Nursing Research Poster Presentation
deoych8
adherence_to_leg_ulcer_lifestyle_advice.pdf
C L I N I C A L I S S U E S
Adherence to leg ulcer lifestyle advice: qualitative and quantitative
outcomes associated with a nurse-led intervention
Ann Van Hecke, Maria Grypdonck, Hilde Beele, Katrien Vanderwee and Tom Defloor
Aim and objectives. Examining the (experienced) changes associated with a nursing intervention to enhance adherence to leg
ulcer lifestyle advice.
Background. Few interventions to enhance adherence to leg ulcer treatment are developed and tested.
Design. Qualitative evaluation approach and pre–post-test design were used.
Method. Twenty-six patients with venous ulcers in a community care setting participated. Data were collected by means of
interviews and participant observation. Frequency and duration of wearing compression, leg exercising and leg elevation,
activity level, pain and ulcer size were registered at baseline, after the end of the intervention and three months later. Inductive
content analysis and Wilcoxon signed-rank test were used.
Results. Knowledge about leg ulcer advice increased. The education contributed to more consciously following of the advice.
The rationale of the advice and its association with healing or recurrence remained often unclear. More patients performed
exercises after the intervention and at follow-up. Patients often looked out onto a ‘new’ perspective where enhancement of
quality of life and even healing might be attainable. Some patients regained independence after learning how to apply and
remove compression garments themselves. The frequency of exercising and the duration of exercises increased significantly. Step
counts had not altered significantly. Patients not elevating the legs at baseline elevated the legs more and for a longer period of
time after the intervention. This effect on leg elevation decreased after three months. No significant changes were reported on
hours wearing compression.
Conclusions. The perceived changes suggest that the intervention holds a promise for current home care. Combining qualitative
and quantitative research assisted to determine the possible effects of the intervention, increasing the potential for a meaningful
randomised trial in the future.
Relevance to clinical practice. Education about leg ulcer advice should be incorporated in nursing practice. Further testing of the
intervention is recommended.
Key words: adherence, evaluation research, leg ulcer lifestyle, leg ulcers, nursing, patient compliance
Accepted for publication: 16 August 2010
Authors: Ann Van Hecke, PhD, RN, Assistant Professor, Faculty of
Medicine and Health Sciences, Department of Public Health –
Nursing Science, Ghent University; Maria Grypdonck, PhD, RN,
Professor Emeritus, Faculty of Medicine and Health Sciences,
Department of Public Health – Nursing Science, Ghent University;
Hilde Beele, MD, PhD, Professor, Faculty of Medicine and Health
Sciences, Department of Dermatology, Ghent University Hospital;
Katrien Vanderwee, PhD, RN, Assistant Professor, Faculty of
Medicine and Health Sciences, Department of Public Health –
Nursing Science, Ghent University; Tom Defloor, PhD, RN, Full
Professor, Faculty of Medicine and Health Sciences, Department of
Public Health – Nursing Science, Ghent University, Ghent, Belgium
Correspondence: Ann Van Hecke, Assistant Professor, Faculty of
Medicine and Health Sciences, Department of Public Health Nursing
Science, Ghent University, U.Z. Blok A 2�v, De Pintelaan 185, B- 9000 Gent, Belgium. Telephone: +32 9 332 36 29.
E-mail: [email protected]
� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443 429 doi: 10.1111/j.1365-2702.2010.03546.x
Introduction
A venous leg ulcer is a chronic problem that mainly occurs as
a consequence of chronic venous insufficiency (Brem et al.
2004). Prevalence in adult populations is estimated at 0Æ63–
1Æ9% in Europe, the UK, the USA and Australia (Briggs &
Closs 2003). Leg ulcers are difficult to heal, frequently recur
(Barwell et al. 2004) and are often associated with pain,
restricted mobility and decreased quality of life (Persoon
et al. 2004, Briggs & Flemming 2007, Herber et al. 2007).
Social isolation often ensues because of restricted mobility,
pain, unsightly and malodorous wounds and compression
bandages (Persoon et al. 2004). Leg ulcers also have a
psychological impact and encompass negative emotions
(Ebbeskog & Ekman 2001), sleeping disorders (Persoon
et al. 2004), depression and anxiety (Phillips et al. 1994,
Jones et al. 2006).
Venous leg ulcers indicate a life-long treatment plan
(Reichardt 1999) including compression therapy (Nelson
et al. 2000, O’Meara et al. 2009), leg exercises and leg
elevation (Heinen et al. 2004). Non-adherence to leg ulcer
treatment frequently occurs. However, few studies report the
development and testing of nursing interventions to enhance
adherence to leg ulcer treatment.
Background
Several authors report the problem of non-adherence among
patients with venous leg ulcers. Jull et al. (2004) found that
only 52% of the included patients (n = 129) reported wearing
compression stockings daily for the first six months after leg
ulcer healing. About one fifth (22%) of the patients had not
worn compression stockings at all. In the study of Raju et al.
(2007), only 37% of the patients with chronic venous disease
(including leg ulcers) reported full or partial adherence and
63% did not use compression stockings at all or abandoned
them after a trial period in the past. Ertl (1992) reported an
even higher percentage of non-adherence to compression
hosiery (83%). Few studies examined non-adherence to leg
exercises and leg elevation. Twenty per cent of the patients
with venous leg ulcers elevated their legs when sitting and
they walked for 1Æ7 hours per day (Johnson 1995). Heinen
et al. (2007b) described less positive results regarding phys-
ical activity: 56% of the 150 patients was physically active
less than 2Æ5 hours per week, 13% of the patients walked for
30 minutes at least five days of the week and 35% performed
lower leg exercises.
Non-adherence is a complex phenomenon (Kyngas et al.
2000). Reasons for non-adherence encompass different
factors, varying from patient-related, condition-related and
therapy-related factors to factors related to the healthcare
team, system-related factors and socioeconomic factors
(World Health Organisation 2003). Published research con-
cerning the determinants of non-adherence to leg ulcer
treatment is limited. Pain, discomfort and inadequate lifestyle
advice by healthcare professionals are the main reasons for
non-adherence, as reported by leg ulcer patients (Van Hecke
et al. 2009). Additional reasons for non-adherence are diffi-
culties in applying compression, skin problems, uncomfort-
able footwear, poor cosmetic appearance of compression
bandages and financial restrictions (Van Hecke et al. 2009).
Interpersonal patient-nurse relationships also influence adher-
ence (Van Hecke et al. 2009). Heinen et al. (2007a) report
that pain, co-morbidity, difficulties in finding appropriate
footwear, compression bandages, incorrect health beliefs, low
self-efficacy and lack of social support are linked to insufficient
activity in leg ulcer patients. The fear that physical activity
will cause injury and aggravate pain has also been documented
as a reason for non-adherence (Walshe 1995, Chase et al.
1997, Hyde et al. 1999, Ebbeskog & Ekman 2001).
Non-adherence has a negative impact on the outcomes of
venous leg ulcers. It increases the time to complete healing
(Mayberry et al. 1991, Erickson et al. 1995, Moffatt et al.
2009). Recurrence rates also increase when patients do not
wear compression stockings (Mayberry et al. 1991, Erickson
et al. 1995, Harper et al. 1999, Finlayson et al. 2009, Moffatt
et al. 2009). Non-adherence is also associated with increased
costs (Korn et al. 2002). Therefore, adherence to leg ulcer
treatment is important. The need to improve patient adherence
to maximise therapeutic benefits is highlighted in the literature.
However, few comprehensive programmes to optimise patient
adherence to leg ulcer lifestyle advice have been initiated
(Van Hecke et al. 2008). Educational programmes combining
cognitive, behavioural and affective components have proved
to be effective in enhancing adherence to leg ulcer lifestyle
advice (Brooks et al. 2004). Patients receiving a multi-level
approach, including education, active patient participation
and negotiation, frequent follow-up visits, provision of support
and changes in types of compression systems, seemed more
adherent (Crookes 1997, Hawkins 2001, Hayward 2002,
Rees 2002, Briggs 2005). Well-documented evidence for the
effectiveness of healthcare system interventions such as Leg
Clubs and community leg ulcer clinics to enhance adherence is
limited (Thambiaya 1996, Lindsay 2001).
The nursing intervention ‘adherence to leg ulcer lifestyle advice’
The nursing intervention ‘Adherence to leg ulcer lifestyle
advice’ intends to enhance patients’ adherence to compression
A Van Hecke et al.
430 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443
therapy, leg exercises, physical activity and leg elevation.
Tissue viability nurses (TVNs) carry out the intervention in
individual sessions at home. The nurses received a two-day
training session at the beginning of the intervention, two
additional training sessions later on and on-the job training
from the researcher. Information on the content of this
training is outlined in Table 1. The intervention consists of
three to five sessions spread over a period of three months.
The decision to offer three, four or five sessions depends on
the fulfillment of three specified criteria: (1) no pain or pain
is acceptable to the patient, (2) patient follows lifestyle
advice as prescribed and (3) perceives positive evolution by
the patient. The intervention starts with listening to the
patient’s narrative of living with a leg ulcer to understand
the patient’s point of view, needs and perceptions concern-
ing the leg ulcer. During the visits, patients are informed
about leg ulcer lifestyle and are involved in goal setting
and in formulating strategies to enhance adherence. The
intervention consists of educational, cognitive and behavio-
ural components. Detailed information is provided in
Table 2. The intervention was theory-based and systemati-
cally developed after analysis of the patients’ needs.
Method
The aim of this study is to examine the changes associated
with the nursing intervention ‘Adherence to leg ulcer lifestyle
advice’ (1) to identify outcomes sensitive to leg ulcer patients’
experience and more specific to the nursing intervention and
(2) to explore the quantitative effects of the intervention.
Design
To document the changes associated with the intervention,
a qualitative evaluation and a pre–post-test design were
used.
Table 1 Overview of the training sessions for TVNs
Period Content of the training session – teacher Duration
Sept 2008 Day 1 – researcher (first author)
Description and situation of the research project
Leg ulcer patient’s needs and experienced problems
Content of the intervention protocol for each visit
7 hours
Day 2 – researcher (first author) and expert in motivational interviewing
Basic principles of motivational interviewing
Role playing of scenarios that are common for leg ulcer patients (e.g. less motivated patients,
patients who think they are not able to adhere to prescribed lifestyle advice) – practicing
various aspects of patient education and motivational interviewing
Practical information about registration forms, work protocol, etc.
7 hours
Sept 2008–Dec 2008 Providing the intervention to four leg ulcer patients
Jan 2009 Researcher (first author)
Experiences of leg ulcer patients with the intervention: preliminary results
Experiences of the TVNs with the intervention
Content based on self-reported data by the TVN and data collected by researcher during
participant observation – points of particular interest:
How to provide tailored verbal information provision
Setting specific and realistic goals (what, when, how often, how)
Demonstration of adequate leg exercises, leg elevation and use of hosiery application aids.
Practical information about registration forms, work protocol, etc.
4 hours
Jan 2009–Apr 2009 Providing the intervention to 11 leg ulcer patients
Apr 2009 Researcher (first author)
Experiences of leg ulcer patients with the intervention: preliminary results
Experiences of the TVNs with the intervention
Content based on self-reported data by the TVN and data collected by researcher during
participant observation – points of particular interest:
Balancing between wound care and leg ulcer information provision and counselling
Giving attention to physical activity and not only leg exercises
Informing the community nurse responsible for daily care
Attention for prespecified criteria when the TVN considers to end the intervention
Practical information about registration forms, work protocol, etc.
4 hours
May 2009–July 2009 Providing the intervention to 11 leg ulcer patients
TVN, tissue viability nurses.
Clinical issues Adherence to leg ulcer lifestyle advice
� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443 431
Participants
Twenty-six patients with a venous leg ulcer participated in
the study. Patients were included if they had an Ankle
Brachial Pressure Index (ABPI) between 0Æ8–1Æ2 (Vowden &
Vowden 2001), had a prescription of compression garments,
spoke Dutch, were able to read and write, received leg ulcer
care by community nurses and were non-adherent. A decision
tree was used to define non-adherent patients (Fig. 1).
Patients were excluded if they had communication impedi-
ments, had a fixed ankle range of motion, were totally
dependent for mobility, or had underlying pathologies like
uncontrolled diabetes mellitus, pyoderma gangrenosum,
myasthenia gravis and vasculitis (Davies et al. 2007). Patients
characteristics are outlined in Table 3. The median age was
79 years. Fifteen patients were women. Most patients had a
low educational level and 10 patients lived alone. The median
ulcer duration was 25Æ5 weeks. Six patients refused to
Table 2 Content of the nursing intervention
Session Content Materials/tools
1 Start with listening to ‘leg ulcer narratives’ to understand patient’s
experiences, viewpoints, needs and experienced ulcer problems;
Inventory of current behaviour regarding compression, leg
exercises, physical activity and leg elevation;
Measurement of pain intensity, ulcer size;
Invite patients to demonstrate leg ulcer knowledge and identify
knowledge deficits;
Provide tailored verbal information and written information
(aetiology, realistic perspective, treatment, lifestyle advice);
Encourage patients to ask questions and verify understanding;
Invite patients to elaborate on own leg ulcer lifestyle and elicit
willing to change statements;
Priority is given to pain and not sleeping in bed;
Inform the nurse who is responsible for daily patient care.
Open conversation combined with a topic guide based on
literature review
Structured assessment form
Verbal/numeric pain scale, wound tracing sheets
Brochure on leg ulcers based on study of leg ulcer patients’
information needs
Pain assessment form and pain intervention protocol
2 Measurement of pain intensity (if necessary);
Involve patients in setting specific and realistic goals (what, when,
how often, how) and assess self-efficacy;
Demonstrate leg exercises, leg elevation, application of
compression as needed and invite patients to demonstrate skills;
Involve patients in formulating strategies for enhancing adherence
to lifestyle advice;
Identify and use practical strategies;
Try to reach habit formation (e.g. performing leg exercises while
watching the news)
Inform the nurse who is responsible for daily patient care.
Verbal/numeric pain scale
Patient goal setting form
Using hosiery application aids, pedometers, card reminders
with specific exercises, leg ulcer lifestyle advice poster
3–5 Perform measurements (pain intensity if necessary, ulcer size);
Invite patients to evaluate behaviour change in the previous week –
let patients express success (e.g. progress in wound healing, pain
reduction);
Discuss and encourage positive behaviour change (what was good
the previous week?);
Discuss barriers experienced for behaviour change (what was
difficult the previous week?);
Adjust goals and strategies for enhancing adherence to lifestyle
advice (if necessary) and assess self-efficacy;
Inform patients about (applicable) causes of delayed healing (if
necessary);
Inform the nurse who is responsible for daily patient care.
Specific for last session:
Invite patients to set future specific and realistic goals and assess
self-efficacy;
Inform the general practitioner and the nurse who is responsible
for daily patient care
Verbal/numeric pain scale
Wound tracing sheets (to visualise progress or
deterioration)
Nurse workbook: patient record
A Van Hecke et al.
432 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443
participate, four of these patients because of ‘the burden of
the research’. Two patients did not complete the intervention.
For one patient, the intervention did not meet his needs and
expectations, the other patient found participation too
cumbersome. A flowchart is given in Fig. 2. Five TVNs from
a community healthcare organisation participated in the
study. General characteristics of the TVNs are presented in
Table 4. The nurses’ median age was 41 years, and the
median duration of their professional experience as TVN was
six years.
Data collection
To explore the changes associated with the nursing interven-
tion, both qualitative and quantitative data were collected. At
the end of the nursing intervention, semi-structured inter-
views were held with 25 patients in their home. Owing to
hospital admission, one patient was not interviewed. The
interviews took place within a week after the end of the
intervention to maximise recall of the experience. A topic
guide with open-ended questions was used. To encourage
patients to tell their experiences and perceptions, the inter-
view started with a general and open-ended question (‘What
was it like for you to receive the intervention?’). The topic list
Wearing compression in the past month? Can participate On average 5 –6 days per week or less
Every day 2 or 3 days per month not
Wearing compression in the past week? 5 –6 days in the past week or less
Every day
Less than 10 hours per day
The whole day, also at night The whole day, not at night
Yes
No
Every day less than 10 minutes Less than 5 days per week
Every day, at least 10 minutes
Less than 5 days per week
More than 5 days per week
Can participate
Hours wearing compression every day? Can participate
Performing leg and foot exercises? Can participate
Frequency and duration of performing leg and foot exercises in the past week?
Can participate
Days walking 10 minutes consecutively in the past week? (for patients who can walk)
Can participate
Frequency and duration of leg elevation in the past week?
Every day, less than 30 minutes Less than 5 days per week
Can participate
Every day, at least 30 minutes
Can not participate Figure 1 Decision tree for inclusion of non-
adherent patients.
Table 3 General characteristics of patients
Characteristics (n = 26) n Median (IQR)
Gender
Female 15
Age in years 79 (76–83)
Education level
High (>18 years)* 6
Medium (16–18 years) 8
Low (£15 years) 12 Living circumstances
Living alone 10
Living with partner/others 16
Mobility status
Using mobility aids 17
No impaired mobility 9
Ulcer duration in weeks 25Æ5 (8Æ8–123Æ5) Ulcer size in cm2
Closed 3
£5 cm2 13 6–10 cm2 5
More than 10 cm2 5
Previous episodes of ulceration
None 6
1 episode 4
2–5 episodes 7
More than 10 episodes 9
*Years of education.
Clinical issues Adherence to leg ulcer lifestyle advice
� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443 433
was based on the themes as described in the Situation-
producing Theory of Dickoff et al. (1968) and the question-
naire of Peters et al. (2003). Peters et al. (2003) focused on
barriers and opportunities to optimise patient care. Themes
like the evaluation of the intervention and experienced
changes associated with the intervention were discussed.
Patient interviews lasted between 18–81 minutes (mean
duration: 44 minutes). The interviews were audio-taped and
transcribed verbatim.
Problems with capturing the perspective of the older
people are acknowledged in literature (Willits & Crider
1988). Therefore, participant observation by the researcher
(AVH) was also used. The researcher observed 38 consul-
tations of the TVN with the patient. Written field notes
regarding conversations, interactions, context and observa-
tions of TVNs’ activities were made. All quantitative data
about wearing compression, performing leg exercises, leg
elevation, physical activity, pain and ulcer size were
collected three times: at baseline (at least one week before
the start of the intervention), at the end of the intervention
(starting within one week after the last visit) and three
months later.
Frequency and duration of wearing compression, performing
leg exercises and leg elevation
As no valid and reliable tool is available to assess the fre-
quency and duration of wearing compression, performing leg
exercises and leg elevation (Van Hecke et al. 2008), patients
kept a diary for seven consecutive days, they recorded the
number of hours wearing compression (including the time
they got up and went to bed) and the frequency and duration
of performing leg exercises and leg elevation. Leg exercises
were defined as tiptoe exercises (standing or sitting on a
chair), ankle circling and plantar and dorsiflexion ankle
exercises during at least one minute. These exercises were
described on cards, the patients received as part of the TVNs
instructions. Only if necessary, community nurses who pro-
vided daily leg ulcer care were asked to help patients in
completing the diary.
Activity level
Step counts were recorded with the ActiGraph accelerometer
GT1M (Fort Walton Beach, FL, USA). Patients were in-
structed to wear the accelerometer continuously during their
waking hours for a period of seven consecutive days. The
accelerometer was held in place with an elastic belt and an
adjustable buckle. Although no information about validity,
accuracy and reliability of the ActiGraph accelerometer steps
counting in the older people was available, it was used in
other research to measure physical activity in older people
(Oliveira et al. 2008, Harris et al. 2009). Two patients had
fewer than five days of analysable data and were not included
in the analysis. One patient refused to wear the accelerometer
in the follow-up assessments.
Pain
Although visual analog pain-intensity scales are recom-
mended for widespread use in adults, they do not work well
in older people (Jones et al. 2007). Numeric rating scales are
valid instruments to assess pain intensity and are often easier
to understand (Breivik et al. 2008). As pain levels across
numeric rating scales and verbal rating scales were highly
correlated in the older people (Jones et al. 2007) and as the
latter were often preferred by older adults (Herr & Mobily
1993, Closs et al. 2004), pain was measured by a researcher
Selection of patients contact general practitioner
n = 43
n = 4; ‘burden’ of the study n = 1; afraid of ‘new’ healthcare professionals n = 1; “would rather be dead”
n = 7; arterial ulcer as stated by general practitioner n = 2; general practitioner refused patient participation
Given informed consent n = 28
n = 1; arterial ulcer (ABPI <0·8) n = 1; provision of care by other community care organisation
Pretest n = 26
Dropped out: n = 2; stopped participation after 3 visits of the TVN
Posttest 1 n = 24
Dropped out: n = 3 (hospital admission, dementia) n = 2 (burden of the study, no merits)
Posttest 2 n = 19
Provision of information about the study to patients
n = 34
Figure 2 Flowchart of patients in the study.
Table 4 General characteristics of nurses
Characteristics (n = 5) n Median (IQR)
Age in years 41 (8Æ5) Education level
Sub-degree level 4
Bachelor’s degree 1
Professional nursing experience in years 20 (13Æ0) Professional experience as tissue viability
nurse in years
6 (3Æ0)
A Van Hecke et al.
434 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443
with a verbal scale (no pain, mild, moderate, severe and worst
pain imaginable). Pain at the moment of assessment (now)
and pain in the previous 24 hours were measured.
Ulcer size
The researcher measured the healing rate by acetate tracing
and computer-assisted counting of the number of squares
(cm2). The acetate method is most commonly used for mea-
suring wounds and has been demonstrated to have good in-
ter- and intrarater reliability (Majeske 1992).
Demographic and illness-related variables
At baseline, a general questionnaire was used to obtain data
about age, gender, education level, living circumstances,
mobility status, leg ulcer duration and recurrence rate. Data
collection took place between September 2008–July 2009.
Procedure
Five TVNs who were responsible for 19 local departments of
a community healthcare organisation were delegated by the
management staff to participate in the study. All the venous
leg ulcer patients in these local departments were listed.
Different characteristics of these patients were inventoried
e.g. inclusion and exclusion criteria, age, education level,
recurrence rate, ulcer duration, amount of social support and
presence of pain. The researcher selected patients who met
the inclusion criteria. By means of purposive sampling, the
researcher ensured that the intervention was tested in patients
with different characteristics (age, gender, education level,
duration of leg ulcer, recurrence rate, pain) and in a different
context (amount of social support, living alone versus
cohabiting). After selection, the researcher contacted the
patient’s general practitioner (and/or specialist) to inform
him/her about the study, to verify the venous origin of the
ulcer and to check for underlying pathologies. Once the
treating physician(s) gave consent, the community nurse
providing daily (leg ulcer) care or the TVN explained the
purpose of the study to the patient. Written consent was
obtained. The researcher performed ABPI measurements to
verify if there was no arterial component. After baseline
assessment, the intervention was initiated. To ensure that the
nursing intervention was adequately and sufficiently used in
practice, several steps were undertaken: (1) the intervention
was delivered by trained TVNs as their professional back-
ground and expertise in leg ulcer care may facilitate adequate
intervention delivery, (2) for each patient, one to three
consultations were observed, (3) when the TVN had ques-
tions regarding the intervention, leg ulcer lifestyle or prob-
lem-solving decision-making, the first researcher was
available and gave advice, (4) the TVN and the researcher
(when present) registered the actions in each visit in a work
protocol and (5) in intermediate training sessions points of
particular interest based on the self-reported data by the TVN
and the researcher were addressed.
Data analysis
Inductive content analysis was used (Elo & Kyngäs 2008).
Qualitative data were entered into QSR N6 (QSR Inter-
national Pty Ltd, Doncaster, Victoria, Australia). The tran-
scripts were read through several times to become immersed
in the data. The transcripts were coded, categories were
created and these were grouped under higher-order headings:
cognitive, behavioural, emotional and physical changes. To
ensure the trustworthiness of the findings and interpretations,
researcher triangulation was used. Coding and interpreta-
tions were discussed with another qualitative researcher who
read most of the transcripts. Insights emerging from these
discussions were checked against the data by critically
rereading the transcripts and by checking these insights in
new interviews. Interview transcripts and observational data
were referred to during analysis, and characteristic quotes
were used to support the credibility of the findings. To verify
the findings against the data, two researchers not yet involved
in the analytical process read a random selection of the
transcripts.
Quantitative data were analysed with SPSSSPSS version 15.0
(SPSS Inc., Chicago, IL, USA). As the variables were not
normally distributed, the Wilcoxon signed-rank test was used
to analyse whether the baseline outcomes differed signifi-
cantly from the outcomes at the end of the intervention and
three months later. The Bonferroni correction was used to
correct for multiple testing (Polit & Beck 2007). A value of
p < 0Æ017 (0Æ05/3) was considered statistically significant.
Ethical considerations
The study was approved by the ethical committee of the
Ghent University Hospital (B67020084230). Nurses and
patients were informed and gave written consent.
Results
Qualitative results
Four clusters of changes were associated with the nursing
intervention: cognitive, behavioural, emotional and physical
changes. The clusters included a range of statements made by
one or more patients.
Clinical issues Adherence to leg ulcer lifestyle advice
� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443 435
Cognitive changes
Two cognitive changes are described: knowing what to do
and knowing why to follow leg ulcer lifestyle advice:
Knowing what to do. Knowledge about leg ulcer lifestyle
advice increased. Performing leg exercises was new for most
patients. Patients with long-lasting or (several episodes of)
recurrent ulcers said to have learned a few ‘new things’. They
had already consulted different healthcare professionals for
advice and had experienced the benefits (e.g. benefits of
wearing compression garments) or disadvantages (e.g. pain
while exercising) of leg ulcer lifestyle advice. The information
provided helped patients to cope with leg ulcer-related
problems (e.g. what to do when experiencing discomfort or
tiring legs). Inadequate leg ulcer lifestyle that patients had
assumed to be correct was now adjusted, especially advice
regarding leg elevation and maintenance of compression
garments:
P: Well, I used to elevate my legs like this [showed the use of a
hassock to elevate the legs], but my legs were lower. X [tissue
viability nurse] said to elevate my legs in a way that I can see my toes.
That’s a good rule of thumb to know if I am elevating my legs
correctly. But lying my legs on a hassock, that is not very effective.
That is something that she has taught me.
Knowing why. Patient education contributed to patients
more consciously following leg ulcer lifestyle advice. How-
ever, the rational for the advice and the relationship between
the advice and wound healing or recurrence often remained
unclear to the patients. Some patients still doubted their own
contribution to enhance leg ulcer healing, doubted the
benefits of the advice (especially of performing leg exercises
and being physically active) and focussed on wound care.
Behavioural changes
Behavioural changes are seen in ‘following and giving lifestyle
advice’ and ‘using creative strategies and use habit formation
to incorporate advice in daily life’.
Following and giving lifestyle advice. The qualitative
findings indicated that not all patients adhered to leg ulcer
lifestyle advice. Some patients apparently judge their adher-
ence by their own standards that may differ from the
recommended regimen (e.g. patients stated to adhere to
compression therapy, whereas they wore it not as recom-
mended). Patients stated that inadequate timing of profes-
sional leg ulcer care hampered the duration of wearing
compression. They mainly adopted performing leg exercises
that they found easy to incorporate in daily living. Walking
and leg elevation were more difficult. Patients were afraid of
walking as they feared falling, and leg elevation was
inconvenient and often caused discomfort. Some patients
carried out leg exercises and leg elevation at fixed times and
related to daily recurring activities (e.g. exercising during
dish washing, when watching the news on television). Other
patients performed exercises or leg elevation when it
‘crossed their mind’. Patients also recommended and taught
leg ulcer lifestyle advice to others confronted with (similar)
problems:
P: Recently, my brother was admitted to the hospital. He is already
82 years old. I said to him – as his mobility is also bad – ‘you should
do some exercises of mine’. We have once done exercises together.
Creative strategies to incorporate advice in daily life and to
seek habit formation. Patients found creative strategies to
incorporate leg ulcer lifestyle advice in daily life, which
enhanced adherence. For example, a patient who often
watched television and initially counted the number of
exercises started to exercise each time commercials came on
television.
Emotional changes
Hoping, feeling safe, regaining independence and enhance-
ment of quality of life were emotional reactions/changes
associated with the intervention:
Hope and a new perspective. During the intervention,
patients often experienced ‘getting out of the rut’. Participa-
tion in the study implied that they received ‘other’ leg ulcer
care than they used to. Some patients looked out onto a ‘new’
perspective where healing and/or enhancement of quality of
life might be attainable. Hope arose again in situations where
hope had been lost. Wound measurements initiated hope,
especially in patients with a positive wound progress. Hope
was less apparent in patients who suffered from long-lasting
leg ulcers and had tried several remedies without attaining leg
ulcer healing:
P: She [tissue viability nurse] said: ‘Let’s measure it. The wound size is
decreased. Look! It is small and the wound looks good’. That gives
you a bit of hope that it will heal. Honestly, I thought that it would
never heal, at my age and such a wound, because they [other nurses
from the hospital] did not gave me courage.
Feeling safe. Receiving the intervention from a TVN was
reassuring for patients. It made them feel safe. They were
confident that leg ulcer care was performed skilfully and that
the provided information was adequate.
Independence. In a few patients, independence was
enhanced after learning how to apply and remove compres-
sion garments themselves. As a consequence, help from
healthcare professionals was no longer needed or less urgent
and patients did no longer have to adjust daily activities to
nurses’ timing of leg ulcer care (e.g. patient had to get up
A Van Hecke et al.
436 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443
early in the morning for application of compression garments
by the nurse):
P: … but that aid [stick to remove compression garments] has made
me independent. You can recommend that to other patients. (…) Probably, I would have given up on wearing compression if I did not
have that stick, because I am an independent person.(…) Indepen-
dence is very important to me and that is what you have given me
with this aid.
Enhancement of quality of life. Several patients experienced
an increase in quality of life, one patient even said to have
‘revived’ during and after the intervention. Previously, she
had received inadequate or incomplete advice that had an
enormous impact on her quality of life. Having received the
advice to rest with legs elevated’, she had refrained from
social activities and got socially isolated. The TVN informed
her that balancing between leg elevation and being physically
active would benefit her healing process. This meant that she
was legitimised to participate in social life again. The ‘revival’
of this patient was also attributed to a relief of severe pain
after the intervention:
P: I was sure that I could be physically active, because they [other
healthcare professionals] always said ‘you should rest’, but then you
are isolated. X [tissue viability nurse] said that I was allowed to walk.
That helped me a lot. (…) I did not walk anymore, because they told me to rest. For me, it was a real revival. [community nurse who
provided daily leg ulcer care] said: ‘You have completely changed’. I
was interested in things again. Of course, when pain is relieved,
things are completely different. The information about exercising was
very supportive to me.
Physical changes
Patients perceived physical improvements by following the
advice. They ‘felt’ that tiptoe exercises were beneficial: they
felt that muscle strength increased, that the ‘blood in the legs
was flowing’ and that their feet warmed up more easily.
Quantitative results
In the quantitative analysis (see Table 5), no significant
changes were found in the number of hours wearing
compression therapy. Significantly, more patients performed
leg exercises at the end of the intervention (Z = �3Æ87, p < 0Æ001) and at three months thereafter (Z = �3Æ00, p = 0Æ003) compared to baseline measurements. The mean
frequency of exercising increased from not exercising at
baseline to 13 times a day after the intervention (Z = �3Æ64, p < 0Æ001) and 17 times a day three months after the end of
the intervention (Z = �2Æ94, p = 0Æ003). The duration of
exercising per day also significantly increased. No significant
changes were found in patients who already performed leg
exercises at baseline. Walking did not increase significantly at
the end of the intervention (Z = �1Æ93, p = 0Æ05) nor three months later (Z = �0Æ21, p = 0Æ84). No significant increase was seen in the number of patients adequately elevating their
legs (Z = �2Æ33, p = 0Æ02) nor in the duration and frequency of elevating the legs.
Pain intensity for patients reporting pain at baseline
significantly decreased from moderate pain before to no pain
at the end of the intervention (Z = �2Æ60, p = 0Æ009) (Table 5). No significant reduction in ulcer size was seen at
the end of the intervention (Z = �1Æ88, p = 0Æ06). Compared to baseline, the ulcer size three months after the end of the
intervention was significantly reduced (Z = �3Æ44, p = 0Æ001). Only ulcer size of ulcers £6 months significantly decreased at the end of the intervention (Z = �2Æ55, p = 0Æ011). In six patients of the 24 patients, the ulcer was
healed at the end of the intervention. One of these patients
had a recurrent ulcer three months after the end of the
intervention.
Discussion
This study sought to identify the changes associated with the
nursing intervention ‘Adherence to leg ulcer lifestyle advice’
primarily through a qualitative evaluation approach. Cog-
nitive, behavioural, emotional and physical changes were
identified. There is sparse literature about home-based
nursing interventions aiming at enhancing adherence to leg
ulcer treatment to compare our results with. Studies mainly
report on the effectiveness of community leg ulcer clinics
(Simon et al. 1996, Ghauri et al. 2000) and Leg Clubs
(Edwards et al. 2005, 2009). Home-based nursing interven-
tions in patients with venous leg ulcers primarily focus on
the effectiveness of therapeutic exercising programmes
(Davies et al. 2007, Jull et al. 2009) and on other leg ulcer
lifestyle advice (e.g. leg elevation) (Brooks et al. 2004). As
only quantitative measures are used and the measurement of
adherence level is hampered by the lack of uniformity,
comparison is impeded. Patients in the study by Brooks
et al. (2004) exposed to the lifestyle programme elevated
their legs for a significantly longer period per day after
52 weeks. In our study, no significant effects on leg
elevation were found. Patient characteristics were different
from the participants in the study by Brooks et al. (2004).
Our patients had more mobility restrictions and used more
mobility aids. Our results suggested that the improvements
regarding leg exercises were more prominent in patients
who did not exercise at baseline compared to patients who
Clinical issues Adherence to leg ulcer lifestyle advice
� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443 437
T a b le
5 C
o m
p a ri
so n
o f
o u tc
o m
e m
ea su
re s
T 0 – T
1 – T
2 *
O u tc
o m
e
T 0
M ed
ia n
(I Q
R )
T 1
M ed
ia n
(I Q
R )
T 2
M ed
ia n
(I Q
R )
n
R es
u lt
s
T 0 – T
1
(p -v
a lu
e) �
Z -v
a lu
e n
R es
u lt
s
T 1 – T
2
(p -v
a lu
e) Z
-v a lu
e n
R es
u lt
s
T 0 – T
2
(p -v
a lu
e) Z
-v a lu
e
L eg
ex er
ci se
s a n d
p h y si
ca l
a ct
iv it
y
N u m
b er
o f
ex er
ci si
n g
p a ti
en ts
6 /2
6 2 0 /2
3 1 3 /1
7 <
0 Æ0
0 1
� �
3 Æ8
7 0 Æ1
8 �
1 Æ3
4 0 Æ0
0 3
� 3 Æ0
0
D a y s
o f
ex er
ci si
n g /w
ee k
– a ll
p a ti
en ts
0 Æ0
(0 Æ0
– 0 Æ5
) 6 Æ0
(5 Æ0
– 7 Æ0
) 7 Æ0
(3 Æ0
– 7 Æ0
) 2 3
< 0 Æ0
0 1
� 3 Æ7
1 1 7
0 Æ5
3 �
0 Æ6
3 1 7
0 Æ0
0 2
� 3 Æ1
6
D a y s
o f
ex er
ci si
n g /w
ee k
– ex
er ci
si n g
o n
T 0
5 Æ5
0 (3
Æ5 – 7 Æ0
) 7 Æ0
(6 Æ0
– 7 Æ0
) 7 Æ0
(7 Æ0
– 7 Æ0
) 5
0 Æ3
6 �
0 Æ9
2 4
1 Æ0
0 0 Æ0
0 4
0 Æ1
1 �
1 Æ6
0
D a y s
o f
ex er
ci si
n g /w
ee k
– n o t
ex er
ci si
n g
o n
T 0
/ 6 Æ0
(3 Æ3
– 7 Æ0
) 7 Æ0
(0 Æ0
– 7 Æ0
) 1 8
0 Æ0
0 1
� 3 Æ4
5 1 3
0 Æ5
3 �
0 Æ6
3 1 3
0 Æ0
0 4
� 2 Æ8
9
F re
q u en
cy o f
ex er
ci si
n g /w
ee k
– a ll
p a ti
en ts
0 Æ0
(0 Æ0
– 0 Æ5
) 1 3
(6 Æ5
– 2 8 Æ0
) 1 7 Æ0
(0 Æ0
– 2 0 Æ0
) 2 1
< 0 Æ0
0 1
� 3 Æ6
4 1 3
0 Æ0
9 �
1 Æ6
8 1 5
0 Æ0
0 3
� 2 Æ9
4
F re
q u en
cy o f
ex er
ci si
n g /w
ee k
– ex
er ci
si n g
o n
T 0
8 Æ5
(4 Æ3
– 1 2 Æ0
) 2 8 Æ0
(8 Æ0
– 3 1 Æ5
) 1 6 Æ0
(1 3 Æ3
– 2 0 Æ3
) 5
0 Æ1
4 �
1 Æ4
8 4
0 Æ1
4 �
1 Æ4
6 4
0 Æ0
7 �
1 Æ8
3
F re
q u en
cy o f
ex er
ci si
n g /w
ee k
– n o t
ex er
ci si
n g
o n
T 0
/ 1 2 Æ0
(4 Æ5
– 2 1 Æ8
) 1 7 Æ0
(0 Æ0
– 2 0 Æ0
) 1 6
0 Æ0
0 1
� 3 Æ1
8 9
0 Æ2
1 �
1 Æ2
4 1 1
0 Æ0
2 �
2 Æ3
8
M in
u te
s o f
ex er
ci si
n g /d
a y
– a ll
p a ti
en ts
0 Æ0
(0 Æ0
– 0 Æ3
) 1 3 Æ6
(1 Æ9
– 2 0 Æ4
) 1 2 Æ5
(1 Æ5
– 2 4 Æ3
) 2 1
< 0 Æ0
0 1
� 3 Æ6
2 1 6
0 Æ7
8 �
0 Æ2
8 1 6
0 Æ0
0 3
� 2 Æ9
8
M in
u te
s o f
ex er
ci si
n g /d
a y
– ex
er ci
si n g
o n
T 0
6 Æ8
(1 Æ4
– 1 7 Æ5
) 1 5 Æ0
(8 Æ4
– 2 7 Æ0
) 1 5 Æ1
(7 Æ9
– 2 2 Æ4
) 5
0 Æ1
4 �
1 Æ4
8 4
0 Æ4
7 �
0 Æ7
3 4
0 Æ1
4 �
1 Æ4
6
M in
u te
s o f
ex er
ci si
n g /d
a y
– n o t
ex er
ci si
n g
o n
T 0
/ 9 Æ0
7 (1
Æ4 – 2 0 Æ0
) 1 2 Æ5
(0 Æ0
– 2 5 Æ4
) 1 6
0 Æ0
0 1
� 3 Æ1
8 1 2
0 Æ4
8 �
0 Æ7
1 1 2
0 Æ0
1 �
2 Æ5
2
S te
p co
u n ts
/d a y
1 1 8 6
(7 3 9 – 2 0 1 2 )
1 7 4 2
(5 6 7 – 3 1 8 4 )
1 2 8 1
(7 1 2 – 3 1 2 5 )
2 1
0 Æ0
5 �
1 Æ9
3 1 6
0 Æ0
7 �
1 Æ8
2 1 6
0 Æ8
4 �
0 Æ2
1
L eg
el ev
a ti
o n
d u ri
n g
th e
d a y
N u m
b er
o f
p a ti
en ts
(e le
v a te
d §
o r
h o ri
zo n ta
l) 1 4 /2
5 1 6 /2
1 1 4 /1
8 0 Æ1
0 1 Æ0
0 0 Æ0
5
N u m
b er
o f
p a ti
en ts
(o n ly
el ev
a te
d )
4 /2
5 1 1 /2
1 7 /1
8 0 Æ0
2 �
2 Æ3
3 0 Æ0
8 �
1 Æ7
3 0 Æ1
0 �
1 Æ6
3
D a y s
o f
le g
el ev
a ti
o n /w
ee k
(e le
v a te
d o r
h o ri
zo n ta
l) –
a ll
p a ti
en ts
3 Æ0
(0 Æ0
– 7 Æ0
) 7 Æ0
(3 Æ0
– 7 Æ0
) 7 Æ0
(1 Æ5
– 7 Æ0
) 2 0
0 Æ0
2 �
2 Æ3
3 1 7
0 Æ3
6 �
0 Æ9
2 1 7
0 Æ0
3 �
2 Æ1
3
D a y s
o f
le g
el ev
a ti
o n /w
ee k
(e le
v a te
d o r
h o ri
zo n ta
l) –
le g
el ev
a ti
o n
o n
T 0
7 Æ0
(5 Æ3
– 7 Æ0
) 7 Æ0
(7 Æ0
– 7 Æ0
) 7 Æ0
(6 Æ0
– 7 Æ0
) 1 1
0 Æ4
6 �
0 Æ7
4 9
0 Æ6
6 �
0 Æ4
5 9
0 Æ4
7 �
0 Æ7
3
D a y s
o f
le g
el ev
a ti
o n /w
ee k
(e le
v a te
d o r
h o ri
zo n ta
l) –
n o
le g
el ev
a ti
o n
o n
T 0
/ 6 Æ0
(0 Æ0
– 7 Æ0
) 3 Æ5
(0 Æ0
– 7 Æ0
) 9
0 Æ0
3 �
2 Æ1
2 7
0 Æ3
4 �
1 Æ0
0 8
0 Æ0
5 �
2 Æ0
0
F re
q u en
cy o f
p er
io d s
o f
le g
el ev
a ti
o n /w
ee k
(e le
v a te
d o r
h o ri
zo n ta
l) –
a ll
p a ti
en ts
3 Æ0
(0 Æ0
– 7 Æ0
) 7 Æ0
(5 Æ3
– 1 3 Æ8
) 7 Æ0
(1 Æ0
– 1 1 Æ5
) 1 9
0 Æ2
0 �
1 Æ2
9 1 5
0 Æ4
5 �
0 Æ7
6 1 5
0 Æ1
5 �
1 Æ4
3
F re
q u en
cy o f
p er
io d s
o f
le g
el ev
a ti
o n /w
ee k
(e le
v a te
d o r
h o ri
zo n ta
l) –
le g
el ev
a ti
o n
o n
T 0
7 Æ0
(4 Æ5
– 1 7 Æ5
) 9 Æ8
(7 Æ0
– 1 4 Æ0
) 7 Æ0
(6 Æ0
– 1 3 Æ5
) 1 0
0 Æ4
4 �
0 Æ7
7 9
0 Æ7
3 �
0 Æ3
4 8
0 Æ6
7 �
0 Æ4
2
F re
q u en
cy o f
p er
io d s
o f
le g
el ev
a ti
o n /w
ee k
(e le
v a te
d o r
h o ri
zo n ta
l) –
n o
le g
el ev
a ti
o n
o n
T 0
/ 7 Æ0
(0 Æ0
– 1 1 Æ0
) 0 Æ0
(0 Æ0
– 7 Æ0
) 9
0 Æ0
3 �
2 Æ2
3 6
0 Æ2
0 �
1 Æ2
9 7
0 Æ1
0 �
1 Æ6
3
M in
u te
s o f
le g
el ev
a ti
o n /d
u ri
n g
th e
d a y
(e le
v a te
d §
o r
h o ri
zo n ta
l) –
a ll
p a ti
en ts
2 3 Æ6
(0 Æ0
– 7 7 Æ4
) 8 9 Æ3
(2 1 Æ4
– 1 3 2 Æ9
) 2 8 Æ9
(4 Æ3
– 1 1 9 Æ3
) 1 8
0 Æ2
7 �
1 Æ1
0 1 3
0 Æ2
5 �
1 Æ1
6 1 4
0 Æ6
1 �
0 Æ5
1
M in
u te
s o f
le g
el ev
a ti
o n /d
u ri
n g
th e
d a y
(e le
v a te
d o r
h o ri
zo n ta
l) –
le g
el ev
a ti
o n
o n
T 0
7 6 Æ2
(4 5 Æ0
– 2 1 0 Æ0
) 1 2 0 Æ0
(5 5 Æ0
– 2 7 0 Æ0
) 8 8 Æ6
(2 7 Æ3
– 1 5 1 Æ6
) 1 0
0 Æ6
8 �
0 Æ4
2 8
0 Æ5
8 �
0 Æ5
6 7
0 Æ5
0 �
0 Æ6
8
A Van Hecke et al.
438 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443
T a b le
5 (C
o n ti
n u ed
)
O u tc
o m
e
T 0
M ed
ia n
(I Q
R )
T 1
M ed
ia n
(I Q
R )
T 2
M ed
ia n
(I Q
R )
n
R es
u lt
s
T 0 – T
1
(p -v
a lu
e) �
Z -v
a lu
e n
R es
u lt
s
T 1 – T
2
(p -v
a lu
e) Z
-v a lu
e n
R es
u lt
s
T 0 – T
2
(p -v
a lu
e) Z
-v a lu
e
M in
u te
s o f
le g
el ev
a ti
o n /d
u ri
n g
th e
d a y
(e le
v a te
d o r
h o ri
zo n ta
l) –
n o
le g
el ev
a ti
o n
o n
T 0
/ 7 7 Æ9
(0 Æ0
– 1 2 0 Æ0
) 0 Æ0
(0 Æ0
– 6 0 Æ0
) 8
0 Æ0
4 �
2 Æ0
3 5
0 Æ2
9 �
1 Æ0
7 7
0 Æ1
1 �
1 Æ6
0
W ea
ri n g
co m
p re
ss io
n
N u m
b er
o f
p a ti
en ts
w ea
ri n g
co m
p re
ss io
n 2 5 /2
6 2 2 /2
4 1 7 /1
9 0 Æ5
6 1 Æ0
0 0 Æ5
6
D a y s
o f
w ea
ri n g
co m
p re
ss io
n /w
ee k
7 Æ0
(7 Æ0
– 7 Æ0
) 7 Æ0
(7 Æ0
– 7 Æ0
) 7 Æ0
(7 Æ0
– 7 Æ0
) 2 4
0 Æ6
8 �
0 Æ4
1 1 7
1 Æ0
0 0 Æ0
0 1 7
0 Æ3
2 �
1 Æ0
0
H o u rs
w ea
ri n g
co m
p re
ss io
n /d
a y
– n o
ch a n g e
in co
m p re
ss io
n sy
st em
(n =
1 9 )
1 3 Æ 8
(1 1 Æ7
– 1 5 Æ5
) 1 3 Æ7
(1 1 Æ7
– 1 4 Æ2
) 1 3 Æ3
(1 1 Æ4
– 1 6 Æ0
) 1 6
0 Æ6
4 �
0 Æ4
7 1 1
0 Æ0
9 �
1 Æ7
2 1 1
0 Æ7
6 �
0 Æ3
1
H o u rs
w ea
ri n g
co m
p re
ss io
n /d
a y
– ch
a n g e
to
m o re
a d eq
u a te
co m
p re
ss io
n sy
st em
(n =
7 )
1 3 Æ6
(1 2 Æ0
– 2 4 Æ0
) 1 9 Æ4
(1 1 Æ8
– 2 4 Æ0
) 1 9 Æ1
(1 2 Æ6
– 2 4 Æ0
) 6
0 Æ6
9 �
0 Æ4
1 6
0 Æ5
9 �
0 Æ5
4 6
0 Æ6
9 �
0 Æ4
1
P a in
in te
n si
ty –
N u m
b er
o f
p a ti
en ts
w it
h p a in
1 1 /2
6 6 /2
4 5 /1
8
P a in
in te
n si
ty (n
o w
) –
a ll
p a ti
en ts
0 Æ0
(0 Æ0
– 2 Æ0
) 0 Æ0
(0 Æ0
– 0 Æ8
) 0 Æ0
(0 Æ0
– 1 Æ3
) 2 4
0 Æ0
7 �
1 Æ8
3 1 8
0 Æ4
1 �
0 Æ8
2 1 8
0 Æ2
5 �
1 Æ1
6
P a in
in te
n si
ty (p
re v io
u s
2 4
h o u rs
) –
a ll
p a ti
en ts
0 Æ0
(0 Æ0
– 2 Æ0
) 0 Æ0
(0 Æ0
– 1 Æ0
) 0 Æ0
(0 Æ0
– 1 Æ3
) 2 4
0 Æ0
4 �
2 Æ0
2 1 8
0 Æ4
8 �
0 Æ7
1 1 8
0 Æ2
0 �
1 Æ2
7
P a in
in te
n si
ty (n
o w
) –
p a ti
en ts
w it
h p a in
o n
T 0
(n =
1 1 )
2 Æ0
(1 Æ0
– 2 Æ0
) 0 Æ0
(0 Æ0
– 2 Æ0
) 0 Æ0
(0 Æ0
– 2 Æ0
) 1 1
0 Æ0
0 9
� �
2 Æ6
0 8
0 Æ6
6 �
0 Æ4
5 8
0 Æ0
2 �
2 Æ2
7
P a in
in te
n si
ty (p
re v io
u s
2 4
h o u rs
) –
p a ti
en ts
w it
h p a in
o n
T 0
2 Æ0
(1 Æ0
– 3 Æ0
) 0 Æ0
(0 Æ0
– 2 Æ0
) 0 Æ0
(0 Æ0
– 2 Æ0
) 1 1
0 Æ0
0 4
� 2 Æ8
9 8
0 Æ6
6 �
0 Æ4
5 8
0 Æ0
2 �
2 Æ4
3
U lc
er si
ze (c
m 2 )
3 Æ7
(0 Æ4
– 6 Æ6
) 0 Æ3
(0 Æ0
– 9 Æ2
) 0 Æ1
(0 Æ0
– 2 Æ9
) 2 4
0 Æ0
6 �
1 Æ8
8 1 9
0 Æ0
2 �
2 Æ2
7 1 9
0 Æ0
0 1
� 3 Æ4
4
U lc
er d u ra
ti o n
£6 m
o n th
s 1 Æ3
(0 Æ2
– 6 Æ0
) 0 Æ0
5 (0
Æ0 – 1 Æ6
) 0 Æ1
(0 Æ0
– 0 Æ4
) 1 2
0 Æ0
1 �
2 Æ5
5 1 0
0 Æ1
2 �
1 Æ5
7 1 0
0 Æ0
0 5
� 2 Æ8
0
U lc
er d u ra
ti o n >
6 m
o n th
s 3 Æ9
(0 Æ8
– 1 9 Æ4
) 3 Æ9
(0 Æ0
– 1 9 Æ3
) 3 Æ0
(0 Æ0
– 1 3 Æ1
) 1 2
0 Æ 3
9 �
0 Æ8
7 9
0 Æ1
7 �
1 Æ3
6 9
0 Æ0
1 1
� 2 Æ5
5
* T
0 ,
b a se
li n e;
T 1 ,
a t
th e
en d
o f
th e
in te
rv en
ti o n ;
T 2 ,
th re
e m
o n th
s a ft
er th
e en
d o f
th e
in te
rv en
ti o n .
� W
il co
x o n
si g n ed
-r a n k
te st
. � S ig
n ifi
ca n t
v a lu
es a re
b o ld
(0 Æ0
1 7 ).
§ L
eg el
ev a ti
o n
1 0 – 3 0
� a b o v e
th e
h ea
rt le
v el
. – P a in
in te
n si
ty ra
n g ed
fr o m
n o
p a in
(0 ),
m il
d p a in
(1 ),
m o d er
a te
p a in
(2 ),
se v er
e p a in
(3 )
a n d
w o rs
t p a in
im a g in
a b le
(4 ).
Clinical issues Adherence to leg ulcer lifestyle advice
� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443 439
already exercised at baseline. The small sample size of the
latter group (n = 5) might explain why no significant
difference could be detected. These patients reached at T0
the scores that the other non-exercising patients reached at
T1. Our results might also support the finding that ulcer
duration >6 months is associated with delayed healing
(Moffatt et al. 2010).
The inclusion of both qualitative and quantitative meth-
ods led to a better understanding of the results. The
qualitative evaluation brought to light new ‘outcomes’ or
aspects of the efficacy of the intervention. A range of
outcomes sensitive to the patient’s experience, highly valued
by leg ulcer patients and specific to the nursing intervention
were detected. These outcomes would not have been
accounted for when a single method approach would have
been used. In accordance with other researchers (Hearn
et al. 2003), we noticed that combining qualitative and
quantitative research provided a more complete picture of
the changes resulting from the intervention. The use of
complementary methodologies to evaluate complex nursing
interventions is also stressed by other authors (Bradley et al.
1999, Campbell et al. 2000, van Meijel et al. 2004) and is
desirable to evaluate how interventions affect patients
(Merkouris et al. 2004, Moffatt et al. 2006). Treating
qualitative and quantitative datasets as complementary also
assisted in exploring or explaining why the quantitative
results occurred and why the intervention did not produce
the expected outcome i.e. wearing compression garments for
more hours, elevating the legs more, walking more fre-
quently. Compared with other research on hours wearing
compression (Jünger et al. 2004), adherence at baseline to
wear compression therapy was already high for our patients.
Our observational data revealed that patients wore com-
pression therapy more adequately, but not necessary for a
longer period. For example, two patients wore long-stretch
bandages mainly at night and scarcely during the day, after
the intervention they wore compression only during the day
as recommended. Patients expressed being afraid of walk-
ing. They feared falling and some of them already fell in the
past. They also refrained from leg elevation as it was
inconvenient, was not easy to incorporate in daily living and
interrupted the daily routine. When legs were elevated,
patients also declared to be more dependent on others when
they wanted to get up from the couch. Some of them
experienced discomfort to muscles/knees.
As adherence is not static, frequent follow-up counselling
visits as part of a multi-level approach for enhancing
adherence in leg ulcer patients are recommended (Crookes
1997, Hawkins 2001, Hayward 2002, Rees 2002, Briggs
2005). Such follow-up sessions were not investigated in this
study for pragmatic reasons. The measurable effect of the
intervention decreased three months after the end of the
intervention which also suggests that adherence requires
ongoing, long-term support to maintain adherence.
This study had several limitations. It is possible that the
experienced changes are presented more favourably. The
interviews indicated that being part of an ‘experiment’
enhanced adherence. As errors in self-report measurements
generally are biased towards an overestimation of adherence
(World Health Organisation 2003) and as no psychometri-
cally tested instrument to assess frequency and duration of
wearing compression, performing leg exercises and leg
elevation was used, results should be cautiously interpreted.
The researcher was in contact with the patients during a
considerable period of time. This prolonged relationship
could also contribute to the positive qualitative and quan-
titative findings as patients could feel an obligation to help
the researcher ‘succeed’. The motivation of the participants
to share their experiences for the benefit of future patients
enhances the reliability of the qualitative findings. Although
several steps were taken that led to a greater improvement in
adherence to the intervention protocol, the way the inter-
vention was delivered by the TVNs could not be totally
controlled. Leg ulcer care provision by the community nurse
was not made a controlled part of the study. However, the
care delivered by the community nurse might influence the
successfulness of the intervention as well. Recruitment bias
by only including motivated patients is particularly likely in
educational interventions (Coster & Norman 2009). It is
unlikely that this was the case in this study as also other
motivations for participation were present (e.g. hope for leg
ulcer healing, receiving new compression garments for free),
and the interviews showed that not all patients were
motivated to change their behaviour at the start of the
study. Recruitment was hampered as some patients found
participation in the study too cumbersome. Although a
combined method approach enhanced and clarified the
results, it also implied a greater (time) commitment for the
patients. Especially the use of diaries three times during a
week was a barrier. Four patients refused to participate after
explaining the study, one patient dropped out of the study in
the post test phase and some quantitative data were sketchy
or incomplete. As only a seven-day registration was per-
formed, no information was available in the periods between.
It was also not possible to differentiate between the
improvement in adherence to lifestyle advice prompted by
the intervention and prompted by the diary registration/
accelerometer as the latter might also be considered as an
intervention increasing physical activity (De Cocker et al.
2007).
A Van Hecke et al.
440 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443
Conclusions
By means of complementary methodologies, the perceived
changes associated with the intervention ‘Adherence to leg
ulcer lifestyle advice’ were depicted. Testing the effectiveness
as well as the cost-effectiveness of the intervention is
advocated because the results indicate that the intervention
helps to acquire behavioural change and can make a
difference in daily living of patients. We believe that the
intervention holds a promise for current home care. A
randomised controlled trial, although not ease to set up,
could prove this.
Relevance to nursing science and clinical practice
The qualitative analysis revealed the (experienced) changes
with the nursing intervention i.e. cognitive, behavioural,
emotional and physical changes or outcomes. These out-
comes can be integrated in research evaluating adherence
promoting interventions in general and the intervention
‘Adherence to leg ulcer lifestyle advice’ in particular. A
combination of research approaches is recommended in
studies evaluating complex nursing interventions. This can
provide further insights into quantitative outcomes and in
understanding the relevance of a wide range of patients’
outcomes. User-friendly, valid and reliable instruments to
measure adherence to leg ulcer lifestyle advice should be
developed. Further research could also focus on the effec-
tiveness of different patient education materials in improving
the understanding of the underlying pathophysiology of leg
ulcers and rational for the advice. It is recommended that
nurses include education about leg ulcer lifestyle advice into
their practice and are aware of its impact on leg ulcer
patients.
Acknowledgements
The authors would like to thank the White Yellow Cross
community care organisation, the participating patients and
tissue viability nurses.
Contributions
Study design: AVH, TD, MG, HB, KV; data collection and
analysis: AVH, TD, MG and manuscript preparations: AVH,
TD, MG, HB, KV.
Conflict of interest
The authors declare that they had no conflict of interests.
References
Barwell J, Davies C, Deacon J, Harvey
K, Minor J, Sassano A, Taylor M,
Usher J, Wakely C, Earnshaw J,
Heather B, Mitchell D, Whyman M
& Poskitt K (2004) Comparison of
surgery and compression with com-
pression alone in chronic venous
ulceration (ESCHAR study): rando-
mised controlled trial. Lancet 363,
1854–1859.
Bradley F, Wiles R, Kinmonth A, Mant D &
Gantley M (1999) Development and
evaluation of complex interventions in
health services research: case study of
the Southampton heart integrated care
project (SHIP). The SHIP Collaborative
Group. British Medical Journal 318,
711–715.
Breivik H, Borchgrevink P, Allen S, Rosse-
land L, Romundstad L, Hals E, Kvar-
stein G & Stubhaug A (2008)
Assessment of pain. British Journal of
Anaesthesia 101, 17–24.
Brem H, Kirsner R & Falanga V (2004)
Protocol for the successful treatment of
venous ulcers. American Journal of
Surgery 188, 1–8.
Briggs S (2005) Leg ulcer management: how
addressing a patient’s pain can improve
concordance. Professional Nurse 20,
39–41.
Briggs M & Closs S (2003) The prevalence
of leg ulceration: a review of the liter-
ature. European Wound Management
Association Journal 3, 14–20.
Briggs M & Flemming K (2007) Living with
leg ulceration: a synthesis of qualitative
research. Journal of Advanced Nursing
59, 319–328.
Brooks J, Ersser S, Lloyd A & Ryan T
(2004) Nurse-led education sets out to
improve patient concordance and pre-
vent recurrence of leg ulcers. Journal of
Wound Care 13, 111–116.
Campbell N, Murray E, Darbyshire J, Emery
J, Farmer A, Griffiths F, Guthrie B, Les-
ter H, Wilson P & Kinmonth A (2000)
Designing and evaluation complex
intervention to improve health care.
British Medical Journal 334, 455–459.
Chase S, Melloni M & Savage A (1997) A
forever healing: the lived experience of
venous ulcer disease. Journal of Vascu-
lar Nursing 15, 73–78.
Closs S, Barr B, Briggs M, Cash K &
Seers K (2004) A comparison of five
pain assessment scales for nursing
home residents with varying degrees
of cognitive impairment. Journal of
Pain and Symptom Management 27,
196–205.
Coster S & Norman I (2009) Cochrane re-
views of educational and self-manage-
ment interventions to guide nursing
practice: a review. International Jour-
nal of Nursing Studies 46, 508–528.
Crookes M (1997) Making a fresh start.
Nursing Times 93, 68–70, 72, 74.
Davies J, Bull R, Farrelly I & Wakelin M
(2007) A home-based exercise pro-
gramme improves ankle range of mo-
tion in long-term venous ulcer patients.
Phlebology 22, 86–89.
De Cocker K, De Bourdeaudhuij I, Brown
W & Cardon G (2007) Effects of
Clinical issues Adherence to leg ulcer lifestyle advice
� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443 441
‘10,000 Steps Ghent’. A whole-com-
munity intervention. American Journal
of Preventive Medicine 33, 455–463.
Dickoff J, James P & Wiedenbach E (1968)
Theory in a practice discipline. I. Prac-
tice oriented discipline. Nursing Re-
search 17, 415–435.
Ebbeskog B & Ekman S (2001) Elderly
persons’ experiences of living with ve-
nous leg ulcer: living in a dialectal
relationship between freedom and
imprisonment. Scandinavian Journal of
Caring Sciences 15, 235–243.
Edwards H, Courtney M, Finlayson K,
Lewis C, Lindsay E & Dumble J (2005)
Improved healing rates for chronic
venous leg ulcers: pilot study results
from a randomized controlled trial of a
community nursing intervention. Inter-
national Journal of Nursing Practice
11, 169–176.
Edwards H, Courtney M, Finlayson K,
Shuter P & Lindsay E (2009) A rando-
mised controlled trial of a community
nursing intervention: improved quality
of life and healing for clients with
chronic leg ulcers. Journal of Clinical
Nursing 18, 1541–1549.
Elo S & Kyngäs H (2008) The qualitative
content analysis process. Journal of
Advanced Nursing 62, 107–115.
Erickson C, Lanza D, Karp D, Edwards J,
Seabrook G, Cambria R, Freischlag J &
Towne J (1995) Healing of venous ul-
cers in an ambulatory care program: the
roles of chronic venous insufficiency
and patient compliance. Journal of
Vascular Surgery 22, 629–636.
Ertl P (1992) How do you make your
treatment decision? Professional Nurse
7, 543–552.
Finlayson K, Edwards H & Courtney M
(2009) Factors associated with recur-
rence of venous leg ulcers: a survey and
retrospective chart review. Interna-
tional Journal of Nursing Studies 46,
1071–1078.
Ghauri A, Taylor M, Deacon J, Whyman M,
Earnshaw J, Heather B & Poskitt K
(2000) Influence of a specialized leg
ulcer service on management and out-
come. British Journal of Surgery 87,
1048–1056.
Harper D, Ruckley C, Gibson B, Brown D
& Prescott R (1999) Randomised trial
of two grades of compression stockings
in the prevention of venous ulcer
recurrence – 5 year outcomes. Venous
Forum 16 April 1999 Weetwood Hall,
Leeds.
Harris T, Owen C, Victor C, Adams R &
Cook D (2009) What factors are asso-
ciated with physical activity in older
people, assessed objectively by accele-
rometry? British Journal of Sports
Medicine 43, 442–450.
Hawkins J (2001) A new cohesive short-
stretch bandage and its application.
British Journal of Nursing 10, 249–
253.
Hayward L (2002) Patient-centred leg ulcer
care. Nursing Times 98, 59–61.
Hearn J, Lawler J & Dowswell G (2003)
Qualitative evaluations, combined
methods and key challenges: general
lessons from the qualitative evaluation
of community intervention in stroke
rehabilitation. Evaluation 9, 30–54.
Heinen M, van Achterberg T, op Reimer W,
van de Kerkhof P & de Laat E (2004)
Venous leg ulcer patients: a review of
the literature on lifestyle and pain-
related interventions. Journal of Clini-
cal Nursing 13, 355–366.
Heinen M, Evers A, Van Uden C, van der
Vleuten C, van de Kerkhof P & van
Achterberg T (2007a) Sedentary
patients with venous or mixed leg
ulcers: determinants of physical activ-
ity. Journal of Advanced Nursing 60,
50–57.
Heinen M, de Rooij M, Uden C, Evers A &
van Achterberg T (2007b) Physical
activity and adherence to compression
therapy in patients with venous leg
ulcers. Archives of Dermatology 143,
1283–1288.
Herber O, Schnepp W & Rieger M (2007) A
systematic review on the impact of leg
ulceration on patients’ quality of life.
Health and Quality of Life Outcomes
5, 44–55.
Herr K & Mobily P (1993) Comparison of
selected pain assessment tools for use
with the elderly. Applied Nursing
Research 6, 39–46.
Hyde C, Ward B, Horsfall J & Winder G
(1999) Older women’s experience of
living with chronic leg ulceration.
International Journal of Nursing Prac-
tice 5, 189–198.
Johnson M (1995) Healing determinants in
older people with leg ulcers. Research
in Nursing and Health 18, 393–403.
Jones J, Barr W, Robinson J & Carlisle C
(2006) Depression in patients with
chronic venous ulceration. British
Journal of Nursing 15, S17–S23.
Jones K, Vojir C, Hutt E & Fink R (2007)
Determining mild, moderate and severe
pain equivalency across pain-intensity
tools in nursing home residents. Journal
of Rehabilitation Research and Devel-
opment 44, 305–314.
Jull A, Mitchell N, Arroll J, Jones M, Waters
J, Latta A, Walker N & Arroll B (2004)
Factors influencing concordance with
compression stockings after venous leg
ulcer healing. Journal of Wound Care
13, 90–92.
Jull A, Parag V, Walker N, Maddison R,
Kerse N & Johns T (2009) The prepare
pilot RCT of home-based progressive
resistance exercises for venous leg
ulcers. Journal of Wound Care 18, 497–
503.
Jünger M, Wollina U, Kohnen R & Rabe
E (2004) Efficacy and tolerability of
an ulcer compression stocking for
therapy of chronic venous ulcer com-
pared with a below-knee compression
bandage: results from a prospective,
randomized, multi-centre trial. Cur-
rent Medical Research and Opinion
20, 1613–1623.
Korn P, Patel S, Heller J, Deitch J, Krish-
nasastry K, Bush H & Kent K (2002)
Why insurers should reimburse for
compression stockings in patients with
chronic venous stasis. Journal of Vas-
cular Surgery 35, 950–957.
Kyngas H, Duffy M & Kroll T (2000)
Conceptual analysis of compliance.
Journal of Clinical Nursing 9, 5–12.
Lindsay E (2001) Compliance with science:
benefits of developing community leg
clubs. British Journal of Nursing 10,
S66–S68, S70, S72.
Majeske C (1992) Reliability of wound
surface area measurements. Physical
Therapy 72, 138–141.
Mayberry J, Moneta G, Taylor L & Porter J
(1991) Fifteen-year results of ambula-
tory compression therapy for chronic
venous ulcers. Surgery 109, 575–581.
van Meijel B, Gamel C, Swieten-Duijfjes B &
Grypdonck M (2004) The development
of evidence-based nursing interventions:
methodological considerations. Journal
of Advanced Nursing 48, 84–92.
Merkouris A, Papathanassoglou E &
Lemonidou C (2004) Evaluation of
patient satisfaction with nursing care:
quantitative or qualitative approach?
A Van Hecke et al.
442 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443
International Journal of Nursing Stud-
ies 41, 355–367.
Moffatt S, White M, Mackintosh J & Ho-
wel D (2006) Using quantitative and
qualitative data in health services re-
search – what happens when mixed
method findings conflict? BMC Health
Services Research 6, 28–37.
Moffatt C, Kommala D, Dourdin N & Choe
Y (2009) Venous leg ulcers: patient
concordance with compression therapy
and its impact on healing and preven-
tion of recurrence. International
Wound Journal 6, 386–393.
Moffatt C, Doherty D, Smithdale R &
Franks P (2010) Clinical predictors of
leg ulcer healing. British Journal of
Dermatology 162, 51–58.
Nelson E, Bell-Syer S & Cullum N (2000)
Compression for preventing recurrence
of venous ulcers. Cochrane Database of
Systematic Reviews, doi: 10.1002/
14651858.
Oliveira J, Ribeiro F & Gomes H (2008)
Effects of a home-based cardiac reha-
bilitation program on the physical
activity levels of patients with coronary
artery disease. Journal of Cardiopul-
monary Rehabilitation and Prevention
28, 392–396.
O’Meara S, Cullum N & Nelson E (2009)
Compression for venous leg ulcers.
Cochrane Database of Systematic Re-
views, doi: 10.1002/14651858.
Persoon A, Heinen M, van der Vleuten C, de
Rooij M, van de Kerkhof P & van Ach-
terberg T (2004) Leg ulcers: a review of
their impact on daily life. Journal of
Clinical Nursing 13, 341–354.
Peters M, Harmsen M, Laurant M &
Wensing M (2003) Ruimte voor veran-
dering? Knelpunten en mogelijkheden
voor verbeteringen in de patiëntenzorg.
[Possibility of change? Threats and
opportunities for improvement of
patient care]. Afdeling Kwaliteit van
zorg (WOK), UMC St Radboud,
Nijmegen.
Phillips T, Stanton B, Provan A & Lew R
(1994) A study of the impact of leg ul-
cers on quality of life: financial, social
and psychological implications. Journal
of the American Academy of Derma-
tology 31, 49–53.
Polit D & Beck C (2007) Nursing Research:
Generating and Assessing Evidence for
Nursing Practice. Lippincott Williams
& Wilkins, Philadelphia.
Raju S, Hollis K & Neglen P (2007) Use of
compression stockings in chronic ve-
nous disease: patient compliance and
efficacy. Annals of Vascular Surgery 21,
790–795.
Rees T (2002) Use of compression therapy
in venous leg ulceration. Nursing Stan-
dard 17, 51–54.
Reichardt L (1999) Venous ulceration:
compression as the mainstay of therapy.
Journal of Wound, Ostomy and Con-
tinence Nursing 26, 39–47.
Simon D, Freak L, Kinsella A, Walsh J, Lane
C, Groarke L & McCollum C (1996)
Community leg ulcer clinics: a compar-
ative study in two health authorities.
British Medical Journal 312, 1648–
1651.
Thambiaya K (1996) Tissue viability. Eval-
uation of a leg ulcer clinic. Nursing
Standard 10, 58–62.
Van Hecke A, Grypdonck M & Defloor T
(2008) Interventions to enhance patient
compliance with leg ulcer treatment: a
review of the literature. Journal of
Clinical Nursing 17, 29–39.
Van Hecke A, Grypdonck M & Defloor T
(2009) A review why patients with leg
ulcers dot not adhere to treatment.
Journal of Clinical Nursing 18, 337–
349.
Vowden P & Vowden K (2001) Doppler
assessment and ABPI: interpretation in
the management of leg ulceration.
Available at: http://www.worldwidewo
unds.com/2001/March/Vowden/Dopp
ler-assessment-and-ABPI.html (access-
ed 10 December 2009).
Walshe C (1995) Living with a venous leg
ulcer: a descriptive study of patients’
experiences. Journal of Advanced
Nursing 22, 1092–1100.
Willits F & Crider D (1988) Health rating
and life satisfaction in the later middle
years. Journal of Gerontology 43,
S172–S176.
World Health Organisation (2003) Adher-
ence to long-term therapies: evidence
for action. WHO Report, Geneva,
Switzerland.
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of
clinically related scholarship which supports the practice and discipline of nursing.
For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://
wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals and with an impact factor of 1Æ194 – ranked 16 of 70
within Thomson Reuters Journal Citation Report (Social Science – Nursing) in 2009.
One of the most read nursing journals in the world: over 1 million articles downloaded online per year and accessible in over
7000 libraries worldwide (including over 4000 in developing countries with free or low cost access).
Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.
Early View: rapid online publication (with doi for referencing) for accepted articles in final form, and fully citable.
Positive publishing experience: rapid double-blind peer review with constructive feedback.
Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley
Online Library, as well as the option to deposit the article in your preferred archive.
Clinical issues Adherence to leg ulcer lifestyle advice
� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 429–443 443
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.
Users should refer to the original published version of the material.
