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Feelings of Powerlessness in Patients with Diabetic Foot Ulcers

Author(s): 
Maria Teresa de Jesus Pereira; Geraldo Magela Salomé; Diego Guimarães Openheimer; Vitória Helena Cunha Espósito; Sergio Aguinaldo de Almeida; Lydia Masako Ferreira
 

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WOUNDS. 2014;26(6):172-177.
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  Abstract: The purpose of this study was to assess feelings of powerlessness in patients with diabetic foot ulcers. Chronic wounds affect the emotional state of patients, who may experience negative emotions including a sense of loss and powerlessness. The assessment of these feelings should contribute to the planning of interventions aimed at minimizing the impact of diabetic foot ulcers on the daily lives of these patients.

 

  Methods. Fifty patients ≥ 18 years of age with type 1 or type 2 diabetes and foot ulcers were selected from 2 outpatient wound-care clinics to participate in the study. Of these patients, 50% were 61-70 years old, 72% were women, 74% were smokers, 10% were alcoholics, 40% had a diabetic foot ulcer for 3-6 years, and 22% for 7-10 years. Wound odor and exudate were present in 82% of patients. Individuals who were unable to respond to a questionnaire due to physical or cognitive deficit were excluded. All participants responded to the Powerlessness Assessment Tool for adult patients (PAT), with scores ranging from 12-60, with higher scores corresponding to feelings of more intense powerlessness.Results. Total PAT scores ranged from 31-40 for 5 (10%) patients, 51-60 for 28 (56%) patients and from 41-50 for 17 (34%) patients. All patients reported total and subscale PAT scores ≥ 34 (moderate to high scores), with a mean total score of 50.12. The maximum PAT score of 60 was reported on the “self-perception of decision-making capacity” domain. Conclusion. These results indicate that patients with diabetic foot ulcers had strong feelings of powerlessness.

Introduction

   An estimated 7.6% of the Brazilian population between the ages of 30 and 69 years have diabetes mellitus.1 However, about 50% of persons who have the disease do not know it, and 24% of persons diagnosed with diabetes do not receive treatment. Chronic complications associated with diabetes are responsible for morbidity and mortality among these patients.1 Foot ulcers are common complications of diabetes, with amputations being the leading cause of morbidity in individuals with diabetes. It has been estimated that 15% of individuals with diabetes will undergo lower-extremity amputation. Population-based studies on diabetic foot ulcers have reported annual incidence rates of 1%-4% and annual prevalence rates of 4%-10%.1-3

  Advances in the treatment of wounds have contributed to improved care of patients with diabetic foot ulcers. While studies have been conducted to determine the best treatment, it is also important to better understand the complex process of wound healing and the biopsychosocial factors that influence the quality of life of these individuals. Wounds that are difficult to heal, and the discomfort associated with the condition, may affect the emotional state of patients. If the wound fails to show improvement, the patient may experience negative emotions, including feelings of loss, powerlessness, low self-esteem, anxiety, and depression.4-6

  According to NANDA International, powerlessness is the “perception that one’s own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening.”7 Thus, assuming that the process of becoming ill may lead to the loss of control over a current situation, the feeling of powerlessness can be seen as a loss. In other words, the patient goes into a state of mourning. If the loss of control is the focus of unsuccessful attempts to change the patient’s self-concept, the diagnosis of anticipatory grief or dysfunctional grief may be more appropriate. On the other hand, if the patient feels that no matter what is done, nothing will change the course of events, then the diagnosis of powerlessness is more appropriate.8

   Emotions such as fear, feelings of loss, grief, and powerlessness are common in patients with lesions. In a society that values autonomy, the need to depend on others will contribute to these emotions, which may lead to a state of emotional distress associated with periods of conflict, doubts, and unexpected reactions.4,9,10

  It is important for health care professionals to develop the skills to assist patients who visit the clinic regularly with their mental health needs as well as their physical health needs. During regular follow-up visits to outpatient wound care clinics, patients with diabetes who have foot ulcers are frequently anxious, without hope that the lesion will ever heal, and express feelings of loss of control over their situation.4,5 Thus, the assessment of feelings of powerlessness may provide important information to improve the care and delivery of services to these patients.

  Although there are studies that have evaluated the mobility and psychological and emotional problems of patients with diabetic foot ulcers,5,8,9,11-13 including their functional status, quality of life, self-esteem, self-image, anxiety, and depression, no studies were found in the literature assessing feelings of powerlessness in this population. Thus, the aim of this study was to assess feelings of powerlessness in patients with diabetic foot ulcers.

Methods

  This was an exploratory, descriptive, analytic, cross-sectional study. The study was approved by the Research Ethics Committee of the Federal University of São Paulo (UNIFESP), Brazil (approval number CEP0383/10) and performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all patients prior to their inclusion in the study and anonymity was assured. Data were collected between May 2010 and April 2012.

  Fifty patients ≥ 18 years of age, with type 1 or type 2 diabetes, foot ulcers, and fasting blood glucose of 100-125 mg/dl, participated in the study. Twenty-five patients were attending an outpatient wound-care clinic of the university hospital in the city of São Paulo, Brazil, and 25 were attending an outpatient wound-care clinic in a city of the state of São Paulo, Brazil. Patients who were unable to complete the questionnaire due to physical or cognitive deficit, such as those with dementia or mental confusion, were excluded from the study. Before their inclusion in the study and at the beginning of the interview, patients were informed that the purpose of the study was to find out how people feel about their condition.

   Two instruments were used for data collection: a questionnaire assessing sociodemographic and clinical characteristics of the patients and the Powerlessness Assessment Tool for adult patients (PAT). The questionnaires were administered by interview by the same researcher.

   The PAT was developed in Brazil and tested in a population sample of 210 adult patients from medical-surgical wards for item selection, reliability, and validity; it showed good internal consistency (total scale Cronbach’s alpha = 0.80) and test-retest reliability (P > 0.05).14 The instrument consists of a 12-item measure of powerlessness rated on a 5-point Likert-type scale in which 1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always. Powerlessness Assessment Tool scores range from 12-60, with higher scores corresponding to feelings of more intense powerlessness. The 12 items are grouped into 3 domains: “capacity to perform behavior” (Cronbach’s alpha = 0.845), “self-perception of decision-making capacity” (Cronbach’s alpha = 0.834), and “emotional responses to perceived control” (Cronbach’s alpha = 0.578).8,14 The “capacity to perform behavior” domain may be referred to as behavioral control and assesses the patient’s feelings regarding his degree of control over his own behavior. The “self-perception of decision-making capacity” domain measures the patient’s perceived ability to make his own decisions in general. The “emotional responses to perceived control” assesses the patient’s feelings regarding his perceived loss of control over aspects of his life.14

Statistical analysis

  Statistical analysis was performed using Student’s t test, the Mann-Whitney test, and chi-square test of independence. Nonparametric tests were used because they are appropriate for analysis of ordinal scale data. The assumption of normality of distribution of data was rejected by the Kolmogorov-Smirnov test. Student’s t test was performed to assess significant differences between means, standard deviations (SD), and maximum and minimum values of PAT scores. The Mann-Whitney test was utilized for comparisons of mean scores on the PAT domains and comparisons of total PAT scores with sociodemographic and clinical characteristics of patients. The chi-square test of independence was used for assessing associations among categorical variables. All statistical tests were performed at a significance level of 5% (P < 0.05).

Results

  Twenty-five (50%) patients with diabetic foot ulcers were 61-70 years of age, and 24 (48%) were ≤ 60 years; 72% of the participants were women, 10% were alcoholics, 74% were smokers, and 50% were illiterate (Table 1). Thirty-five (70%) patients had diabetes for ≥ 6 years. Twenty (40%) patients had an ulcer for 3-6 years and 11 (22%) for 7-10 years. Wound odor and exudate were present in 82% of patients (Table 2).

   Total PAT scores ranged from 51-60 for 28 (56%) patients and from 41-50 for 17 (34%) patients (Table 3). All patients reported total and subscale PAT scores ≥ 34 (moderate to high scores), with a mean total score of 50.12. The maximum PAT score of 60 was reported on the “self-perception of decision making capacity” domain (Table 4). These results indicate that patients with diabetic foot ulcers had strong feelings of powerlessness.

   There were no significant associations of total PAT scores with gender (P = 0.899), age group (P = 0.662), alcohol abuse (P = 0.232), smoking (P = 0.866), presence of exudate (P = 0.378), duration of diabetes (P = 0.372), and age of lesion (P = 0.642). The comparisons of total PAT scores with duration of diabetes and age of lesion are shown in Table 5.

Discussion

  Diabetic foot ulcers negatively impact the quality of life of patients and result in significant costs to the health care system.11,12,15,16 Health professionals should be prepared to provide not only medical treatment, but also psychosocial support, helping the patient to overcome limitations and develop coping mechanisms.12,13,17-19

  The results of this study are similar to others that reported that most patients with diabetic foot ulcers are women ≥ 61 years of age who have feelings of powerlessness.3,17,18,20,21 The majority of participants (74%) in the present study were smokers and 10% were alcoholics, which is also in agreement with the literature.4,5,9,12,17 Smoking reduces tissue oxygenation, affects the body’s immune system, compromises the body’s ability to fight infection, and impairs wound healing by inhibiting collagen synthesis.22,23 Nicotine causes vasoconstriction, which increases the risk of ischemia and development of ulcers.24,25 The relatively large percentage of participants who abused alcohol (10%) might be an indication of the high level of emotional distress present in some patients with diabetic foot ulcers, but this was not investigated in the present study. These results showed that 20 (40%) patients had an ulcer for 3-6 years, and 15 (30%) for 7-10 years; in 41 (82%) patients wound odor and exudate were present. These findings are consistent to those reported in other studies.5,9,12 Living with a painful large ulcer with odor and exudate can make the patient feel frustrated, angry, useless, discouraged, and disheartened. Some studies have reported that the odor and exudate associated with ulcers may cause psychological problems regardless of the age, sex, or socioeconomic status of the patient. The presence of odor and exudate and changes in physical appearance also lower the patient’s self-image, impair their ability to participate in social and leisure activities, affect their well being, and diminish the patient’s confidence in their treatment. This negative emotional state may be detrimental to treatment adherence.4-6,10,12,13,17,18,26-29

   The presence of diabetic foot ulcers is also associated with pain, fear of leg amputation, and decreased functional status, which affects activities of daily living and intensifies the dependency needs of these patients, resulting in loss of control and autonomy, and consequent feelings of powerlessness.18,26

  The PAT domains “capacity of performing behaviors” and “perception of the capacity of making decisions” seems to reflect the patient’s perceived ability (or inability) to act or to give opinions, and to contribute or to make choices throughout the course of his condition or disease.14 The “emotional responses to perceived control” domain portrays a dimension of powerlessness that could be attributed to the emotional response to the loss of control over a given situation.14 In the present study, all patients reported moderate to high scores (≥ 34) on all PAT domains, resulting in a mean total score of 50.12. The maximum PAT score of 60, which corresponds to the strongest feelings of powerlessness measured by this scale, was reported on the “self-perception of decision making capacity” domain. The results of this study indicated that these patients with diabetic foot ulcers experienced very strong feelings of powerlessness.

  Several studies5,8,11,28-29 have suggested that the level of well being of patients with diabetic foot ulcers is associated with the amount of daily activities (eg, recreation, work, and sports) performed by these individuals, and highlighted the importance of glucose control in patients with diabetes. Glucose control serves to prevent, or at least decrease the frequency or severity of, complications in patients with diabetes, thus increasing their functional status.5,8,12,28-29

  Diabetic foot ulcers may affect the daily life of patients, including changes in sleep pattern and impaired mobility, resulting in reduced quality of life, interference with aspects such as sexuality, and feelings of powerlessness, anxiety, and depression.4,5,9,10,12,17,18,26 On the other hand, patients with positive feelings cope better with their situation and live life more fully, even when faced with adversities caused by the lesion and its treatment.8,14,29,30

  The sample size and the lack of calculation of the power of the sample were limitations of this study. The lack of data on glucose control (HBA1c) of the subjects is also a limitation of the study. Further studies with larger sample sizes, providing data of glucose control, and comparing feelings of powerlessness in patients with diabetes with and without foot ulcers are necessary to better understand the impact of these lesions in this population and to extend the results.

Conclusion

  The assessment of feelings of powerlessness should be a factor in the planning of interventions aimed at creating positive feelings to minimize the impact of diabetic foot ulcers on the daily life of these patients. This study emphasizes the need to focus on other aspects of the health of patients with diabetic foot ulcers, and the importance of health professionals in public health services, hospitals, outpatient clinics, and family health centers to identify changes in the self-esteem, self-image, and quality of life of patients undergoing treatment. Of course the basic care needs of patients living with this condition must be met; but it is also important that caregivers develop the expertise to deal with the emotional difficulties faced by this patient population.

References

1. Ministério da Saúde. Secretaria de Políticas de Saúde. Manual de hipertensão arterial e diabetes mellitus 2002. Brazil: Ministério da Saúde; 2001.

2. Genuth S, Eastman R, Kahn R, et al; and American Diabetes Association. Implications of the United Kingdom prospective diabetes study. Diabetes Care. 2003;26(suppl 1):S28-32.

3. Martin IS, Beraldo AA, Passeri SM, Freitas MCF, Pace AE. Root causes for the development of foot ulcers of people with diabetes mellitus. Acta Paul Enferm. 2012;25(2):218-224.

4. Salomé GM, Espósito VH. Nursing students experiences while caring people with wounds [in Portuguese]. Rev Bras Enferm. 2008;61(6):822-827.

5. Salomé GM, Blanes L, Ferreira LM. Assessment of depressive symptoms in people with diabetes mellitus and foot ulcers. Rev Col Bras Cir. 2011;38(5):327-333.

6. White R, McIntosh C. A review of the literature on topical therapies for diabetic foot ulcers. Part 2: Advanced treatments. J Wound Care. 2009;18(8):335-341.

7. NANDA International. Nursing diagnoses: Definitions and classification 2007-2008. Kaukauna, WI: NANDA International; 2007.

8. Braga CG, da Cruz Dde A. Powerlessness: differentiation from other diagnoses and concepts [in Portuguese]. Rev Esc Enferm USP. 2005;39(3):350-357.

9. Salomé GM, Blanes L, Ferreira LM. Functional capability of patients with diabetes with foot ulceration.Acta Paul Emferm. 2009;22(4):412-416.

10. Shah S. Clinical and economic benefits of healing diabetic foot ulcers with a rigid total contact cast.WOUNDS. 2012;24(6):152–159.

11. Salome GM, Pereira VR, Ferreira LM. Spirituality and subjective wellbeing of patients with lower-limb ulceration. J Wound Care. 2013;22(5):230-236.

12. Salomé GM, Blanes L, Ferreira LM. Evaluation of depressive symptoms in patients with venous ulcers. Rev Bras Cir Plast. 2012;27(1):124-129.

13. Wagner G, Icks A, Albers B, Abholz HH. Type 2 diabetes mellitus and depressive symptoms: what is the cause of what? A systematic literature review [in German]. Dtsch Med Wochenschr. 2012;137(11):523-528.

14. Braga CG, da Cruz Dde A. Powerlessness assessment tool for adult patients. Rev Esc Enferm USP. 2009;43:1063-1070.

15. Ministério da Saúde. Manual de condutas para úlceras neurotróficas e traumáticas. Série J. Cadernos de Reabilitação em Hanseníase. Brazil: Ministério da Saúde; 2002.http://bvsms.saude.gov.br/bvs/publicacoes/manual_feridas_final.pdf.

16. Tang JC, Vivas A, Rey A, Kirsner RS, Romanelli P. Atypical ulcers: wound biopsy results from a university wound pathology service. Ostomy Wound Manage. 2012;58(6):20-29.

17. Salomé GM, Pellegrino DM, Blanes L, Ferreira LM. Self-esteem in patients with diabetes mellitus and foot ulcers. J Tissue Viability. 2011;20(3):100-106.

18. Navicharern R. Diabetes self-management, fasting blood sugar and quality of life among type 2 diabetic patients with foot ulcers. J Med Assoc Thai. 2012;95(2):156-162.

19. Bakker K, Schaper NC; International Working Group in Diabetic Foot Editorial Board. The development of global consensus guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev. 2012;28(1):116-118.

20. Harrison MB, Graham ID, Lorimer K, Friedberg E, Pierscianowski T, Brandys T. Leg-ulcer care in the community, before and after implementation of an evidence-based service. CMAJ. 2005;172(11):1447-1452.

21. Vieira-Santos IC, Souza WV, Carvalho EF, Medeiros MC, Nóbrega MG, Lima PM. Prevalence of diabetic foot and associated factors in the family health units of the city of Recife, Pernambuco State, Brazil, in 2005 [in Portuguese]. Cad Saude Publica. 2008;24(12):2861-2870.

22. Thomsen T, Tønnesen H, Møller AM. Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. Br J Surg. 2009;96(5):451-461.

23. Kean J. The effects of smoking on the wound healing process. J Wound Care. 2010;19(1):5-8.

24. Lindström D, Wladis A, Pekkari K. The thioredoxin and glutaredoxin systems in smoking cessation and the possible relation to postoperative wound complications. WOUNDS. 2010;22(4):88-93.

25. Gottrup F, Apelqvist J, Price P; Eurpean Wound Management Association Patient Outcome Group. Outcomes in controlled and comparative studies on non-healing wounds: recommendations to improve the quality of evidence in wound management. J Wound Care. 2010;19(6):237-268.

26. Salomé GM, Pellegrino DMS, Blanes L, Ferreira LM. Sleep quality in patients with diabetic foot ulcers.WOUNDS. 2013;25(1):20-27.

27. L de Lima E, Salomé GM, de Brito Rocha MJ, Ferreira LM. The impact of compression therapy with Unna’s boot on the functional status of VLU patients. J Wound Care. 2013;22(10):558-561.

28. Salomé GM, Alves SG, Costa VF, Pereira VR. Feelings of powerlessness and hope for cure in patients with chronic lower-limb ulcers. J Wound Care. 2013;22(6):300-304.

29. Waidman MAP, Rocha SC, Correa JL, Brischiliari A, Marcon SS. Daily routines for individuals with a chronic wound and their mental health [in Portuguese]. Texto Contexto Enferm. 2011;20(4):691-699.

30. Salomé GM, Openheimer DG, de Almeida SA, Bueno MLGB, Dutra RAA, Ferreira LM. Feelings of powerlessness in patients with venous leg ulcers. J Wound Care. 2013;22(11):628-634.

Maria Teresa de Jesus Pereira, Geraldo Magela Salomé, and Diego Guimarães Openheimer are from the Sapucaí Valley University (UNIVÁS), Pouso Alegre, Minas Gerais, Brazil. Vitória Helena Cunha Espósito is from Pontifical Catholic University of São Paulo (PUC-SP), São Paulo, Brazil. Sergio Aguinaldo de Almeida works in Private Practice. Lydia Masako Ferreira is from Federal University of São Paulo (UNIFESP), São Paulo, Brazil.

Address correspondence to:

Geraldo Magela Salomé

Av. Francisco de Paula Quintanilha Ribeiro 280

Apartment 134

Jabaguara

CEP- 04330-020 São Paulo, SP, Brazil

[email protected]

Disclosure: The authors disclose no financial or other conflicts of interest.

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Author

PV Mayer

Dr. Perry Mayer is the Medical Director of The Mayer Institute (TMI), a center of excellence in the treatment of the diabetic foot. He received his undergraduate degree from Queen’s University, Kingston and medical degree from the Royal College of Surgeons in Ireland.

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