The History Of Nurse Patient Relationship Nursing Essay

Julie Puterman

St. Lawrence College/Laurentian University

LUSL 3416

Mona Burrows RN (EC), BScN, MScN, NP-PHC

How Venous Leg Ulcerations Affect a Patient’s Quality of Life

Once the diagnosis of venous leg ulceration is made, the patient has been handed a life long sentence of chronic disease management. These ulcers reoccur frequently, are difficult to heal and community nurses can spend over 50% of their time with these patients (Edwards, Courtney, Finlayson, Shuter, & Lindsay, 2009; Faria, Blanes, Hochman, Filbo, & Ferreira, 2011; Franks & Moffatt, 2006). When the nurse’s attention is directed at the clinical component of this diagnosis, the aspect of the patient’s quality of life (QoL) is often lost in the process (Jones, 2008; Franks, Moffatt, Doherty, Smithdale, & Martin, 2006).

This critical literature review will examine 15 articles, centered on how a patient’s QoL can be affected and what steps have been identified in the research to help alleviate some of the distress the patient experiences. Pain, psychological effects and the nurse-patient relationship are themes identified in the literature that affect QoL. Future research and information gaps are also identified. The research articles include five quantitative, seven qualitative, one mixed and two descriptive articles with publication dates from 2001-2012 with sample sizes ranging from one to 758 participants.

Pain

Pain and how it affects an individual’s QoL is one of the themes identified. Grounded theory and phenomenological approaches were used to show how this symptom could devastate a patient’s QoL (Husband, 2001; Hopkins, 2004; Ebbeskog & Ekman, 2001; Price, 2001). Purposeful sample sizes ranged from one to 39 participants. Samples were homogeneous, as all participants had a verified diagnosis of venous insufficiency and the duration of the ulcer > two months (Flurrie, 2001; Ebbeskog & Ekman, 2001; Hopkins, 2004; Husband, 2001). Using unstructured interviews over a period of 120 minutes to two years, the essence of the participants’ lived experience was heard (Hopkins, 2004; Ebbeskog & Ekman, 2001; Flurrie, 2001; Husband, 2001). Data collection varied from taped to individual verbal interviews with researchers using field notes (Husband, 2001) transcription of interviews (Ebbeskog, & Ekman, 2001; Hopkins, 2004) and constant rechecking of transcriptions to verify the lived experience was portrayed accurately. All studies were credible, as each outlined the procedures and methods used, and decisions made with an audit trail that were easily identified to accurately describe the participants’ lived experience.

Pain is a subjective concept and it is the most common problem in leg ulcers (Ebbeskog & Ekman, 2001; Flurrie, 2001; Hopkins, 2004; Husband, 2001; Price, 2001). Pain, described by the patients, was not believed by nursing staff and the doctors, or the pain was assessed based on the nurse’s judgment and not the patients (Flurrie, 2001; Husband, 2001; Sibbald, Orstead, Coutts, & Keast, 2006). Pain is what the patient reports. Research has shown the need for professional pain assessment tools and validating patient’s verbalization of pain are essential components in wound and pain assessment and without it nurses cannot provide care that would ensure a better QoL (Ebbeskog & Ekman, 2001; Flurrie, 2001; Husband, 2001).

Psychological Effects

The psychological effects venous ulceration cause, are numerous. Researcher used quantitative non-experimental studies that incorporated cross sectional designs and descriptive surveys to assemble data (Jones, 2008; Franks & Moffatt, 2006; Finlayson, Edwards, & Courtney, 2010). Quasi-experimental and random controlled trials were also used to gain a better understanding of the experience (Faria et al., 2011; Edwards et al., 2009). Sample sizes ranged from 67-758 participants incorporating both convenience sampling and randomization. Chi-square tests, Mann-Whitney, t-tests and one-way ANOVA tests were used to examine data to show the relationships in the variables (Jones, 2008; Faria et al., 2011; Finlayson et al., 2010). This provided scientific rigor to the results of the studies. Statistical significance existed between the physical aspects of venous ulcers and how it affected the patient’s QoL. This was shown extensively with p-values measured lower than the set alpha level (Edwards et al., 2009; Faria et al., 2011; Finlayson et al., 2010; Franks & Moffatt, 2006).

Using tools such as the Nottingham Health Profile (NHP), Lindsay Leg Club Model of Care and Geriatric Depression Scale (GDS), it was shown venous leg ulcers affect patient morale, anxiety levels, depression, self-esteem, lack of social networks, decreased mobility and feelings of inadequacy (Edwards et al., 2009; Faria et al., 2011; Finlayson et al., 2010; Franks & Moffatt, 2006; Jones, 2008). The use of these tools provided reliability and validity to the results.

From the patient’ perspective, teamwork of the medical staff was identified as a significant factor in QoL. When care is divided between hospital and home and wound care is not consistent, healing times can be affected. This can lengthen recovery time and decrease QoL (Edwards et al., 2009; Flurrie, 2001). The lived experience, using phenomenological studies, with purposeful sampling of five to 39 participants, tells a story of hopelessness, depression and loss of mobility and how these feelings can bring about social isolation and embarrassment (Ebbeskog & Ekman, 2001; Hopkins, 2004; Husband, 2001; Jones, 2008; Price, 2001).

Nurse-Patient Relationship

The nurse-patient relationship theme reverberates through the research. Using grounded theory and phenomenological approaches, researchers used unstructured and taped interviews as well as field notes with constant comparative data analysis until data saturation (Ebbeskog & Ekman, 2001; Husband, 2001; Hopkins, 2004). Homogeneous purposeful samplings was done ranging from five to 39 participants as all participations were homebound with a verified diagnosis of venous insufficiency and the duration of the ulcer > two months (Ebbeskog & Ekman, 2001; Husband, 2001; Hopkins, 2004).

Non-experimental quantitative studies used a combination of cross-sectional designs and descriptive to gather data (Jones, 2008; Friman, Klang, & Ebbeskog, 2010; Finlayson et al., 2010; Franks & Moffatt, 2006). Convenience sampling, ranging from 26-758 participants was utilized. Even though this is the weakest form of sampling, p-values showed a statistical significance in the variables.

Two key points were evident in the qualitative studies; nurses can play a positive or negative role regarding care, understanding and assistance with coping skills for patients. Ebbeskog & Emami, (2005) and Hopkins (2004) observed when therapeutic communication, patience and competence were followed, it allowed the patient to become involved in their own care and in the healing process. The negative aspect of nursing care was evident when nurses were more focused on the task and pathology of the ulcer and not the individual, lack of communication between nursing staff and clinical wound advisors and not understanding the specific needs of each patient (Ebbeskog & Ekman, 2001; Flurrie, 2001; Husband, 2001).

Key points were also brought out in the quantitative studies; again, nurses can play both a positive or negative role. According to Edwards et al. (2009), a supportive network in a community Leg Club had improved QoL scores compared to the control group. Whereas Friman, Klang, & Ebbeskog (2010) and Jones, (2008) found incongruity of care, nurses focusing on the disease process solely and nurses not allowing patients of voice their concerns had negative impacts on QoL.

Pain is one of the most devastating symptoms any patient can suffer and throughout the research articles this was clearly evident when suffering from venous leg ulcers (Ebbeskog & Ekman, 2001; Flurrie, 2001; Hopkins, 2004; Husband, 2001; Price, 2001; Sibbald et al., 2006). The psychological effects on patients’ QoL were clearly stated in both quantitative and qualitative articles (Ebbeskog & Ekman, 2001; Edwards et al., 2009; Faria et al., 2011; Finlayson et al., 2010; Franks & Moffatt, 2006; Franks et al., 2006; Hopkins, 2004; Husband, 2001; Jones, 2008; Price, 2001; Sibbald et al., 2003; Sibbald et al. 2006), indicating the many factors affecting QoL. The nurse-patient relationship is at the heart of all nursing practice and it was shown to have both a positive and negative affects on QoL (Ebbeskog & Emami, 2005; Hopkins 2004; Ebbeskog & Ekman, 2001; Flurrie, 2001; Friman et al., 2010; Husband, 2001; Jones, 2008; Sibbald et al., 2003).

The impact of pain, psychological factors and the nurse-patient relationship has been clearly made evident throughout this review and how it affects QoL. Each of these themes show how important it is to develop a holistic care plan for the patient and put the needs and values of the patient first.

There are still gaps in the literature. According to Friman et al., (2010) and Jones, (2008), there needs to be more development in wound care and more cooperation within disciplines to avoid unnecessary procedures and pain for the patient. Future research is needed to examine relationships between the various factors (depression, social support, etc.) of a patient’s perspective and preventative strategies for living with venous leg ulcers (Finlayson et al., 2010; Ebbeskog & Ekman, 2001; Ebbeskog & Emami, 2005; Jones, 2008).

It has been shown patients suffering from venous leg ulcers have a significant decrease in their QoL. In order for nurses to provide a holistic plan of care, pain, psychological effects and relationships with their patients need to be assessed, acknowledged, reflected upon and then put into action. Without these steps taking place, a patient’s quality of life will continue to suffer.