Clinician's perspectives on the treatment of venous leg ulceration

ABSTRACT

Treatment of venous leg ulcers (VLU) represents a considerable challenge to the health care professional and to the patient alike. Much of the current literature regarding VLU focuses on either wound pathophysiology and treatment of chronic venous insufficiency or the patients' experience of the condition. We present two studies that examine more closely the clinicians' experience of treating VLU and reflect upon how that understanding may further enhance better outcomes for patients in the future. The first of these studies is a qualitative investigation of 49 clinicians treating VLU in the UK and USA. The second is a quantitative, online survey of 304 clinicians' beliefs, attitudes and practices in the UK, Germany and USA. Findings show that the clinicians' experience of treating VLU is often accompanied by frustration and dissatisfaction with treatment challenges and uncertain outcomes. Practices and treatment choices were found to vary widely and differ by countries. We conclude that a key aspect in improving VLU treatment is in listening to the frustrations of the clinician when considering new approaches to therapy.

BACKGROUND

In common with all chronic wounds, the treatment of venous leg ulcers (VLU) is widely acknowledged to be a complex task 1, 2, 3. VLU continue to present considerable challenges to the health care professional, health care resources and patient quality of life (4).

The majority of research into VLU has focused on two key areas: the pathophysiology and treatment of chronic venous insufficiency, and the patient perspective 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17. It is on the clinician that we focus our attention in this article. There is a universal agreement that compression therapy is central to the management of VLU 1, 17, 18. In addition, there is consensus that the healing of these wounds is a joint effort between patient and clinician 3, 11, 19, 20 often navigating a complex web of psychological, nutritional and social factors (11). Bringing these elements together has been described as the ‘science and art' (20) of clinical medicine. Chronic venous ulcers are often longstanding or recurrent (21) and thus can negatively affect patient quality of life 4, 5, 10. The uncertain healing prognosis of these wounds impacts not only the patient but also the clinician; this may influence the way in which the patients and their condition is viewed.

In this article, we explore the range of practices, beliefs and opinions amongst clinicians in the UK, North America and Germany. We describe two research projects that create a picture of VLU treatment from the clinician perspective, which may impact outcomes and patient care.

RESEARCH METHOD

Two studies were conducted. The first study was a broad qualitative exploration of challenges faced by clinicians who treat VLU in the UK and USA. This aspect of the research was exploratory and did not impose a specific frame of reference. Instead, the focus was upon the clinician's experiences in managing the patient with VLU.

The second study was a quantitative survey of clinicians treating VLU in the UK, USA and Germany with the objective of understanding their practices, beliefs and challenges.

For both studies, third party country research providers carried out the data collection according to best practice conventions in each country. The research sponsor was not revealed to the participants. No personal or identifying information was collected by the author or sponsoring institution. In accordance with normal research procedures, all respondents gave informed consent.

Study 1: qualitative exploration of the clinician perspective of treating VLU

Sample and data collection

Research participants were recruited using a non probability quota‐based technique and reflect a spectrum of clinicians commonly treating VLU in the UK and USA. Recruitment criteria and numbers interviewed are shown in Table 1.

Table 1.

Study 1 recruitment criteria and numbers interviewed

USA		UK
Primary care physicians (PCPs)	7	GPs	6
Home care nurses	3	District nurses	6
Specialist care nurses (including WOCN)	6	Vascular/ulcer specialist nurses	4
Vascular surgeons	6	TVNs	4
Plastic surgeons	5	Vascular surgeons	2
Total	27	Total	22

GP, general practitioner; PCP, primary care physician; WOCN, wound, ostomy and continence nurse; TVN, tissue viability nurse.

In the UK, interviews were held at central facilities in London and Manchester. In the USA, interviews took place in central facilities in Chicago and metropolitan areas of New Jersey. Interviews lasted between 40 and 60 minutes and were audio‐ and video‐recorded and transcribed for analysis.

A single interviewer conducted all the interviews in each country and was guided by a semi‐structured interview guide. Because the research was exploratory, subjects could construct their own narratives and explore the themes important to them. The structure of the interview was as follows:

• •What's the process by which the patient first arrives in your care?
• •Thinking about the overall treatment of VLU, and everything that it involves, what are the challenges and successes?
• •Where there are challenges and how are these dealt with? Who does it impact? How does it impact?
• •Thinking about everything to do with your role in the treatment of VLU; what could be changed/improved that would be a real help to you?
• •What would make your life easier?
• •Why would that make such a difference? What would be the consequence of that change?
• •And how would you feel personally if that was achieved?

Analysis

Primarily, a grounded theory approach was used to establish generalities, patterns and causal attributions from within the data.

Study 2: online survey of clinician practices, challenges and beliefs in relation to VLU

Sample and data collection

The survey was conducted online. Research participants were recruited on a non probability quota‐based approach and were a spectrum of those practitioners commonly treating VLU in the UK, USA and Germany. These included the following:

• •Physicians
• –  Specialists‐Vascular Surgeon, Phlebologist, Dermatologist, Plastic Surgeon
• –  General practitioners (GPs)/primary care physicians (PCPs) (US‐GPs/FPs/IMS; other countries‐general physicians)
• •Nurses
• –  Specialty‐wound, ostomy, incontinence nurses (WOCN) in the USA; tissue viability nurses (TVN) in Europe
• –  Generalists including general practice nurses, district nurses, home health care nurses or nursing home/long‐term care nurses
• •All respondents had to meet the following additional criteria:
• –  Be in practice between 2 and 30 years
• –  Personally treat or manage five or more patients with VLU per month
• –  Be involved in making decisions or recommendations regarding VLU treatments or product use
• –  Have used or recommended at least one of seven specific compression types in VLU treatment in the past 12 months
• –  Have no affiliation with a pharmaceutical or health care company and have not participated in wound care research within the past month.

The sample was as follows:

	USA	UK	Germany	Total
Specialists	51	50	52	153
Vascular surgeons/other	25	25	25	75
Nurse specialists (tissue viability‐TVN and wound, ostomy and continence‐WOCN)	26	25	27	78
Generalists	52	50	49	151
Primary care physicians/GPs	25	25	25	75
Nurse generalist (GP nurses, district nurses, home healthcare nurses and nursing home/long‐term care nurses, etc.)	27	25	24	76
Total	103	100	101	304

Analysis

Data were analysed using a proprietary statistical software package (SPSS, version 10). Significance testing was carried out with the alpha level set at 0· 05. Where analysis of differences between percentages was carried out, a t‐test was used. Where analysis between mean scores was carried out, the z‐test was used. Significant differences are indicated here by superscripts showing differences between columns.

RESULTS

Study 1: qualitative exploration of the clinician perspective of treating VLU

A number of very strong and consistent themes emerged united around the principal theme of ‘frustration’. In all the interviews, clinicians wanted to do the utmost for the patient, yet they expressed an overwhelming sense that there were many factors outside their control. More detailed analysis begins to unravel the clinicians' perceived causes of this lack of control and the potential consequences, both for them and for patient care.

Theme: VLU is hard to heal therefore I am frustrated

All those interviewed conceded that although VLU could be healed, they were difficult to treat. Beyond this acceptance there are a series of consequences for the clinician. At one end of the spectrum, there is the acceptance that VLU are difficult to heal and that the journey to achieve healing will be difficult and have accompanying setbacks, but it will be a worthwhile challenge. However, at the other end of the spectrum, the degree of frustration felt could also manifest itself in a dislike and even avoidance of these patients. These contrasts can be illustrated in the following examples:

We want to see results. We want to succeed. Maybe it will take several steps, but we want to have some progress. These are my patients. It's my responsibility because this patient is coming to me and giving his care into my hands. So there is always discomfort when there is no success, and the patient comes and says, ‘now what?’ I would love to have more to offer patients–to give more hope. I mean that's what a physician needs to do, right? It's objectively to treat, but also to give more hope. (PCP, USA)

Frustration begins to be expressed as disappointment and dissatisfaction.

Disappointed that there is no immediate solution, you feel the patient is not getting the best care, for some surgeons this becomes–I'm not doing my best for this patient–but you have to look at it as I have done all I can (Vascular Surgeon, UK)

Clinicians believe that they cannot offer as much as they would like .This appears to significantly impact their sense of well‐being and their attitude to the patient with VLU.

Theme: VLU ‘an emotional rollercoaster’

Interviews suggest that clinicians expectations are set low, and when things go well the unexpected emotional ‘high’ generated is very rewarding. Nurses in both the USA and UK described this sense.

You feel fantastic… for the patients you empathise and sympathise with what they’ve been going through, their frustrations…… the cycle of infections, five steps back… you go through the ups and downs with the patient. We always have a big hug and a handshake and a who‐hoo! At the end, it's a great feeling. It's some form of emotional catharsis after all the pain and frustration. A job well done, pride, a result, it's why I do nursing, very rewarding. (Ulcer Specialist Nurse, UK)

The joy when it's healed. The other day I went in and saw this leg healed, and I was like, ‘oh my God! I can't believe it's you!’ I didn't really think it would heal, but it did and it was great. Usually, you feel like you’re beating your head against the wall. (WOCN, USA)

For some respondents, the pain and joy of the VLU journey are expressed as a shared venture between the patient and carer and even other health care professionals: relationships are very important.

You can feel very frustrated… but (when it works) it's very rewarding, job satisfaction… doing something worthwhile… the nice thing about the job. You’ve liaised with everyone to get the care (District Nurse, UK)

These findings support other studies exploring the patients' perspective .Patients are highly appreciative of carers when at least some emotional connection was in evidence (7).

In contrast, frequent treatment failures negatively affect clinician self esteem, and for some, leaving at least some of them not wanting to work with the disease. Two aspects reflecting underlying clinician values and motivations begin to appear: for some, the desire to fix and treat the ulcer is foremost; for others, the desire to manage and care is foremost. However, in all cases achieving healing outcomes is important.

Expectations are often determined by the clinicians' sense of professional identity. The division of ‘treat’ and ‘fix’ versus ‘care’ and ‘manage’ begins to appear in some of the interviews. Unsurprisingly, the clinician who sees their role as a fixer experiences greater degrees of frustration with VLU. Conversely, where the focus is more on aspects traditionally more associated with nursing such as caring and relationship formation, VLU are seen as less frustrating. In these situations, a sense of positive engagement and satisfaction can be obtained.

Theme: frustration and compliance: ‘the patient won't help themselves'

Clinician frustration with patient compliance encompassed two areas. First, it is difficult to make patients to follow the treatment requirements to achieve healing. Second, once healing was achieved patients frequently fail to continue with compression leading to ulcer recurrence.

Patients don't elevate their legs, they don't take the medication, they don't come back for their visit, they play with the bandage, and they don't see the specialist I referred them to. (PCP, USA)

Compliance during treatment. They don't go to the wound care centre. If they don't change their dressings, if they don't apply compression stockings, if they don't exercise, if they don't manage their diabetes, all these things are important for healing the ulcer. (Vascular Surgeon, USA)

This is only half the battle. Clinicians find patient compliance a key factor in recurrence:

Healing ulcers is only part of the game, 90% will heal but you can't keep them healed without ongoing commitment (from the patient) (Vascular Surgeon, UK)

It is a cycle. Once you get them to heal, you have to convince the patient that it isn't healed; it's just sitting there under the surface. Even a little bit of a drop in your treatment and soon enough you’re back. (Plastic Surgeon, USA)

Recurrence is sometimes linked to expectations at the outset of the therapy. If the expectation that is established with the patient is aimed primarily at healing the leg ulcer, there may be a failure to establish that this is in fact not the real endpoint. Thus, patients may become less compliant after the wound heals, failing to appreciate that the underlying venous problem remains.

Compliance is also important in gauging when a treatment is working. The physician may assume it is the treatment which is not working when it is the patient who may not be complying with the treatment.

An insight into what drives non compliance suggests that VLU can sometimes becomes the ‘norm’ for some patients, becoming part of their identity and helps them to negotiate a social life 5, 6, 7, 8, 9, 10. This motivation for non compliance can become a particularly challenging facet of managing chronic VLU.

They have had them for years and see coming to clinic as a social event, they meet their friends and they accept it (District Nurse, UK)

The attention becomes a way of life… they are quite lonely (Vascular Specialist Nurse, UK)

They don't want to heal… they become dependent on the nursing service… it's a social visit (District Nurse, UK)

In these interviews, it can be seen that there is often an understanding that patient cooperation and engagement is important to the success of treating VLU. Clinicians frequently describe the patient in terms of what they do not do; that the patient is not behaving as directed. Frequently, this attribution of patient non compliance is cited as the main reason for treatment failure and this is seen in other research 7, 23. However, in these interviews clinicians expressed concern that it is often not clear how to attain ‘patient ownership’ and even if it were, practical constraints of time and resource may make this aim hard to achieve. In addition, if the clinician mindset is more directed at ‘fixing the problem’, a focus on relationships and caring may be harder to embark upon.

Theme: frustration: time and money

The two countries studied operate very different health care systems. As a consequence, although more time with the patient was important in both the USA and UK, issues of finance and reimbursement are significant factors in the minds of US clinicians. In the USA, these financial considerations compound the treatment frustrations of clinicians with complex and often poor reimbursement for the doctor and limited, if any, coverage of medical supplies.

You spend a lot of time with these patients and the reimbursement rate is very low. That's a big frustration. They’re typically Medicare patients. Time spent with these patients you almost treat it as a courtesy. (Plastic Surgeon, USA)

Having more time with patients was identified by respondents in both countries as important, because any intervention to increase understanding, cooperation and ownership would increase compliance and result in fewer problems.

With more time I can fine tweak the situation, listening and discovering aspects of their life that might impact healing. (Ulcer Specialist Nurse, UK)

You are squeezing them in your lunchtime… explanations aren't as full, there's less encouragement, and the message is diluted and… you see them more often! (GP, UK)

If they have better understanding of the disease, they would realize this is not a cure for the disease. It's just a cure for the acute problem they have. They have to understand how we treat it, and how to reduce other risk factors. If they are compliant, they will get better. And then if they come back a year later, they understand it's not really my fault. We don't want somebody out there thinking that this is OUR fault. (Vascular Surgeon, USA)

Some respondents in the USA commented that if there was greater reimbursement for VLU treatments they would probably take more of an interest.

If reimbursement was better, we'd probably invest more time in it. (PCP, USA)

Theme: types of compression

Respondents occasionally mentioned specific products or compression types. It was not so much what kind of treatment was applied but whether the patient could tolerate and comply with it that mattered. Throughout the interviews the thinking around compression therapies did not suggest that there were any clearly differentiated or ‘best’ options.

It's not the specific product. You could use anything for compression–an ace wrap, a 4‐layer wrap, an Unna boot. As long as it's something being used and the patient is compliant, I don't think the specific exact product is that important. (Plastic Surgeon, USA)

Many reflected that treatment practices for VLU have changed little or, if there are new advances, perhaps they simply have not been made aware of them.

You take a step back and think we are still doing the same things (Vascular Specialist Nurse, UK)

Theme: VLU are not exciting

VLU is perceived as more of a nursing issue than a medical one, a comment perhaps relating to the chronic nature of the condition and the patient demographic.

You don't find doctors writing articles in GP magazines about VLU (GP, UK)

Not exactly a thrilling bit of medicine… not a name in the headlines… probably less research than the more glamorous areas (GP, UK)

Results study 2: online survey of clinician practices, challenges and beliefs in relation to VLU

Health care professionals' satisfaction in their ability to treat VLU

We asked respondents about their ‘overall’ satisfaction at being able to treat VLU, and how satisfied they were with different types of compression therapy.

Overall satisfaction at being able to treat VLU averaged 4· 6 on a 7‐point (low–high) satisfaction scale. The proportion of respondents rating satisfaction in the top 2 points of this scale was 21% overall. Thus, although many respondents express mid‐scale or slightly above mid‐scale levels of satisfaction, few express high levels of satisfaction in their ability to treat VLU.

Table 2 shows this data. Few differences are noted on compression types across the different countries apart from:

Table 2.

Rating of satisfaction with the ability to treat VLU with different compression types (% using top two ratings on a 7‐point scale)

Compression therapy type	UK (a)	USA (b)	Germany (c)	Total
Overall satisfaction at being able to treat VLU (irrespective of compression type)	17	24	19	21
Compression stockings	34	37	38	36
3–4 Layer bandage	50bc	18	13	25
2 Layer bandage	30bc	12	8	16
Single layer elastic bandage	7	16	8	12
Unna boot	14	43ac	13	33
Ace bandage	9	27c	5	20
Single layer short stretch (inelastic bandage)	9	18	0	11
Intermittent pneumatic compression (IPC)	11	37	23	30

VLU, venous leg ulcers.

• •significantly greater satisfaction with both two and three to four layer compression bandaging in the UK than in Germany or the USA.
• •Significantly greater satisfaction with the Unna boot and Ace bandaging in the USA than in the UK and Germany.

These differences in satisfaction with compression types broadly mirror the degree to which they are used within each country.

Current practices in VLU and compression therapy

Types of compression therapy used. We asked clinicians to tell us what percentage of patients was treated by them over the last year with different types of compression for VLU only. As shown in Table 3, overall the treatment that the largest numbers of patients receive is compression stockings, but there are differences between countries. For the UK, three to four layer compression bandaging is the most frequently used treatment.

Table 3.

Types of compression therapy used

Compression therapy type	UK (a)	USA (b)	Germany (c)	Total
Compression stockings	33	40	41	39
3–4 Layer bandage	40bc	14	15	21
2 Layer bandage	23c	16	11	16
Single layer elastic bandage	9	11	24ab	14
Unna boot	<1	20ac	5	11
Ace bandage	<1	19ac	2	10
Single layer short stretch (inelastic bandage)	4	10a	10a	9
Intermittent pneumatic compression (IPC)	<1	10a	5a	6

N.B.: Percentages add up to more than 100% because many patients may receive multiple types of therapy. VLU, venous leg ulcers.

First line choice of therapy and the need to use second line therapies

When the patient fails to achieve satisfactory healing with the first line of therapy the clinician may select an alternate form of compression. Table 4 shows the proportion of patients for whom the clinician belieive they achieve satisfactory healing using each of these therapies as their first line of treatment.

Table 4.

Percentage of patients that achieve satisfactory healing

Compression therapy type	Proportion of patients with VLU that achieve satisfactory healing (%)
	UK (a)	USA (b)	Germany (c)	Total
Compression stockings	57b	43	57b	50
3–4 Layer bandage	72bc	49	49	59
2 Layer bandage	58b	34	50	46
Single layer elastic bandage	50	22	52b	47

N.B.: Only these treatment types are indicated here as small base sizes mean that data on this question is limited. VLU, venous leg ulcers.

The need to move to a second line of therapy is indicated in the Table 5. In all therapy types, there are a sizeable proportion of patients that require a second line of therapy.

Table 5.

Proportion of patients on each type of compression therapy that clinicians estimate will have to go to a second line of therapy

Compression therapy type	Proportion of patients with VLU (%)
	UK (a)	USA (b)	Germany (c)	Total
Compression stockings	40	39	35	38
3–4 Layer bandage	29	49a	38	37
2 Layer bandage	28	54	52	43
Single layer elastic bandage	50b	19	49b	44

VLU, venous leg ulcers.

These results show that for the USA and UK, the treatment most likely to result in healing is three to four layer bandaging, but even then the outcome is variable. In the UK, only 72% of patients will heal with multilayer compression and 29% of patients will need to try some other form of compression. In the USA, the picture is even more pronounced; with three to four layers being stated as the most effective first line of therapy, it only achieves 49% of patients healed with the same number again needing a second line of therapy.

German clinicians consider compression stockings to be the most effective first line therapy. However, the proportion of patients that clinicians believe as achieving satisfactory healing is low. In Germany, 57% of patients treated with compression stockings are judged to have achieved satisfactory healing and 35% will need to use a second line of therapy.

Overall, many patients do not achieve satisfactory healing at the first attempt and many are switched to a second compression type.

Challenges in treating VLU

From a list of 16 treatment challenges listed in Table 6, participants were asked to pick the five biggest facing them in treating VLU.

Table 6.

Proportion of clinicians who selected the following statements as top five challenges relating to VLU

Challenge in treating VLU	% of clinicians who chose each challenge as one of their top 5
	UK (a)	USA (b)	Germany (c)
Patient compliance	60	79ac	52
Dealing with oedema	57	50	56
The chronic nature of VLU and a lifetime of care	59c	49	30
Effective dressings	45	28	46
Exudate management	54b	21	51b
Time taken to apply compression	40	32	37
Overall cost of treatment	17	41a	34
Variability of care in home care settings	22	37c	17
Dealing with the underlying chronic venous insufficiency	35c	29c	12
Indolent wounds	29b	13	39b
Reimbursement of products	4	37ac	13
Level of patient education	19	19	24
Quality of evidence base	18	16	11
Communicating with other health care professionals	9	6	20b
Learning about new advances	10	9	13
Ensuring the patient sees the same clinicians over time	16c	9	4

VLU, venous leg ulcers.

Overall, the top three were, ‘patient compliance’, ‘dealing with oedema’ and ‘the chronic nature of VLU/a lifetime of care’. Clinicians reported that on average 57% of patients were compliant with compression therapy and that 39% of patients suffered from recurrent ulceration.

Another four challenges (effective dressings, exudate management, the time taken to apply compression and the overall cost of treatment) were chosen by between 33% and 37% of the respondents.

Overall, the UK and Germany are broadly similar in the profile of challenges selected. In the USA, cost of treatment, reimbursement and variability of care in the home care setting are more prevalent issues, reflecting the findings from the qualitative study.

Challenges in the use of compression therapy

Clinicians were given a list of 11 compression therapy challenges shown in Table 7 and were asked to pick the leading five facing them. The top challenges identified were ‘getting precise pressures', ‘combining wound care with compression’ and ‘reduction in oedema thus reducing effective compression’.

Table 7.

Challenges facing clinicians in treating VLU

Challenge in the use of compression therapy	% of clinicians who chose each challenge as one of their top 5
	UK (a)	USA (b)	Germany (c)
Getting precise pressures	53	48	64
Combining wound care with compression	57	47	48
Reduction in oedema thus reducing effective compression	43	40	69ab
Finding the most appropriate compression for a particular patient	46	50	36
Lack of patient motivation	30	58ac	29
A fear of having too high/low level of compression	57b	31	43
Time taken to apply compression	66bc	21	30
The need for high level training to apply compression	44	36	34
Bulkiness of bandages	42c	41c	15
Large differences in leg shapes and sizes	29	30	29
Portability of compression devices	2	39a	26a

VLU, venous leg ulcers.

Information sources

The major informational sources found useful in treating VLU are shown in Table 8. The information sources chosen by the greatest proportion of respondents are ‘peers’, ‘journal articles' and ‘conferences’. In this instance, respondents could select as many or as few of these information sources as they deemed appropriate. It is interesting and worth noting that overall two thirds of clinicians did not think that randomised controlled trials were important or useful.

Table 8.

Major informational sources useful in treating VLU

Sources of information important/useful in clinical treatment of VLU	% of respondents
	UK (a)	USA (b)	Germany (c)
Peers	68	57	77a
Journal articles	81bc	58	50
Conferences	43	59c	30
Patients themselves	36	29	50b
Sales representatives	35	34	42
Randomised controlled trial results	35	26	43
Case studies	29	22	47b
Key opinion leaders	45c	28c	<1
Physiology studies	12	13	23
Web sites	22c	14	3
Associations	4	14	17a
Journal advertisements	11	9	5
Other sources	7c	3	0

VLU, venous leg ulcers.

DISCUSSION

These studies give an insight into the clinicians' experience in dealing with VLU. Expectations of timely and consistent healing are frequently low. The large number of variables involved in the successful healing of VLU, uncertain outcomes, the anticipation of a protracted period of therapy and the often limited degree of control that clinicians have resulted in frustrations and dissatisfactions.

Broadly, this research showed the following clinician insights:

• •The ulcer and the underlying chronic venous insufficiency are acknowledged as difficult to treat and determining the best approach is not straightforward
• •Many clinicians feel dissatisfied with the care that they can provide for patients with VLU
• •Current compression therapy is not uniformly effective
• •There is inconsistency in the outcomes delivered by compression therapies
• •There was little sign of common treatment approaches or the emergence of any single ‘standard’
• •In line with previous research 19, 22, 24, 25, 26, 27, 28, significant levels of patient non compliance are reported
• •Treating VLU can be a very rewarding experience for the clinician, but this is often the exception. The greatest degree of feedback from clinicians was of an experience that is dissatisfying and frustrating
• •Clinician dissatisfaction relates to the difficulty in overcoming the key challenges they report; patient compliance and motivating/educating them, dealing with oedema and the chronicity of the underlying condition

Current compression therapy treatment

Clinicians viewed the range of current therapies as being broadly similar in terms of their effectiveness. The range of treatments, variation across countries, frequent poor results and need to move to alternate compression therapies are perhaps linked to some broader themes.

Achieving and maintaining precise pressures and combining good wound care practices with compression are challenging. Moffat (29) comments on the variability in pressures delivered by most current compression therapies, a finding echoed in the qualitative aspect of this study; the primary challenge in compression therapy was selected as ‘getting precise pressures'. In addition, the primary information sources in treating VLU are peer to peer. The experiential and often non evidence‐based approach, as Hecke et al. (25) also comments, may account for the great variation in types of therapy used and the degree of unsatisfactory healing often achieved at the first attempt.

The challenge of patient compliance

A significant theme in this and other research is that patient compliance issues are at the forefront of clinicians' minds, both as a challenge and as a source of frustration. Success was principally related to patient participation and compliance.

Much is written in the literature about the nature of patient compliance particularly with compression. Many authors conclude that it is not the task of the clinician to coerce or enforce the unwilling patient 16, 19, 22, 23, 26, 27, 30, 31 but to create a shared venture in which the patient chooses to participate in their therapy. Yet frustration about how to educate and motivate the patient can lead to a situation in which the patient is ‘blamed’ or even pre‐judged in advance for their actual or even predicted lack of compliance (28). In many instances 5, 6, 7, 8, 9, 10, 11, the patient can be passive recipients of care and can feel objectified, quite the opposite of the creation of effective relationships and understanding.

It is accepted that compression therapy which is tolerable to the patient is vital if compliance is to be achieved. This was not strongly acknowledged from the respondents in this research suggesting that calls from authors like Flaherty (11) to shift treatments towards ones that are more socially acceptable may have had, as yet, minimal impact.

The findings from this research suggest that clinicians tend to consider patient compliance in one or more of three ways: first, the patient is simply uncooperative or difficult (7); second, the patient lacks motivation or education because they cannot understand the importance of treatment compliance; third, the clinician is limited in terms of time or expertise in how to increase compliance. These differences of view were expressed in the nature of the respondents' comments and the language used. In contrast, ‘They don't…’ with ‘Need to get their commitment' through to ‘The patient is part of the team’. The latter concept is considered in depth by Kyngas et al (30) who described ‘the spirit of cooperation’ as being the optimal route in encouraging compliance.

Given the frustration in treating VLU and the challenge of patient compliance, how can clinicians educate and motivate the patient? Perhaps, a key is a better understanding of the patients' perspective 19, 28, 30. However, the time and the resources available to clinicians frequently constrain them in this endeavour (25).

Although it appears that the challenge of compliance is related to patient understanding and motivation, it can also be argued that it relates to caregiver understanding and motivation (as well as time and resource) in order that the patient is ‘part of the team’. The frustrated and de‐motivated caregiver is likely to find engagement with VLU patients less satisfying. Satisfaction with managing the patient with a VLU is likely to relate to a common set of features described more fully in research into task and workplace motivation 32, 33, primarily: a desire to help, care and feel a sense of productive relationships, the need for a sense of achievement and self validation.

The uncertainty of VLU

This research suggests that there is considerable variability in treatment approaches and outcomes for venous ulcers. Other studies also confirm that clinicians use a range of treatment options as first line therapy and then often have to move to alternative therapies. As others have commented, VLU treatment is not as standardised as it perhaps could be (25).

Clinicians express frustration and uncertainty and identified feelings of hopelessness when it comes to treating VLU. As others have suggested 32, 33, a difficult task combined with uncertain outcome and many factors outside the clinicians' control will be frustrating and demotivating, which in turn could lead to less than ideal outcomes for the patient.

The needs of the clinician

The needs of the clinician need to be considered if they are to be motivated in helping the patient achieve that same state.

In this study, clinicians spoke of frustrations. Despite doing the best that they could, they were frequently not rewarded with the personal satisfaction of achievement. Achievement is related to two concepts: the reward of personal relationships and caring for the patient, and the reward of achieving results in a timely and consistent fashion. This finding is consistent with much of the research into clinical motivation 32, 33 Bringing greater control and certainty back to the clinician through product improvements, education and effective tools and strategies to engage and motivate the patient are consequently likely to be energising factors for the clinician dealing with VLU.

VLU as ‘delegated’ to nursing

Although often unsatisfactory for many clinicians in terms of the ability to treat, fix and heal, the ability to care for a patient and share in that experience can exist in VLU. The observation that the satisfactions in VLU tend to align more with attributes traditionally associated with nursing as opposed to medicine or research may be a factor in the physicians' perception that VLU are not interesting and research in the field is limited. Hicks (34) comments that the ‘characteristics demanded by high quality nursing are diametrically opposed to those required by research, such that research activities may be perceived to be inappropriate within the traditional nursing role’. In addition, Aston et al. (35) comment that much of wound care in general is ‘delegated’ to nursing.

CONCLUSIONS

Treatment of VLU in the UK, North America and Germany is associated with a wide range of challenges and often uncertain outcomes. These factors contribute to clinician feelings of dissatisfaction, frustration and demotivation. The lack of consistent and predictable healing outcomes can make clinicians feel that they are not offering the best they can in terms of care.

For this picture to change a number of improvements in health care provision for VLU are necessary. First, compression products themselves have evolved little over time and are known to be inconsistent in their delivery of correct and sustained therapeutic pressures. Second, the patient is central to the healing process, and their compliance with therapy is closely linked to their understanding and motivation to wear the compression products consistently. However, clinicians may not currently have the time, the means or the motivation to be able to obtain this level of patient cooperation. Arguably, even if they did, patient compliance may relate to many other factors 19, 22, 26, 27, 30 such as the social impact that current compression therapies have on the patient in restricting their abilities to participate in and enjoy everyday activities. Third, how well are health care systems actually serving the patient and the clinician? Clinicians report that little time is available to give to patients and in the USA they report financial pressures. In all cases, such a wide range of therapy choices implemented differently in different places suggests little standardisation or agreement on what is the best approach. Although many papers have focussed on the patient perspective in VLU, our research suggests that treatment of this condition can often be frustrating for the clinician. New approaches to therapy, patient concordance and health care systems may reenergise the approach to this chronic clinical problem.