychological strain for the patient. However, it is not just the wound that can cause these problems- it may also be the treatment for their wound. This chapter explores some of the psychological issues related to the treatment for chronic wounds, detailing three particular areas of treatment. Firstly, the stresses and strains of dressing change are explored. This highlights how the pain and stress may be associated with the dressing regime and, how, changing to an appropriate dressing choice may reduce both pain and stress. In such a way it may be possible to improve healing by reducing the stress associated with inappropriate dressing technique. Secondly, compression therapy will be explored and how concordance with this may be low and thereby reducing the effectiveness of the treatment. Techniques to improve concordance with treatment will also be explored. Finally, the pain and stress of Negative Pressure Wound Therapy (NPWT) will be outlined and how this may change across the course of treatment- emphasising the need to assess psychological variables throughout the course of any health related intervention.

Wound pain and stress continue to be an important clinical focus in wound care. In light of this, many consensus documents and statements have been published to provide healthcare professionals with best practice guidance on the management of wound pain (WUWHS 2007). Specifically, the pain caused by the removal of dressings has been identified as a major contributor of wound pain (White 2008), from a patient and healthcare professional perspective (Price et al. 2008b; Kammerlander and Eberlein 2002). In particular, a survey by Hollinworth and Collier (2000) indicated that healthcare professionals were aware of the importance of preventing pain during wound care, however they were unaware of the types of dressings that can be used to minimise this. It has been suggested that patients with wounds should have an individual pain management plan, including regular review and reassessment (Solowiej et al. 2010a, b). It is therefore important that particular attention is paid to dressing selection for patients on an individual basis, as it is known that poor dressing choice can lead to increased wound pain.

Wound dressings have often been classified in simplistic terms, with reference to the interaction that takes place between the wound and the dressing itself – adherence (Thomas 2003) (see Table 6.1).

Traditional dressings such as cotton gauze and bandages were often replaced with more modern technology once clinical research demonstrated that keeping wounds moist was beneficial for wound healing (Rippon et al. 2008). However, even some modern dressings cause skin damage from repeated application and removal, which causes additional skin damage and increased wound pain. More recently a category of wound dressings have been introduced that are designed to minimise the skin trauma and pain caused by removal. Atraumatic dressings present a category of products that do not cause trauma to the wound or surrounding skin on removal and reapplication, thus reducing pain (Thomas 2003). Specifically, atraumatic dressings utilise technologies that have been developed to avoid adhesion, for example soft silicone adhesive technology (Rippon et al. 2008). The term atraumatic can refer to dressings that are adhesive and non-adhesive, coated in soft silicone to interact with dry skin, but not the fragile wound surface. Therefore, it is suggested that careful selection of atraumatic dressings would benefit the wound healing process, as they contribute significantly to a reduction in pain. In support of this, White (2008) demonstrated that the introduction of atraumatic dressings with soft silicone adhesive in replacement of other dressings (including, adhesive foams and hydrocolloids) significantly reduced further trauma to the skin and wound-associated pain in a large multinational survey of patients with chronic wounds.

In a study by Upton and Solowiej (2012) the impact of dressing type on wound pain and stress was explored. It was hypothesised that patients with atraumatic dressings as part of their treatment regime would experience less pain at dressing change, in comparison with patients who are treated with conventional dressings. It was found that patients being treated with conventional dressings experienced significantly higher numerical pain ratings, numerical stress ratings, along with the physiological measures of stress- systolic BP, and GSR (Galvanic Skin Response)- at dressing change in comparison with the atraumatic dressings group (see Table 6.2).

In addition to the increased physiological indicators of stress amongst patients receiving conventional dressings, the self-reported severity of acute pain and stress also demonstrated higher pain and stress at dressing change for the conventional dressing group (see Fig. 6.1).

Overall, the findings of this research demonstrated that patients receiving atraumatic dressings as part of their wound treatment experienced significantly lower episodes of acute pain and stress at dressing change in comparison with patients being treated with conventional dressings. In particular, atraumatic dressings appear to improve and minimise the experience of acute stress and pain at dressing change.

Overall, the results of the Upton and Solowiej (2012) study support the notion that appropriate selection of dressings can contribute to a reduction in acute pain and stress, which could lead to an overall improvement in wound treatment experience. A more recent study, reported by Parvaneh et al. (2014) monitored the stress in a group of patients (n = 20) continuously whilst they waited for their treatment, underwent a dressing change and then in the post-dressing period. Their results indicated higher stress during the dressing change compared to before the treatment. Unfortunately in this pilot study no comparison between dressing types or wound care regimes was explored but their innovative technique of recording stress through a wearable sensor in real time does open this possibility in the future.

These studies have demonstrated the impact of the dressing type on various psychological measures. Although Upton and Solowiej (2012) explored atraumatic dressings in comparison to other dressings, the nature of the dressing was less relevant than the key message: dressing type can influence stress and pain experienced. Hence, the clinician has to consider the use of appropriate dressings for the individual patient. As has been highlighted by many, the choice of dressing should be made on the basis of a clear assessment of the patient and their wound- if the dressing is right for the patient and their wound and can minimise pain then the stress will be ameliorated and healing promoted (see the Fig. 6.2).

For those with leg ulceration of venous aetiology, compression therapy is the gold standard treatment, with compression bandages accelerating ulcer healing when compared with no compression, and multicomponent bandages appearing to be more effective than single layered bandages (O’Meara et al. 2009). However, in 60–70 % of cases, ulcers recur with those that do heal requiring a lifelong plan to prevent recurrence, usually consisting of the on-going use of compression bandages, which imposes a life-long chronic treatment on the individual (Abbade et al. 2005). Moffatt et al. (2009) identified that recurrence rates of wounds were 2–20 times greater when patients did not correctly comply with their prescribed compression bandages suggesting that compliance to treatment is vital for the complete healing of wounds.

Although compression bandages are considered to be the gold standard treatment for venous leg ulcers concordance of them by patients can be poor, which has been noted to be between 48 and 83 % (Moffatt 2004b; Jull et al. 2004a; Van Hecke et al. 2007). Although compression bandages may be considered the cornerstone of venous leg ulcer treatment, this is only if they are fitted correctly and used appropriately. Unfortunately, this is not always the case (Feben 2003; Filed 2004; Todd 2011). This is important as correct application can lead to faster healing times, reduced nursing time and improved patient concordance with treatment (Todd 2011). Indeed, the healing of leg ulcers is largely dependent on the consistency and accuracy of the bandaging technique (Todd 2011). It has been suggested that the right bandaging technique is achieved with experience (Hopkins 2008), however, as Satpathy et al. (2006) identified in their study the correct pressure is often not always achieved even by experienced practitioners. Furthermore, studies have reported that nurses who claim to have experience in applying compression bandages often bandaged in a way that did not produce sustained graduated compression (Feben 2003). Consequently, although there may be a link between experience and accurate technique this is neither linear nor straight-forward. The inaccurate bandaging could lead to delayed healing times, problems relating to ill-fitted bandages and reduced patient concordance with treatment. Furthermore, if the compression is incorrect then there could be poor clinical outcomes for the patient including tissue damage, pain, oedema and necrosis (Todd 2011), which could (obviously) significantly impact patients’ overall wellbeing (Milne 2013).

It has also been identified that national guidelines (e.g. RCN 2006; SIGN 1998; CREST 1998) for compression bandaging are not always followed (Sadler et al. 2006; Templeton and Telford 2010). Randell et al. (2009) identified that nurses’ decision on which compression dressing to apply usually relied upon past clinical experience with some nurses more than willing to give a particular dressing ‘a go’. Additionally, nurses who were interviewed felt as if guidelines for compression bandaging were of limited use to them and their patients and they worked outside of these guidelines for these reasons. It was also noted by Randell et al. (2009) that these guidelines were often prepared by GP’s without consultation with the expert nurses who took primary responsibility for caring for those with wounds. This subsequently led to many guidelines never being properly consulted by nurses, and ‘bending them’ to suit the health care professionals needs.

Research has also suggested reasons for reluctance on the part of nurses to use compression bandages: fear of compression damage; the patient having mobility or footwear issues; problems with patient concordance; and uncertainty over treating mixed aetiology ulcers (Field 2004; Annells et al. 2008; Randell et al. 2009; Todd 2013; Ashby et al. 2014). Furthermore, it is essential that nurses who apply these types of bandages understand the theory behind it and the differences in sub-bandage pressure, failure to do so may lead to longer healing times, pressure damage and even amputation (Todd 2011).

In sum, nurses’ understanding of compression bandages, including using the correct compression recommended, the type of compression bandage used, the bandaging technique used, and, indeed, even if nurses decide to use compression bandages, can all impact on their correct use, patient concordance and the patient experience (Feben 2003; Puffett et al. 2006; Annells et al. 2008; Randell et al. 2009; Todd 2013; Ashby et al. 2014).

Compression bandages need to feel firm, especially around the ankle and patients need to be able to move the ankle and foot freely, as a loss of range of motion at the ankle increases an individual’s risk of developing ulceration and reduces healing (Barwell et al. 2001). Indeed, it has been recommended that people wear the highest level of compression that is comfortable (Nelson 2012). However in some cases it has been reported that this causes pain for the patient as they are unable to move their toes (Stephen-Haynes 2006). Furthermore, not all patients can tolerate high compression bandages due to the pain and discomfort, and according to some studies, compression bandages can cause pain for patients that can result in poor concordance (Briggs and Flemming 2007; Todd 2011; Weller et al. 2013). For instance, Briggs et al. (2007) found that one participant they interviewed indicated that compression bandages began to cause excessive discomfort and pain that was intolerable and they would contact their clinic immediately to be seen at the earliest time available to review the situation. Furthermore, failure of satisfactory pain relief for the patient caused non-concordance of compression bandages, which resulted in poor patient outcomes. Indeed, Miller et al. (2011) identified that increased pain was a significant predictor of non-concordance with compression bandages.

Additionally, it has been noted that adherence to treatment depends on patient willingness to adapt to treatment regimes. Annells et al. (2008) explored the willingness of patients to comply with compression bandages reporting that one of the reasons for low concordance was that pain caused by either the tightness, or the resultant swelling, from bandages. As well as this, bandages that were uncomfortable for the patient and caused pain can be a constant reminder of the wound and therefore affect the patient’s self-image, identity and day-to-day life. Furthermore, Dereure et al. (2005) identified that over 65 % of patients considered applying compression very difficult and 23 % found wearing compression bandages painful. Although multicomponent compression bandages are reported to achieve the best healing rate without pain, research has indicated that this type of bandaging causes pain, and achieving the correct compression is nurse dependent (Anand et al. 2003).

As highlighted, compression bandages are required for as long as there is venous leg ulceration, which may be a lifetime (O’Meara et al. 2009; Moffatt 2004b). Bandages are typically applied from the base of the toes to just below the knee and this may have a significant impact on both an individual’s body appearance and their body image. Indeed, a number of studies have suggested that compression bandages may negatively affect body image, appearance and social activity, which may significantly reduce patient concordance with treatment. For example, Annells et al. (2008) suggested that patients decided to stay at home when not being able to wear normal shoes due to bulky bandages or because of the unsightly visibility of the bandages. Similarly, Finlayson et al. (2009) identified that in their sample of 122 patients with venous leg ulcers more than half used padding or covered their legs or avoided going outside or in any situation which may cause any trauma to the legs, which again could lead to social isolation. Furthermore, Dereure et al. (2005) evaluated concordance rates with compression therapy in patients with venous leg ulcers using a questionnaire completed by 1,397 patients. It was identified that 40 % were unable to wear their regular shoes and 45 % regarded compression bandages as unaesthetic which then led to lower concordance to treatment.

Similarly, Mudge et al. (2006) identified that specialist footwear formed a central focus of the patient’s body image. Having to wear specialist footwear caused patients embarrassment and consequently affected them going out or socialising This also affected a patient’s decision on what to wear, with many feeling that wearing trainers was unacceptable with a skirt, and therefore wore trousers. As well as this the authors found that patients would modify their footwear to accommodate the bandages. Furthermore, King et al. (2007) reported on the views of 102 patients, of which 26 % of patients wore socks, slippers or no foot wear at all due to compression bandages. Thirty- two per cent needed to wear open toe shoes, sandals or slip-ons to be able to wear footwear. Furthermore, some patients wore washable footwear, with others having to wear footwear that was stained. All of these could contribute to reduced patient concordance, as well as restricting individuals to only going out when it was dry, limiting the amount of daily walks they could take, which ultimately may hinder the healing process (Kroger and Assenheimer 2013).