Processes underlying adherence to leg ulcer treatment: a qualitative field study

Abstract

Background: Non-adherence to leg ulcer regimen is a major problem. Reasons for non-adherent behaviour are not fully understood. Literature about processes underlying adherence in leg ulcer patients is scarce.

Objectives: To explore the processes underlying adherent behaviour in patients with leg ulcers who received an intervention to enhance adherence to leg ulcer lifestyle advice.

Design: A qualitative field study was conducted among patients receiving an adherence-promoting intervention.

Settings: The study was carried out in a home care setting in Belgium.

Participants: Twenty-six patients with venous leg ulcers were included and received the intervention from five tissue viability nurses in a community healthcare organisation.

Methods: Semi-structured interviews with open-ended questions were held with patients and nurses after the end of the intervention. Data were also collected by means of participant observation. Data collection and data analysis took place iteratively and analysis was validated by means of researcher triangulation.

Results: Trust in the nurse was central to leg ulcer treatment adherence. Patients who had a trusting relationship with their nurse showed better adherence to the recommended lifestyle modifications. Trust was facilitated by nurses spending meaningful time with the patient, which means they took time to talk with the patient. Trust was also established because nurses provided care beyond patients' expectations, taking time for wound care and being attentive to pain and other problems. A trusting relationship promoted 'compliance' even if patients were not convinced of the benefits of the leg ulcer lifestyle advice. Perceived physical improvement and diminished discomfort after following the lifestyle advice convinced patients of the importance and positive effect of the regimen, which they doubted at first. Self-efficacy for performing leg exercises was often much higher than self-efficacy for being physically active and elevating the legs. Physical impediments, co-morbidities and socio-structural impediments influenced the patient's ability to adhere to leg ulcer advice.

Conclusions: A conceptual framework to understand adherence to leg ulcer treatment was developed. Nurses should be aware of how nurse-related factors can affect adherence. Aspects that foster trust could be incorporated into leg ulcer care.