Nursing Interventions Aimed at Persons with Venous Ulcers: an Integrative Review*

Objectives: This work sought to identify and describe the theoretical foundations, components, duration, delivery mode, and results of the nursing interventions aimed at persons with venous ulcers as available in the literature. Materials and method: Integrative review between 2000 and 2018 in the Pubmed, Ovidnursing, and EBSCOhost electronic databases. Results: This review includes 16 articles. Most of the interventions were of educational nature; three were developed in the community (through the Leg Club model) and the other ones were delivered by a nursing professional, face to face. The minimum time of duration for these was eight weeks, with telephone follow up. The most-common result variables were venous ulcer healing and reduction of the wound area. Conclusions: Diversity existed in relation with the components of the interventions and the results expected. Report of the interventions must be reinforced, along with the use of nursing theories that support their design.


Introduction
Venous ulcers (VU), also known as varicose ulcers, are open cutaneous lesions that, generally, occur on the medial side of the lower leg, between the ankle and knee, as a result of chronic venous insufficiency and ambulatory venous hypertension. Its healing can take between four and six weeks, after their initial onset (1).
Between 75 % and 80 % of all lower limb ulcers is of venous etiology, their prevalence ranges between 0.5 % and 2.7 %, and increase with age (2,3). It has been estimated that active VU have a mean age of 210 days, with periods of < 1 to > 67 years and up to 70 % recurrence rate within three months after wound closure (4)(5)(6). These aspects turn them into a complex chronic condition, not only for patients and their families, but also to health systems.
The role the nursing discipline has played in caring for these patients has been fundamental to now understand the complexity of living with VU in lower limbs and its negative impact in all the dimensions of the quality of life of the people. The common problems confronted by patients with VU include pain, exudate, odor, limitations in mobility, depression, anxiety, social isolation, sense of sadness, and sleep disorders (7)(8)(9). Venous ulcers, like any other chronic condition, demand long-term nursing care, significant changes in lifestyle, and adherence to therapeutic regimes by the patients. These call for using compression therapy for life (the gold standard for caring and managing VU) and prevention and maintenance strategies to avoid recurrence, like leg elevation, weight control, physical activity, skin care, and protection against lesions, among others (10,11).
Due to the aforementioned, recently, nurses have begun to design interventions to investigate if such could contribute in healing, diminished recurrence, or improved quality of life of patients with VU, besides other physical and psychosocial variables. Identifying in the literature nursing interventions available for patients with VU permits knowing the elements that compose them and how these produce beneficial results. Hence, the objective of this review is to identify and describe the theoretical foundations, components, duration, delivery mode, and results of nursing interventions aimed at persons with VU as available in the literature.

Materials and Methods
Integrative literature review based on the method proposed by Whittemore and Knafl (12), which includes the following stages: The inclusion criteria were: 1) articles published in indexed journals; 2) descriptive, experimental, and quasi-experimental studies developed exclusively by nursing; and 3) articles clearly presenting the development or implementation of the intervention. The work included reviews, Masters and PhD theses, unpublished articles, as well as studies centered on diagnostic methods or intervention studies with laboratory products or pharmaceutical companies.
3. Data assessment: during this stage, seeking to estimate their methodological quality, the critical reading was made of the articles selected, under criteria proposed by the Joanna Briggs Institute (13). Consequently, the reviewers examined the titles independently, in function of the abstract, excluding irrelevant studies; thereafter, they selected the articles according to the inclusion criteria and examined each of the articles independently.
4. Data analysis: a work instrument was designed to extract the principal characteristics of the studies included in the analysis. The instrument was composed of the following sections: 1) identification data of the study, author, year, and country; 2) study objective; 3) study design and sample; 4) description of the intervention: type of intervention, theoretical foundation, components, duration and delivery mode; and 5) intervention result variables. For their classification according to their level of evidence, the work followed the criteria proposed by the Joanna Briggs Institute (13). The final stage of the review describes the findings through the synthesis of the information and is presented hereinafter.

Results
According to their content, 207 studies were found, of which 42 were discarded due to duplication in the databases; then, the titles and abstracts of the remaining articles were revised, according to the inclusion and exclusion criteria; finally, three reviewers, through consensus, kept 16 articles in the review.
According with their design, the studies were: quantitative, randomized clinical trial type (10); pre and post-test with a single group (3); quasi-experimental (1); prospective with control group (1); and comparative (1). Levels of evidence prevailed in levels I and II (Table 1).
The 16 articles included 1249 patients from different community nursing care centers, outpatient injury and dermatology clinics, and care services to patients with tissue disturbance in university hospitals. Among the participants, female sex had the highest prevalence, and age ranged between 54 and 80 years.

Target population
Herein, 100 % of the interventions were aimed at patients with VU; their relatives or caregivers were not considered.

Type of intervention and theoretical foundation
Of the 16 interventions found in the studies, 11 were educational (14-24); among these, four promoted the development of progressive resistance exercises (14,18,19,21); two, of clinical characteristics, evaluated change in the quality of life of patients receiving a system of four-layer and short stretch compression bandage; and three were community type (25,26).     -Intervention: educational, of behavioral change.
-Components: education on resistance exercises of lower limbs (walking); record of exercises and education on behavior changes; telephone follow up (6 calls from 10 to 15 minutes); adherence to the program. -Time to heal the wound and its area through digital planimetry.

González A, 2014, The United
States (20). II Design of a single group with pretest and post-test n = 30 patients -Intervention: educational.
-Components: development and progress of the disease, self-care activities to favor healing the venous ulcer and prevent its recurrence.
-Material: guide and booklet with information regarding the intervention components.
-Place: homes of patients with venous ulcers attending a center specialized in wound care.
-Follow up: via telephone, during 30 minutes on weeks 2 and 9, from recruitment.
-An ad-hoc check list that measured the process of the disease and self-care activities.
-Healing the venous ulcer.
Author, year, country The cognitive social theory by Bandura supported four educational interventions (14,18,22,24). Two studies added elements from the goal setting theory by Locke, besides using the motivational interview by Miller and Rollnick as technique to facilitate behavioral change among participants during their meetings (22,24).
The three community interventions proposed were based on the so-called Leg Club care model, which proposes that wound care take place in an informal setting (nonclinical), owned by the community (like community halls), which promote social interaction, support among peers, information exchange, health promotion, education, and continuous care for all age groups with problems related with their legs (27-29) ( Table 1).
The community interventions (27)(28)(29) included assessing the health status, measuring the ankle-arm index, treating the VU, applying a short stretch compression bandage system, counseling and support regarding VU, follow up and attendance to the community's Leg Club. All the interventions considered an essential clinical element, which was the clinical evaluation of the wound area (Table 1).

Delivery mode and duration
All the interventions took place face to face; however, 13 were delivered individually, and three collectively (27)(28)(29). Four studies had telephone follow up with the participants (14,17,18,20). The first made six calls from 10 to 15 minutes to reinforce development of resistance exercises (14); the second indicated regular telephone follow up during the first, fourth, and last week, without stipulating the time (16); the third made calls only when the patient required it (18); and the fourth indicated that the two monitoring were of 30 minutes (20).
Based on this integrative literature review, the recommendation is to strengthen the design and report of the interventions in this specific area of nursing knowledge. For this, entities exist, like the Medical Research Council, which offers guidelines for their construction, or the Template for intervention description and replication (TIDieR) checklist and guide (30), among others.

Discussion
The objective of this review was to identify and describe the theoretical foundations, components, duration, delivery mode, and results of nursing interventions aimed at persons with VU available in the literature. The findings described confirm the variety of nursing interventions seeking to improve care and potentiate care aimed at this population.
Although most of the interventions were educational, few mentioned the theory, concepts or proposals that guided their construction. The use of conceptual models and nursing theories facilitate understanding common problems in the practice from a unique perspective. This permits testing disciplinary knowledge, demonstrating positive results in the health of individuals, and acquiring autonomy and jurisdiction in the practice (31). As reported with the use of the nursing care model for patients with VU in Australia, denominated Leg Club, this model is based on the community; patients are treated collectively while operating without prior schedules, and incorporating a well leg regime, a preventive education and counseling program, once the ulcer heals. Its objective is to empower patients and turn them into participants in their treatment, through modification of behaviors that diminish the recurrence of VU (32)(33)(34). It has been recognized as a viable, replicable, and profitable model in The United Kingdom, Australia, and other European countries (35).
In terms of the components of the interventions, the promotion of physical activity and exercise was the central theme of the studies where it was prescribed and patients were motivated to walk and elevate their legs. Evidence exists that demonstrates the positive effect of exercise in improving the calf muscle pump function and its subsequent effects on healing VU, besides their use as complementary therapy to compression systems that, until now, are considered the gold standard in treating these types of chronic wounds (36)(37)(38)(39)(40). More than 50 % of the authors considered wound assessment an essential component and a positive effect of their interventions (14-19, 21, 22, 26-29).
The delivery mode was face to face; 15 studies conducted follow up, but only four specified that it was via telephone, and its objective was to reinforce the education taught (14,16,17,20). Systematic literature reviews have validated the efficacy of telephone support in interventions developed by different health professionals and have reported positive results in patients, like quality of life and reduced rates of hospitalization and costs in health systems (41,42). Consequently, the telephone calls could be a useful tool and more effective than other communication devices to offer care to patients with VU, considering that mobility impairment is one of the most common negative effects in this population.
The time invested in delivering the interventions is paramount in identifying cost-effective nursing practices. Notwithstanding, few mentioned the specific time invested in each session with patients and their follow ups. With regards to the support mate-rial, only one study used multimedia presentation (23). Probably, the use of digital media results problematic for elderly patients, who often lack the knowledge and skills needed to use electronic resources (43). However, eHealth literacy interventions could offer an opportunity to the elderly with VU, by permitting access to resources, like electronic health records, on-line support groups, and self-management tools that guide patients to solve habitual problems, make informed decisions, and communicate with health providers (44,45). Likewise, involving relatives and caregivers would contribute to the identification, follow up, and timely control of complications related with the venous ulcer (46).
With respect to the result variables, two aspects are highlighted; the first has to do with the psychometric properties of the instruments used to measure the result variables proposed, given that only four studies did so, and most of the scales used were not specific for patients with VU. This could be explained by the limited number of specific instruments available for patients with VU. Concretely, six instruments have been identified for this type of population, but such have demonstrated poor criterion and construct validity. Additionally, generic questionnaires, like the EQ-5D and the SF-36 of quality of life evidenced weak response capacity, or did not support their use in patients with VU (47). These aspects would have important repercussions on the validity of the data reported. Secondly, the fact that clinical aspects prevail, like wound healing and the healing process against other variables. Empirical evidence exists that holds that wound healing processes are complex, and these affect physical, psychological, and even sociological factors, in favorable or unfavorable manner (5,(48)(49)(50)(51)(52)(53). With this, it must be stated that, although the clinicaltype variables as objectives are important, including behavioral variables is also important. It is likely, in many cases, to achieve significant behavioral changes, but not clinical in the short term.
In consequence, it is not possible to rule that a nursing intervention is effective if it did not manage to get patients with VU to heal their wounds in a given time, but it is possible perhaps if it contributed to improving they experience and cope with this chronic health condition. Thus, the question would be if it is pertinent to establish as results only clinical variables in this type of population.

Limitations
The articles included were published only in English, so that studies in other languages and contexts could ratify or contradict the way the interventions are developed and the results expected. The lack of specific instruments for patients with VU and the use of other generic questionnaires without satisfactory validity tests could limit the interpretation of the results. This review did not include in its search interventions aimed at caregivers or relatives of patients with VU.

Conclusions
The findings presented in this integrative review permit identifying the existence of few nursing interventions aimed at persons with VU, although it is a chronic condition that tends to increase its incidence and prevalence. Unfortunately, less than half of the studies mentioned the theoretical foundation supporting the intervention, and those which did so did not expose which concepts or propositions were selected as guides in their development. Diversity existed regarding the delivery time of the intervention and the dynamics of the face-to-face meetings, as well as the follow up carried out. Few studies reported the thematic content of their interventions, a fact that limits understanding if these generate impact or not on the primary results established, with the priority being the venous ulcer healing. It is considered necessary to rethink the approach of nursing interventions in this area of knowledge, given the prevalence of people as holistic beings, and the object of nursing is that of caring for the human health experience.
Conflict of interests: none declared.