Abstract
The recurrence of venous leg ulcers (VLUs) is of concern to both patients and health care systems, with large amounts of resources being consumed by this chronic condition. Self‐management has been recommended to decrease the recurrence of VLUs. However, this concept has not been clearly defined in VLU recurrence prevention. The aim of this concept analysis was to describe self‐management in VLU recurrence prevention, and explore the terms used and their application in preventing VLU recurrence. Using Walker and Avant's method of concept analysis, 19 articles were systematically reviewed. The primary term used was that of self‐care. The defining attributes included (a) completing preventative tasks of compression, elevation and exercise; (b) lifelong compliance with preventative tasks by patients; (c) internal factors of understanding why tasks are needed, and motivation/belief they will help prevent recurrence, hence changing routines/lifestyles; (d) environmental support through local health care systems and support systems, while avoiding risk. Inconsistent terminology use can cause communication issues within wound management as well as multidisciplinary teams. Although self‐management is evolving, its development may have been constrained by the medical model, which emphasises compliance with direct preventative tasks for this chronic condition. There is minimal focus on external or environmental factors that support behaviour change. The use of the term self‐management may be more beneficial to communication between professions as it aligns with the chronic disease research. Presently the concept focuses on concordance of the patient with completing the preventative tasks of lifelong compression, elevation and exercise/mobility. The person's beliefs and understanding that compliance with these tasks will reduce the risk of recurrence, and hence, lifelong changes to routines, habits and lifestyles must be made by the person.
1. INTRODUCTION
The prevalence of venous leg ulcers (VLUs) is reported to impact between 0.2 and 0.5% of the population internationally, with a recent systematic review suggesting 0.32% prevalence in the population 1 , 2 ; however, their impacts are significant. VLUs directly impact the physical aspects of people, including increased pain and oedema, and are therefore linked with limited mobility and an increased risk of falls. 3 , 4 Emotionally, VLUs are linked to anxiety and depression as well as social isolation and problems with self‐identity. 4 , 5 Moreover, indirect cost of VLUs, such as the inability to work and impact on carers is detrimental but often largely unquantified. What is more clearly known is the direct cost impact on a country's health care system, which is estimated to range from 235 million to almost 5000 million USD annually. 6
The issue of VLU recurrence is also significant, with reports of 57%–76% recurrence rate, and people experiencing an average of four VLUs in a lifetime. 7 However, evidence exists regarding the prevention of VLU recurrence. Lifelong compression therapy is reported to be the foundation of recurrence prevention, with daily leg elevation and exercise also minimum recommendations. 1 , 8 , 9 , 10 , 11 , 12 However, recurrence continues, with research reporting general poor concordance with prevention strategy application. Furthermore, concordance with prevention applications appears to decrease over time, especially with regards to compression concordance. 9 , 12 , 13 , 14 Research discusses a lack of understanding, discomfort, physical limitations and psychosocial impact being related to poor concordance with compression therapy. 12 , 13 , 15 However, difficulties in transitioning from health care dependent, during wound healing, to being able to self‐manage care independently, may also have a significant influence. 16
2. BACKGROUND
Self‐management as a concept has been well explored in literature in relation to chronic disease. In general, self‐management is the key approach for maintaining health and preventing relapse in chronic conditions. 17 While the area of self‐management has been developing in VLUs in recent years, the focus has been on the self‐management of actively healing wounds. Research on self‐management to prevent recurrence of VLUs, and the processes needed to support this, is still developing.
The experience of self‐management has been explored post healing, with evidence that education, patients' knowledge and beliefs around VLUs and compression strongly influence concordance with ongoing prevention activities. 1 , 8 , 9 , 12 , 13 , 15 Evidence also states that without guidance and education patients are not managing this chronic condition. 18 , 19 However, the concept of self‐management, post healing to prevent VLU recurrence, appears to have inconsistencies in terminology, with no clear definitions and possible conflicts in understanding and applications at times.
Avant and Walker define concepts as the mental image of a thing, action or phenomenon. Concepts are important, as they not only inform and direct clinical practice, but are also essential in the communication between clinicians and between health care professions. 20 However, concepts can be poorly understood or limited in emerging areas of research and practice. This concept analysis is used to enhance our understanding of self‐management for people with healed VLUs, and will highlight the explicit and implicit meanings of the concept through a systematic analysis of published evidence. 21 Concept analysis can be useful in refining concepts or developing standardised language, to enhance communication. 20 This method has been used to both define and clarify concepts in other similar areas such as self‐management and self‐care in chronic diseases and older populations. 22 , 23 , 24 , 25 However, the fledgling concept of self‐management in recurrence prevention in wound management will be explored in the terms of its use and application in preventing VLU recurrence.
3. METHODS
Walker and Avant's 20 approach to concept analysis is employed, which encompasses eight steps: (i) select a concept; (ii) determine the aims or purposes of analysis; (iii) identify all uses of the concept that you can discover; (iv) determine the defining attributes; (v) identify a model case; (vi) identify borderline, related, contrary, invented, and illegitimate cases; (vii) identify antecedents and consequences; and (viii) define empirical referents.
To ensure systematic gathering of evidence, the protocol from the Joanna Briggs Institute (JBI) guidelines for Scoping Reviews was used to complete the systematic literature review. The use of the scoping review protocol limits the potential bias of the researchers, when considering concept analysis. In addition, the JBI scoping review protocol allowed for the inclusion of a wider range of articles, such as expert opinions, providing a better opportunity to represent the current understanding in the professional area.
Aim: Describe the concept of self‐management to prevent recurrence after VLU healing.
What are the main and surrogate terms used within the literature to describe the concept?
What are the antecedents, attributes and consequences?
As per the JBI review protocol, 26 the question was broken into the three core parts of the question: Population, Concept and Context:
Population: Adults (over 18 years) with healed leg ulcers, including venous and mixed aetiologies. Exclusions within this population were children and adults with diabetic ulcers/wounds or sickle cell anaemia wounds as this was outside the scope of this study.
Concept: Self‐management to prevent the recurrence of leg ulcers after healing. This will exclude self‐treatment of healing leg ulcers.
Context: Completing self‐management within the community, excluding the provision of management within the acute or supported accommodation (nursing home) contexts.
From the JBI question structure, key words were identified by completing an initial trial search on EBSCO (CINAHL and Medline). The terms were then finalised, in consultation with a librarian, and a systematic literature search was conducted (YP) using CINAHL, MEDLINE and Scopus databases as these were relevant to the concept being investigated. The search terms used included (self‐management or self‐care or self‐monitoring) AND (“leg ulcers” or “chronic leg ulcers” or “venous leg ulcers” NOT [DFU or “diabetic foot” or “sickle cell”]) AND recurrence AND prevention. This included the use of MESH terms and CINAHL headings, as well as keyword search terms.
3.1. Article selection
Online software (Covidence & Endnote) was used to assist with the screening and data extraction process. Articles from the separate database searches were imported into ENDNOTE, then combined into a raw data group. At this point duplicates were removed, and the raw combined data sent to Covidence. An additional two duplicates were removed at this point, and the titles and abstracts screened (YP) and articles which did not meet the inclusion criteria (see Appendix A) were discarded. Two researchers (YP & SM) then reviewed the full text of the remaining articles, and again, articles which did not meet the criteria were discarded.
3.2. Data extraction
To complete the data extraction, the Walker and Avant 20 , 27 , 28 concept analysis headings were utilised. The headings for the concept analysis included: main term, surrogate terms, definitions, antecedents, attributes, consequences and cases. Data extraction was completed by the authors (YP & SM) using Covidence software independently, then compared and agreement reached through discussion. To ensure consistency in approach, the following definitions of concept analysis terms were used. 20 , 28
Main term: The most frequent term within the article reviewed.
Surrogate term: Surrogate terms are words that express a concept's ideas through words other than the concept/main term that the authors have chosen in their study.
Antecedents: Events or phenomena that have previously been related, immediately preceding or required for the concept to occur.
Attributes: Clusters of characteristics that make it possible to identify situations that can be categorised under the concept.
Consequences: The result of the use of a concept in a practical situation.
Empirical referents: Classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself.
3.3. Findings
From the databases, 106 articles were identified using PUBMED, CINAHL and Scopus. Duplicates were then removed, and the remaining 62 articles were entered into the Covidence program, where another four duplicates were removed. From the remaining 58 studies, a title and abstract screening excluded 17 articles as not meeting the inclusion criteria and another 21 excluded during the full‐text screening. Reasons for exclusion included language (n = 2), including wound healing (n = 13), not examining self‐management (n = 2), two unable to retrieve full text, one sickle cell anaemia and one conference abstract. A final 19 articles were identified as meeting the inclusion criteria to address the research question (see Figure 1).
FIGURE 1.
PRISMA diagram.
3.4. Concept description and model
The concept did not have a clear definition identified in any article. In addition, the terminology of the concept was inconsistent within the articles, with only one article using the same terminology throughout the article. The main term found to be used within articles was that of self‐care, with 14 out of the total 19 articles using self‐care (or a derivative such as self‐care strategies). The five remaining articles used the term self‐management as the main term (Table 1).
TABLE 1.
Terminology by study.
| Study ID | Main terms | Surrogate terms |
|---|---|---|
| Anderson 2015 | Self‐management | Maintaining |
| Atkin 2019 | Self‐management | Self‐manage, lifelong management, self‐care, patient adherence |
| Brown 2021 | Self‐care | Self‐care strategies, self‐caring activities, self‐care, recurrence prevention activities, self‐management |
| Brown 2014a | Self‐care | Self‐care activities, preventative self‐care strategies, self‐care programmes |
| Brown 2014b | Self‐care | Self‐care activities, self‐regulation strategies, supplementary self‐care activities, daily self‐care activities, self‐care routine |
| Brown 2018 | Self‐care | Self‐care strategies, self‐care management, self‐care activities |
| Elwell 2018 | Self‐care | |
| Finlayson 2009 | Self‐care | Self‐care activities, self‐care behaviours, self‐care management |
| Finlayson 2010 | Self‐care | Self‐care activities, self‐management activities |
| Finlayson 2011 | Self‐care | Self‐care activities, self‐management activities, self‐care behaviours, preventive activities |
| Finlayson 2015 | Self‐management | Self and family management of a chronic condition, self‐care activities, self‐care regimens, lifelong self‐management, successful chronic disease self‐management, disease self‐management |
| Finlayson 2014 | Self‐care | Self‐care strategies, self‐care activities, self‐management |
| Freeman 2007 | Self‐care | Healthy legs, self‐care strategies, self‐care knowledge, self‐care messages, care for the legs themselves |
| Janaina de Souza 2019 | Self‐care | Self‐care activities, self‐management strategies, self‐care measures |
| Kapp 2008 | Self‐care | Self‐care, maintenance strategies, maintenance therapy, self‐management |
| Kapp 2014 | Self‐management | |
| Kapp 2015 | Self‐management | Post‐healing management, self‐management behaviours, self‐management practices after healing, self‐, self‐management experience, self‐management actions, successful self‐management, self‐managing, self‐management strategies |
| Madeira 2023 | Self‐care | Self‐care measures, self‐care prevention, self‐management, self‐treatment, self‐nurturance, secondary prevention |
Surrogate terms are classified as alternative terms used when discussing the same/similar concept within the same article. A range of surrogate terms were used both within the same article and between different articles, with 41 different terms noted (see Appendix B). Self‐care and its derivatives were used most frequently (n = 30) (see Appendix A) with self‐care activities (n = 7), self‐care (n = 5) and self‐care management (n = 3), the most used. Self‐management and its derivatives were the second most frequently used (n = 22) with self‐management 5 and self‐management strategies, 3 activities 2 and behaviours. 2
3.5. Antecedents
The phenomena regularly associated immediately prior was that of a healed ulcer, as in general preventing recurrence first requires a healed ulcer. The other antecedents can be divided into internal and external requirements for the person to complete the concept of self‐management. The internal factors here included the person's skills and ability to complete the tasks (compression hosiery donning); mental health issues (depression); health beliefs and ability or willingness to change routines and behaviours and the person's understanding of the disease and reasoning for compression. It is noted here the focus was on the individual's ability to comply or adhere to lifelong compression and/or completing the tasks included in self‐care. External factors identified in the articles included the provision of expert intervention, such as the prescribing of compression or provision of information and the influence of the family/social structure supporting the person as well as the systemic structure, such as the health care service (Tables 2 and 3).
TABLE 2.
Antecedents for self‐management to prevent venous leg ulcer recurrence.
| Term | Area | Source ID |
|---|---|---|
| Healed leg ulcer (n = 12) | Anderson 2015; Atkin 2019; Brown 2014a; Brown 2014b; Brown 2014c; Brown 2021; Elwell 2018; Finlayson 2009; Finlayson 2010; Kapp 2014; Freeman 2007; Madeira 2023 | |
| Internal factors | Skills/abilities (n = 5) | Finlayson 2010; Finlayson 2011; Finlayson 2014; Finlayson 2015; Kapp 2008 |
| Mental health (n = 3) | Finlayson 2009; Finlayson 2010; Finlayson 2015 | |
| Belief/attitudes (n = 5) | Brown 2014b; Finlayson 2010; Finlayson 2014; Finlayson 2011; Kapp 2015 | |
| Understanding (n = 4) | Finlayson 2010; Finlayson 2014; Janaina de Souza 2019; Kapp 2015 | |
| Ability for compliance/adherence (n = 2) | Elwell 2018; Finlayson 2014 | |
| External | Expert intervention (n = 1) | Kapp 2014 |
| Provision of education (n = 3) | Brown 2014a; Freeman 2007; Kapp 2015 | |
| Support structure (n = 3) | Finlayson 2009; Finlayson 2011; Finlayson 2015 | |
| Health care structure (n = 3) | Anderson 2015; Finlayson 2014; Finlayson 2015 | |
TABLE 3.
Defining attributes of self‐management to prevent venous leg ulcer recurrence.
| Term | Derivative | Source |
|---|---|---|
| Tasks/activities | Compression (n = 16) | Anderson 2015; Atkin 2019; Brown 2014a; Brown 2014b; Brown 2014c; Brown 2018; Brown 2021; Elwell 2018; Finlayson 2009; Finlayson 2010; Finlayson 2011; Finlayson 2014; Finlayson 2015; Freeman 2007; Kapp 2015; Madeira 2023 |
| Elevation (n = 12) | Brown 2014a; Brown 2014b; Brown 2014c; Brown 2018; Brown 2021; Finlayson 2009; Finlayson 2010; Finlayson 2011; Finlayson 2014; Finlayson 2015; Freeman 2007; Janaina de Souza 2019 | |
| Exercise (n = 14) | Brown 2014a; Brown 2014b; Brown 2014c; Brown 2018; Brown 2021; Finlayson 2009; Finlayson 2010; Finlayson 2011; Finlayson 2014; Finlayson 2015; Freeman 2007; Janaina de Souza 2019; Kapp 2015; Madeira 2023 | |
| Skin care (n = 7) | Brown 2021; Freeman 2007; Finlayson 2010; Finlayson 2015; Janaina de Souza 2019; Kapp 2015; Madeira 2023 | |
| Nutrition (n = 1) | Kapp 2015 | |
| Lifelong | Adherence/compliance (n = 11) | Anderson 2015; Atkin 2019; Brown 2014b; Brown 2018; Brown 2021; Elwell 2018; Finlayson 2009; Finlayson 2010; Finlayson 2014; Kapp 2008; Kapp 2014 |
| Internal factors | Knowledge/understanding (n = 5) | Atkin 2019; Brown 2014a; Brown 2014c; Brown 2014c; Brown 2021 |
| Habits/routine/lifestyle (n = 4) | Brown 2014b; Brown 2014c; Kapp 2015; Finlayson 2015 | |
| Motivation/beliefs (n = 6) | Brown 2014b; Brown 2014c; Finlayson 2009; Finlayson 2015; Freeman 2007; Kapp 2015 | |
| Environment | Risk avoidance (n = 2) | Brown 2014c; Finlayson 2010 |
| Supportive health/community services (n = 2) | Brown 2014b; Finlayson 2015 |
3.6. Defining attributes
For the area of defining 17 out of the 19 articles identified the management tasks and activities that support preventions as either the defining attributes or at least part of the attributes of the concept of self‐management. Within these tasks and activities, use of compression (n = 16), elevation (n = 12) and exercise (n = 12) were the most common cited attributes. Attributes of lesser priority were related to skin care (n = 7) and other tasks including nutrition, avoiding injury or shoe choice.
Approximately half (n = 9) of the articles were focused on the person's compliance or adherence to the prescribed activities, mainly compression, with the focus on the lifelong nature of the tasks. Other attributes included the person's motivation or internal beliefs, such as self‐efficacy (n = 6); the person's knowledge about the cause of the leg ulcer and/or the need for compression therapy (n = 5) and personal routine/habit for lifestyle changes (n = 5) as part of self‐management. The environment (social, family or health service) was only mentioned in two articles (Figure 2).
FIGURE 2.
Defining attributes.
3.7. Consequences
All articles agreed with the fact that completing self‐management had the consequence of a reduction in the risk or number of recurrences of leg ulceration. Two articles also discussed the consequence of self‐management as increasing leg health, quality of life and a decrease in the financial impact on the health systems (see Table 4).
TABLE 4.
Consequences of self‐management to prevent venous leg ulcer recurrence.
| Consequences | Source |
|---|---|
| Prevent/lower risk of recurrence (n = 18) | Anderson 2015; Atkin 2019; Brown 2014a; Brown 2014b; Brown 2014c; Brown 2018; Elwell 2018; Finlayson 2009; Finlayson 2010; Finlayson 2011; Finlayson 2014; Finlayson 2015; Freeman 2007; Janaina de Souza 2019; Kapp 2008; Kapp 2014; Kapp 2015; Madeira 2023 |
| Leg health (n = 3) | Freeman 2007; Kapp 2008; Kapp 2015 |
| Adherence (n = 2) | Atkin 2019; Finlayson 2015 |
| Quality of life increased (n = 1) | Brown 2021 |
| Decreased burden on health system (n = 1) | Brown 2021 |
3.8. Example cases
3.8.1. Model case
An older woman completes the tasks of donning compression stockings, elevating her legs, completing leg exercises and walking, and she completes these tasks independently on a daily basis. She has a strong belief that completing these tasks will prevent her ulcer from returning, and she has made lifestyle changes to ensure she will do these things for the duration of her life.
3.8.2. Contrary case
A middle‐aged man has been discharged from the tissue viability/wound care services after healing of his VLU. Now that the ulcer is healed, he feels he can return to his normal life and no longer uses compression therapy or completes his leg elevation and exercises. He feels that it is inevitable that his ulcer will return and will seek support from health care services when the ulcer returns.
3.8.3. Borderline case
An older male is currently getting his wife to put the compression stockings on him when he feels there is an issue developing. He continues his daily walk but feels the responsibility of VLU is beyond his control and he relies on significant others to maintaining healthy skin (it is his wife's or the nurse's job to keep an eye on his healed leg ulcer).
3.9. Empirical referents
TABLE 5.
Empirical referents of self‐management to prevent venous leg ulcer recurrence.
| Empirical referent and description | Source |
|---|---|
| Completing preventative tasks: Use of compression therapy, leg elevation, leg exercise/mobility (n = 16) | Anderson 2015; Atkin 2019; Brown 2014a; Brown 2014b; Brown 2014c; Brown 2018; Brown 2021; Elwell 2018; Finlayson 2009; Finlayson 2010; Finlayson 2011; Finlayson 2014; Finlayson 2015; Freeman 2007; Kapp 2015; Madeira 2023 |
| Concordance: Adhering to lifelong compression therapy. Compliance with completion of preventative tasks (n = 11) | Anderson 2015; Atkin 2019; Brown 2014b; Brown 2018; Brown 2021; Elwell 2018; Finlayson 2009; Finlayson 2010; Finlayson 2014; Kapp 2008; Kapp 2014 |
| Health beliefs: Belief that concordance with tasks, especially compression therapy will address the underlying condition and reduce the risk of recurrence (n = 6) | Brown 2014b; Brown 2014c; Finlayson 2009; Finlayson 2015; Freeman 2007; Kapp 2015 |
| Lifestyle redesign: Developing a lifelong change in routines to facilitate incorporation of prevention tasks into daily life (n = 4) | Brown 2014b; Brown 2014c; Kapp 2015; Finlayson 2015 |
4. DISCUSSION
Within the scope of this study ‘self‐care’ is the main term used within the area of recurrence prevention in wound management. The predominant use of self‐care reflects the current terminology used in wound management and nursing literature. 23 , 24 , 29 , 30 , 31 , 32 Herein may lie an issue, with the term of self‐care holding different meanings in other areas. Examples of these areas include chronic disease management where self‐care is understood as an all‐encompassing concept enriching health/preventing disease. 33 , 34 In the area of occupational therapy, self‐care is specifically understood in a different manner which includes activities of daily living, tasks such as personal hygiene and grooming. 35 For generic or academic nursing, the concept again has a different understanding as the ability of the health care practitioner, to care for oneself through awareness, self‐control and self‐reliance in order to achieve, maintain or promote optimal health and well‐being. 24 With this wide range of understanding of the concepts, and terminology being used interchangeably, there is a risk of miscommunication, within the multidisciplinary nature of health care. This is similar to the literature, which suggests that the use of ambiguous language may impact clinical decision‐making and shared decision‐making, especially in multidisciplinary teams. 36
Both the terminology used and the concepts are also influenced by the dominant professional; culturally, the lead or dominant professional can vary across health systems in which the articles/literature is based. In the area of wound management, the dominant profession is nursing, influenced by the medical model. This is clearly described within the area of the defining attributes, demonstrating a focus on completion and adherence/compliance of preventative activities, including compression application (in the form of hosiery), leg elevation and completion of physical activity and/or mobility. These defining attributes are mechanistic in nature and are strongly aligned with the reductionist medical model, reducing a complex intervention to simplistic steps.
Furthermore, the antecedents are firmly anchored in the medical model, with the healed ulcer being the primary precursor needed for self‐management, with less emphasis on the internal factors (such as skills, beliefs and understanding) and very limited identification on the external factors (availability for expert intervention, provision of education, support and health system structures). This is in stark contrast to the emphasis of chronic conditions self‐management literature on personal factors including; identity, knowledge, skills, the person's own agency and the importance of external factors of the culture/environment of both the person and the health service as essential precursors or antecedents to successful self‐management. 23 , 24 , 32 This may be influenced by the delivery of wound management services within acute medical systems, as literature does suggest that the chronic nature of VLUs may be limited by the delivery and funding within the acute health care system. 37
VLU recurrence is still a significant global issue, 2 with the consequences of recurrence still impacting people's quality of life. However, the consequences of self‐management of healed VLUs, within the literature, appear to be focused on the medical management of symptoms, that of the recurrence of the ulcer, and less on the impact on a person's quality of life and reduction of health system burdens. Conversely, within the literature, the emotional and mental well‐being consequences of chronic VLUs are well documented. 4 , 5 , 7 Furthermore, VLUs are associated with people self‐restricting activities, both in and out of the home environment, leading to decreased physical well‐being, increased falls risks and further social isolation. 4 , 5 , 7 Indeed, evidence suggests that the social, physical and mental health consequences strongly impact on the risk of VLU recurrence. 9 Finally, the impact of the cost to the person, in terms of direct costs such as compression garments and indirect costs, such as taking time off work to attend treatment or transport to access treatment should be included. These personal costs are acknowledged as a barrier to adhering to VLU treatment and hence should be considered in secondary prevention of VLU recurrence. 38
This contrasts to how self‐management is understood and articulated in other chronic conditions. Disease‐specific self‐management has been reported as including ‘symptom awareness and disease knowledge; lifestyle changes and behavioural management; and psychology and stress management’. 17 When focusing specifically on an older population, the inclusion of financial resources to access education and support from professionals, receiving ongoing social supports and developing psychologically and emotionally sound ways to actively participate in sustained management and engagement with the health system. 17 This highlights the importance of a holistic approach to self‐management, with ongoing support, financial, social and by the health system and professionals, to counter issues such as social isolation, inaccessible community environments and financial constraints experienced by older populations. The concept of self‐management, in this context, is shown to be focused on adherence by the person to completing prescribed tasks to prevent recurrence of the ulcer.
4.1. Limitations
Firstly, the articles included healed VLUs only, excluding articles which discussed actively healing ulcers, and articles that combined both healed and healing VLUs. This exclusion was due to the difference in management skills needed for healing versus healed leg ulcers; however, this limited the range of articles reviewed. In addition, the inclusion of lower levels of evidence, such as expert opinions, may have skewed the data collected, as most expert opinions were directed towards providing information for treatment of VLUs.
4.2. Implications for practice
The prevention of VLU recurrence is of importance to the person, the community and the health system. The understanding of the concept of self‐management for prevention of VLUs is currently emerging; however, further clarity about what is needed for the self‐management to occur (antecedents) and what self‐management encompasses (attributes) would benefit the wound management area. Furthermore, the inclusion of terminology, consistent with other areas of practice, such as chronic disease management, would support clear communication in multidisciplinary teams. This may also extend to increasing transference of research findings from the wound care area to chronic disease and vice versa, further strengthening the importance of this area to policy makers.
How this translates into practice needs further investigation, as the understanding and definition of a concept, such as self‐management, will influence how self‐management is implemented by health care professionals, as well as understood by persons with healed VLU and their caregivers.
5. CONCLUSION
This review set out to clarify the concept of self‐management to prevent VLU recurrence, in the area of wound management. As yet, there are no clear definitions of self‐management within this area, and terminology is used inconsistently and interchangeably. From a clinical perspective, the interchangeable use of self‐care and self‐management may cause communication issues with other health care professionals, impacting the multidisciplinary team, due to different understandings of the concept of self‐care. 33 , 34 In addition, the use of self‐management of a term, is also more in alignment with the chronic disease management literature. 33 , 34 Aligning with chronic disease management, consistent term use may assist with the promotion of prevention as a key area for health care policy makers and add weight to this emerging area of wound management research.
Self‐management primarily begins after a leg ulcer has healed, focusing on the person's adherence to preventative tasks such as compression, leg elevation, exercises and mobility. The literature defines self‐management by this adherence and the belief that these actions will reduce recurrence risk. Consequently, people with healed VLUs must make lifelong changes to their routines and lifestyles to incorporate these preventative measures.
CONFLICT OF INTEREST STATEMENT
The authors have no conflicts of interest to declare.
ACKNOWLEDGEMENTS
Open access publishing facilitated by University College Cork, as part of the Wiley—Irish Research eLibrary (IReL) agreement. Open access funding provided by IReL.
APPENDIX A. Overview of Inclusion and Exclusion Criteria
A.1.
| Inclusion | Exclusion |
|---|---|
| Adults (over 18 years) | Participants under age of 18 years |
| Healed leg ulcers (venous, arterial, mixed, unknown) | Unhealed leg ulcers/healing; foot ulcers (diabetic foot ulcers); sickle cell anaemia; acute wounds; injecting sites |
| Self‐management (and alternative terms) | Self‐treating (self‐care when related to personal hygiene) |
| Recurrence prevention | Acute; prevention of first ulceration |
| English language | Other languages |
| Articles published in peer‐reviewed journals—including expert opinions, systematic reviews, study protocols and case studies. | Materials published in non‐peer‐reviewed publication/literature, news articles; books and book chapters, conference proceedings; thesis publications |
| Community‐based or home‐based | Acute health services; hospitals; supported accommodation/nursing homes |
APPENDIX B. Frequency and Use of Surrogate Terms, as Deriving from Main Terms
B.1.
| Main term | Surrogate term/s | Frequency used |
|---|---|---|
| Self‐car* | ~ management; ~ activities; ~ strategies; ~ messages; ~ knowledge; ~ regimens; ~ measures; ~ behaviours; ~ programmes; ~ prevention; ~ routine; preventative self‐care strategies; daily self‐care activities; supplementary self‐care activities | 30 |
| Self‐manag* | Self‐management; ~ activities; ~behaviours; ~strategies; ~actions; ~experience; self‐management practices after healing; lifelong self‐management; successful self‐management; successful chronic disease self‐management; disease self‐management; self and family management of a chronic condition; post‐healing management | 22 |
| Maintenance | Maintenance strategies; maintenance therapy; maintaining | 3 |
| Prevent* | Preventive activities; recurrence prevention activities; secondary prevention | 3 |
| Miscellaneous | Self‐treatment; self‐nurturance; healthy legs; care for the legs themselves; patient adherence; self‐regulation strategies | 6 |
Note: Asterisk represents a truncation as part of the Boolean logic used within the literature search.
APPENDIX C. Entire Data Set
C.1.
| Study ID | Citation | Consensus | Date | Main terms | Surrogate terms | Antecedents | Internal factors—antecedents | External factors—antecedents | Defining attributes | Definition | Combined consequences | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Skills/ability; mental health; beliefs/attitudes; understanding; ability for compliance/adherence | Expert intervention; health care structure; support structure; provision of education | ||||||||||||
| 44 | Madeira 2023 | Madeira ÁCM, Oliveira LSN, da Silva Brandão E. Self‐care measures to prevent venous ulcer recurrence: a scoping review protocol. Online Braz J Nurs. 2023;22:13–11. https://ucc.idm.oclc.org/login?URL=https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=162111345&site=ehost‐live | Yes | 2023 | Self‐care | Self‐care measures; self‐care prevention; self‐management; self‐treatment; self‐nurturance; secondary prevention | Healed leg ulcer | Tasks/activities | Compression; exercises; skin care | No | Prevent/lower risk of recurrence | ||
| 41 | Kapp 2008 | Kapp S, Miller C, Donohue L. The use and acceptability of devices for compression stocking application and removal. Wound Pract Res. 2014;22:34–43. https://ucc.idm.oclc.org/login?URL=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=107899576&site=ehost‐live | Yes | 2008 | Self‐care | Self‐care; maintenance strategies; maintenance therapy; self‐management | Internal factors | Skills/ability | Lifelong | Adherence/compliance | No | Prevent/lower risk of recurrence; leg health | |
| 40 | Kapp 2014 | Kapp S, Miller C, Donohue L. The use and acceptability of devices for compression stocking application and removal. Wound Pract Res. 2014;22(1):34–43. https://ucc.idm.oclc.org/login?URL=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=107899576&site=ehost‐live | Yes | 2014 | Self‐management | NA | Healed leg ulcer | Expert intervention | Lifelong | Adherence/compliance | No | Prevent/lower risk of recurrence | |
| 39 | Kapp 2015 | Kapp S, Miller C. The experience of self‐management following venous leg ulcer healing. J Clin Nurs. 2015;24(9–10):1300–1309. https://doi.org/10.1111/jocn.12730 | Yes | 2014 | Self‐management | Post‐healing management; self‐management behaviours; self‐management practices after healing; self‐; self‐management experience; self‐management actions; successful self‐management; self‐managing; self‐management strategies | Beliefs/attitudes; Understanding | Provision of education | Tasks/activities; internal factors | Compression; exercises; skin care; nutrition; habits/routine/lifestyle; motivation/beliefs | No | Prevent/lower risk of recurrence; leg health | |
| 36 | JanainadeSouza 2019 | Janaina de Souza F, Santos Tomaz de Aquino JF, Guimarães Silva MA, Ferreira de Oliveira M, Pérez Evangelista Dantas SR. Non‐invasive measures of venous ulcer recurrence prevention: integrative review. Rev Estima. 2019;17:1–9. https://doi.org/10.30886/estima.v17.713_IN | Yes | 2019 | Self‐care | Self‐care activities; self‐management strategies, self‐care measures | Understanding | Tasks/activities | Exercise; elevation; skin care | No | Prevent/lower risk of recurrence | ||
| 33 | Freeman 2007 | Freeman E, Gibbins A, Walker M, Hapeshi J. ‘Look After Your Legs’: patients' experience of an assessment clinic. Br J Community Nurs. 2007;12:S19–15. https://doi.org/10.12968/bjcn.2007.12.sup1.23047 | Yes | 2007 | Self‐care | Healthy legs; self‐care strategies; self‐care knowledge; self‐care messages; care for the legs themselves | Healed leg ulcer | Provision of education | Tasks/activities; Internal factors | Compression; exercise; elevation; skin care; motivation/beliefs | No | Prevent/lower risk of recurrence; leg health | |
| 32 | Finlayson 2014 | Finlayson KJ, Edwards HE, Courtney MD. Venous leg ulcer recurrence: deciphering long‐term patient adherence to preventive treatments and activities. Wound Pract Res. 2014;22(2):91–97. https://ucc.idm.oclc.org/login?URL=https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=96709560&site=ehost‐live | Yes | 2014 | Self‐care | Self‐care strategies, self‐care activities, self‐management | Ability for adherence/compliance; beliefs/attitudes; understanding; skills/ability | Health care structure | Tasks/activities; lifelong | Adherence/compliance; compression; elevation; exercise | No | Prevent/lower risk of recurrence | |
| 31 | Finlayson 2015 | Finlayson K, Min‐Lin W, Edwards HE. Identifying risk factors and protective factors for venous leg ulcer recurrence using a theoretical approach: a longitudinal study. Int J Nurs Stud. 2015;52(6):1042–1051. https://doi.org/10.1016/j.ijnurstu.2015.02.016 | Yes | 2015 | Self‐management | Self and family management of a chronic condition; self‐care activities; self‐care regimens; lifelong self‐management; successful chronic disease self‐management; disease self‐management | Skills/ability; mental health | Health care structure; support structure | Tasks/activities; internal factors; environments | Compression; elevation; exercise; skin care; habits/routines/lifestyle; motivation/beliefs; supportive health/community services | No | Prevent/lower risk of recurrence; adherence | |
| 30 | Finlayson 2011 | Finlayson K, Edwards H, Courtney M. Relationships between preventive activities, psychosocial factors and recurrence of venous leg ulcers: a prospective study. J Adv Nurs. 2011;67(10):2180–2190. https://doi.org/10.1111/j.1365‐2648.2011.05653.x | Yes | 2011 | Self‐care | Self‐care activities, self‐management activities; self‐care behaviours, preventive activities | Skills/ability; beliefs/attitudes | Support structure | Tasks/activities | Compression; exercise; elevation | No | Prevent/lower risk of recurrence | |
| 29 | Finlayson 2010 | Finlayson K, Edwards H, Courtney M. The impact of psychosocial factors on adherence to compression therapy to prevent recurrence of venous leg ulcers. J Clin Nurs. 2010;19(9–10):1289–1297. https://doi.org/10.1111/j.1365‐2702.2009.03151.x | Yes | 2010 | Self‐care | Self‐care activities, self‐management activities | Healed leg ulcer | Understanding; beliefs/attitudes; mental health; skills/ability | Tasks/activities; lifelong; environment | Compression; exercise; elevation; skin care; adherence/compliance; risk avoidance | No | Prevent/lower risk of recurrence | |
| 28 | Finlayson 2009 | Finlayson K, Edwards H, Courtney M. Factors associated with recurrence of venous leg ulcers: a survey and retrospective chart review. Int J Nurs Stud. 2009;46(8):1071–1078. https://doi.org/10.1016/j.ijnurstu.2008.12.012 | Yes | 2009 | Self‐care | Self‐care activities, self‐care behaviours, self‐care management | Healed leg ulcer | Mental health | Support structure | Tasks/activities; lifelong; internal factors | Compression; exercise; elevation; adherence/compliance; motivation/beliefs | No | Prevent/lower risk of recurrence |
| 26 | Elwell 2018 | Elwell R. European Class compression hosiery: a new range of garments. J Community Nurs. 2018;32:40–44 | Yes | 2018 | Self‐care | Healed leg ulcer | Ability for adherence/compliance | Tasks/activities; lifelong | Compression; adherence/compliance | No | Prevent/lower risk of recurrence | ||
| 19 | Brown 2014c | Brown A, Kendall S, Flanagan M, Cottee M. Encouraging patients to self‐care ‐ the preliminary development and validation of the VeLUSET©, a self‐efficacy tool for venous leg ulcer patients, aged 60 years and over. Int Wound J. 2014;11(3):326–334. https://doi.org/10.1111/iwj.12199 | Yes | 2014 | Self‐care | Self‐care activities, self‐care behaviours | Healed leg ulcer | Task/activities; internal factors; environment | Compression; exercise; elevation; knowledge/understanding; habits/routines/lifestyle; motivation/beliefs; risk avoidance | No | Prevent/lower risk of recurrence | ||
| 18 | Brown 2021 | Brown A. Recurrent venous leg ulcers: management in general practice. Pract Nurs. 2021;32(6):220–225. https://doi.org/10.12968/pnur.2021.32.6.220 | Yes | 2021 | Self‐care | Self‐care strategies; self‐caring activities; self‐care; recurrence prevention activities; self‐management | Healed leg ulcer | Task/activities; lifelong; internal factors | Compression; elevation; exercise; skin care; adherence/compliance; knowledge/understanding | No | Prevent/lower risk of recurrence; increased QoL; health system burden decreased | ||
| 17 | Brown 2018 | Brown A. Self‐care strategies to prevent venous leg ulceration recurrence. Pract Nurs. 2018;29(4):152–158. https://doi.org/10.12968/pnur.2018.29.4.152 | Yes | 2018 | Self‐care | Self‐care strategies. Self‐care management. Self‐care activities | Healed leg ulcer | Tasks/activities; lifelong | Compression; exercise; elevation; adherence/compliance | No | Prevent/lower risk of recurrence | ||
| 16 | Brown 2014a | Brown A. Evaluating the reasons underlying treatment nonadherence in VLU patients: Mishel's theory of uncertainty. Part 2 of 2. J Wound Care. 2014;23(2):73–80. https://doi.org/10.12968/jowc.2014.23.2.73 | Yes | 2014 | Self‐care | Self‐care activities; preventative self‐care strategies; self‐care programmes | Healed leg ulcer | Provision of education | Tasks/activities; internal factors | Compression; elevation; exercise; knowledge/understanding | No | Prevent/lower risk of recurrence | |
| 15 | Brown 2014b | Brown A. Evaluating the reasons underlying treatment nonadherence in VLU patients: Introducing the VeLUSET Part 1 of 2. J Wound Care. 2014;23(1):37–47. https://doi.org/10.12968/jowc.2014.23.1.37 | Yes | 2014 | Self‐care | Self‐care activities; self‐regulation strategies; supplementary self‐care activities; daily self‐care activities; self‐care routine | Healed leg ulcer | Beliefs/attitudes | Lifelong; tasks/activities; internal factors; environment | Adherence/compliance; compression; elevation; exercise; habits/routine/lifestyle; motivation/beliefs; supportive health/community services | No | Prevent/lower risk of recurrence | |
| 9 | Atkln 2019 | Atkln L. Venous leg ulcer prevention 3: supporting patients to self‐manage. Nurs Times. 2019;115(8):23–26 | Yes | 2019 | Self‐management | Self‐manage; lifelong management, self‐care, patient adherence | Healed leg ulcer | Lifelong; tasks/activities; internal factors | Adherence/compliance; compression; knowledge/understanding | No | Prevent/lower risk of recurrence; adherence | ||
| 5 | Anderson 2015 | Anderson I. Optimising concordance with compression hosiery in the community setting. Br J Community Nurs. 2015;20(2):67–72. https://doi.org/10.12968/bjcn.2015.20.2.67 | Yes | 2015 | Self‐management | Maintaining | Healed leg ulcer | Health care structure | Lifelong; tasks/activities | Adherence/compliance; compression | No | Prevent/lower risk of recurrence | |
Pennisi Y, Müller N, Buckley C, Hartigan I, Murphy S. Self‐management to prevent recurrence in venous leg ulcers: A concept analysis. Int Wound J. 2024;21(6):e14944. doi: 10.1111/iwj.14944
DATA AVAILABILITY STATEMENT
The data that supports the findings of this study are available in the supplementary material of this article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that supports the findings of this study are available in the supplementary material of this article.