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Wound Management in Vulnerable Populations
While wound management is a significant challenge for many rehabilitation patients, vulnerable populations are at particular risk. In addition, considerable focus is being placed on vulnerable populations within health care. Rehabilitation nurses should understand issues related to working with vulnerable patients with wounds, including poverty and payment for care, culture, and literacy. Nursing research to advance the care of individuals from vulnerable populations requires a special approach designed to establish the integrity of the research and gain the trust of potential participants.
Wound management is a significant challenge for many rehabilitation clients, and vulnerable populations are at particular risk for skin breakdowns that may be difficult to treat. Vulnerable populations include those who are subject to violent trauma, engage in illicit injectable drug use, and who are immobile. Violent trauma causes wounds that may need surgery. Injectable drug use increases the risk of abscess formation for which incision and drainage may be needed, and occurrence of venous ulcers, particularly among young people. Immobility, and a lack of knowledge about or assistance in preventing pressure ulcers, increases the risk for pressure ulcer development.
There is currently considerable focus on vulnerable populations within health care. Vulnerability is the degree to which a system is likely to experience harm due to exposure to a hazard (Turner et al., 2003). Vulnerability comes from the Latin word vulnare, meaning “to wound” (Leffers et al., 2004). Vulnerable populations have been identified as people of color, people living in poverty, and/or people marginalized by sexual preference, immigrant status, and religion or creed (Flaskerud et al., 2002), as well as those with less education and those in poorer health (Carlson & Blustein, 2003).
Vulnerable groups often are subjected to discrimination, intolerance, subordination, and stigma; they are marginalized and disenfranchised from mainstream society. They typically have low social and economic status and lack environmental resources. The central constructs of vulnerable populations are poverty and payment for care, culture/race, and literacy in terms of wound care. Eeach construct implies considerations for the rehabilitation nurse that can be applied to a professional role or in work environment.
Poverty and Payment for Care
Poverty and payment for health care are serious issues affecting wound care that need to be examined by rehabilitation nurses. The number of adults without health insurance is increasing in the United States (Baker, Sudano, Albert, Borawski, & Dor, 2001). Patients without health insurance have greater difficulty obtaining care than those with insurance (Blanchard, Haywood, & Scott, 2003). Persons who lack health insurance often lack a primary clinician, have greater unmet health-related needs, have increased risk of a decline in overall health, and experience higher rates of hospitalization. For wound care, these circumstances mean patients are more ill and wound healing may be more difficult to achieve. A major dilemma in health care is, “Who will accept the poor?” For wound care, it is, “Who will provide wound care to the poor, especially long-term, chronic wound care?”
Poverty and vulnerability occur in both rural and urban settings. Rural older adults tend to have less access to healthcare resources, and more unmet health needs, and therefore, an increased risk of poorer health (Clark & Dellasega, 1998). Rural residents often are dependent upon family members and friends for management of their illnesses (Leight, 2003), including wound care. When they are involved in wound care programs outside the home, the distance rural clients may need to travel to access wound care may be great and decrease the chances they will complete the program, thus impairing the healing process.
More than 75% of Americans live in urban and suburban areas (Fleischman, Levin, & Meekin, 2001; Leviton, Snell, & McGinnis, 2000). Urban centers are places of complexity, diversity, and heterogeneity. Urban hospitals are faced with trying to provide care while confronting multiple challenges, including (a) inadequate payment for care of the poor and uninsured, (b) patients with high-cost illnesses, AIDS, substance abuse issues, and psychiatric illness, who may face violence and/or homelessness in the community, and (c) lack of community-based alternative care for referral (Connors, 1990). Like all services provided by urban hospitals, these challenges affect the types of wound care services that can be offered.
For economic or mental health reasons, homelessness is a worldwide problem affecting both urban and rural dwellers. Since many shelters restrict entry, the homeless live in bus stations, abandoned buildings, encampments, and similar areas. Homeless individuals report greater difficulty accessing care, adhering to the treatment regimen, and understanding instructions (Trevena, Simpson, & Nutbeam, 2003). The homeless are at risk for many types of wounds, but they lack resources for wound care, have poor nutrition, feel embarrassed to go to wound care clinics, and may experience negative attitudes from clinicians.
Considerations for Rehabilitation Nurses
Rehabilitation nurses need to examine wound care services for vulnerable individuals in terms of access, cost, and community resources. Interventions often fail to reach those most disadvantaged. Nurses must be aware of health insurance programs offered in their community and learn how to help patients apply for or use these programs. The application process for health insurance may be cumbersome and complicated. Forms may be difficult to read and understand. The wait in the social service department may be long. Therefore, nursing involvement may be needed to encourage patients to complete the process.
Patients ask many questions about their health insurance. Therefore, rehabilitation nurses also should know what health care is allowed within a given insurance program. Such an understanding can help nurses know what types of wound care products are allowed, how the patient is to access wound care supplies, if home care is an option, and how frequently the patient may come to the clinic for wound care. Pharmaceutical products for wound care may be restricted to a formulary. Rehabilitation nurses or case managers may need to telephone the insurance carrier for authorization for dressing supplies, medications, and medical equipment. Although the process can be time-consuming, it is critical for treatment of the wound.
Rehabilitation nurses have a role in helping to develop wound care clinics for vulnerable persons based upon knowledge of the community. Clinic services should promote wound prevention and early treatment by teaching patients the components of skin health and providing skin assessments during each visit to identify wounds. Rehabilitation nurses also should be aware of organizations, such as church, military, stroke, spinal cord injury, and cancer groups, that may provide dressings and wound care, visit homebound patients, support caregivers, and help with the coordination of services. The use of trusted social institutions and social networks helps to promote programs and ensure their continuance (Wolff et al., 2003). Wound care provided in a coordinated manner with community agencies is helpful to patients and their families, who feel such coordinated assistance will better help them with answers to questions and supplies provision.
Good nutrition affects skin condition by providing the nutrients needed for healthy skin and proper healing, but persons belonging to a vulnerable population may lack proper nutrition because they lack money to purchase food, outlets to purchase or obtain it, or means to reach stores or soup kitchens. Clinical manifestations of malnutrition can be overlooked. Therefore, rehabilitation nurses must conduct a nutritional assessment. Nurses should calculate a body mass index (W/H2 [the weight in kilograms divided by the height in meters squared]). Nurses also should ask a person what he or she typically eats each day and determine whether the diet is sufficient in vitamins and protein for wound healing.
Rehabilitation nurses should be aware of ways nutritious meals can be obtained by vulnerable persons. Free food programs may be available for some indigent patients, depending upon the criteria of the agency. Soup kitchens may provide one meal per day. A list of food programs and soup kitchens, their days and time of operation and requirements for accessing services is very helpful to patients, but challenging to keep current. Depending upon the person’s income, food stamps may be available; the patient needs to work with social services to determine eligibility. Some religious and community organizations have food pantries and provide basic food items in emergency situations and/or on a long-term basis depending upon the patient’s need. Meals on Wheels programs may provide food to immobile patients or to those without transportation; a fee may be associated with the meals.
Dental health also affects what a person eats. Indigent persons frequently cannot afford dental care, and have poor dental health as a result. Again, rehabilitation nurses need to be aware of dental programs in a community that are financially and logistically available to their wound care patients.
Lack of transportation has been found to negatively affect initial and follow-up wound care (Pieper & DiNardo, 1998). Rehabilitation nurses need to be aware of transportation services in a community. For example, does the community offer a free or discounted ride service or bus/subway passes? What are the qualifications to receive a bus/subway pass? Will transportation services accept patients who use wheelchairs or walkers? Are there options for persons who cannot use mass transportation?
To provide good-quality wound care, rehabilitation nurses must be adept at wound, physical, and psychosocial assessments. Wounds should be assessed for causative factors, location, size, depth, color, drainage, odor, pain, and infection. Since chronic illnesses can interfere with wound healing, such illnesses must be evaluated and treated. Mental health problems can affect a person’s ability to follow wound care instructions and a long-term treatment plan and also need to be evaluated for treatment or some other type of intervention. Family information and living arrangements are part of the psychosocial assessment. Who provides the wound care—the patient, family and/or friends? Where is the patient living? If the patient is homeless or temporarily living with friends or relatives, the nurse must be creative in issuing dressing protocols. How many dressings can the person carry or store where he or she is living? Wound care supplies that must be refrigerated should not be prescribed for a patient who does not have a refrigerator.
Cleanliness and sanitation issues in the living environment also must be assessed in terms of dressing storage and location of dressing changes. The home may lack running water or indoor plumbing, or bathrooms may be shared. Because patients at home often clean wounds with tap water, the lack of indoor plumbing may affect the quality of the water used (Pieper, Templin, Dobal, & Jacox, 1999). Shared bathroom facilities may compromise the cleanliness of dressing cleansing and changes. Odor from a chronic wound can be an issue in finding and maintaining housing arrangements; therefore, odors must be minimized when possible. Odor can be controlled by the type of dressing used, frequent dressing changes, debridement of necrotic tissue, and, at times, antibiotics.
Wound pain must be treated. Oral opiate and/or nonsteroidal anti-inflammatory drugs (NSAIDs) are used in outpatient wound care. Patients and families need to understand how to safely use pain medications and to monitor for their side effects.
Culture is an important factor when examining vulnerable groups for wound care. Culture refers to unique language, thought, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, and social groups (Anderson et al., 2003). Culture may affect which symptoms patients choose to report, when they report them, and how they interpret symptoms. Culture may also affect wound care practices patients are willing to undertake. Wolff et al. (2003) identified some cultural barriers that impede cancer care for underserved African Americans, most of which are applicable to wound care: (a) competing priorities, (b) lack of knowledge, (c) culturally inappropriate or insensitive educational materials, (d) mistrust of the healthcare system, and (e) fear and fatalism. People of color and immigrants may believe that healthcare systems look at them as statistics and not as people (Abrums, 2000). They may fear pain, discomfort, and embarrassment. They may lack money for health care. If a person is in the country illegally, he or she may be afraid to seek care due to fear of being deported.
Persons not proficient in English are increasing in the United States because many of them emigrate from non-English-speaking countries (U.S. Department of Homeland Security, 2003). Patients for whom English is a second language—or who do not speak English at all—are less likely to receive empathy from the clinician, establish rapport with the clinician, receive sufficient information, and be encouraged to participate in healthcare decisions (Ferguson & Candib, 2002). Immigrants also may engage in wound care practices from their country of origin, and these practices may differ radically from those used in the United States (Pieper & Caliri, 2003).
Considerations for Rehabilitation Nurses
Rehabilitation nurses need to consider continuously the importance of culturally appropriate care. This consideration may necessitate the development of culture-based staff education programs. Cultural competency training enhances self-awareness of attitudes toward people of different racial or ethnic groups, increases knowledge about unique beliefs and practices, and improves communication skills (Anderson et al., 2003). Training programs may include hosting speakers from the community, giving video presentations, having a culture fair with ethnic food, music, and art are featured, and assigning readings. Culturally specific health care will better address patient’s total healthcare needs and help dispel cultural stereotypes (Leviton, Snell, & McGinnis, 2000).
Patient assessment forms should include culturally specific questions. Patients may have wound care practices that are culturally specific. For example, patients report using iodine, salt, bleach, and whiskey for wound cleansing. They report leaving the wound open to the air for a specific period of time each day so that it can breathe and dry. They may use honey, papaya, sugar, potatoes, and herbal products for wound care (Pieper & Caliri, 2003). It is important to listen, remain nonjudgmental, and determine if the patient’s wound care practices are safe and can be included in the wound care plan. If wound care practices are potentially injurious, rehabilitation nurses should use appropriate strategies to help teach patients appropriate care.
Nurses should consider the definition and meaning of family for different cultural groups. Some persons have large extended families. Extended families can be very helpful and an untapped potential for providing care (Bowser, 1992). In other families, there are fewer persons to support the family unit financially, assist with the care of children and other household activities, and participate in the health and wound care of a family member. Disruption in the home may disrupt wound care. Nurses may try to counsel the patient and family as to how family dynamics are affecting wound care and/or recommend community agencies that may assist them.
Literacy is the ability to read and write. The National Literacy Act of 1991 extended the definition of literacy to include the ability to speak English and solve problems at levels necessary to function in jobs and society. Health literacy is the person’s ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions (Williams, Davis, Parker, & Weiss, 2002). Low literacy has been associated with poorer self-reported health, poorer compliance rates, increased hospitalizations, lack of understanding of preventive care, and increased healthcare costs (Andrus & Roth, 2002; Lee, 1999). Health literacy is a stated objective of Healthy People 2010 (U.S. Department of Health and Human Services, 2001) and is a concern of the Joint Commission on Accreditation of Healthcare Organizations (Andrus & Roth, 2002).
Literacy can affect wound care. Patients may not understand the information or cannot absorb what is being taught, appreciate its relevance, believe it, or decide to act upon it. Persons with low literacy often feel ashamed and embarrassed of this deficiency and/or may have difficulty articulating their learning needs especially when English is not their primary language.
Considerations for Rehabilitation Nurses
Rehabilitation nurses should develop patient wound care literature that is sensitive to the reading level and the language of the population being served. Patients who are informed about their care are better able to manage their health and treatment, have better mental health outcomes, and have fewer exacerbations of their condition (Royal College of Nursing, 2003). Rehabilitation nurses should use an array of teaching methods, including verbal, written, pictures, videotape, audiotape, and computer. A Cochrane review recommended use of both written and verbal information (Johnson, Sandford, & Tyndall, 2003).
Rehabilitation nurses should analyze educational materials about wound care. Written materials need to be evaluated for their reading level and readability, such as the use of simple words, bullets to highlight content, critical content, print size, white space, length, and pictures/illustrations (Winslow, 2001). Pamphlets that are difficult to read are a wasted expense and can contribute to patient dissatisfaction (Lee, 1999).
Rehabilitation nurses should communicate wound care clearly, using interactive teaching approaches and open-ended questions to assess what a patient knows. Nurses should encourage discussion, and be respectful of a patient’s learning level. Nurses need to be careful with the use of medical terminology about wound care because patients may have a limited health vocabulary and difficulty understanding it. Asking patients to repeat what was stated is helpful to reinforce learning and ensure that understanding has taken place. When English is not the patient’s primary language, rehabilitation nurses should work with their institution to make interpreters available. Friends and family members often are not a good choice to act as interpreters because of issues related to confidentiality and patient privacy (Dreger & Tremback, 2002). Interpreters must be educated about medical terminology and trained in ethics and the importance of confidentiality.
For persons who use computers, Internet-based wound information can be a double-edged sword—helpful or confusing. Wound information found on some sites may not be based upon scientific information and may provide confusing, inaccurate information. Patients may need help in finding Web sites that are scientifically sound and up-to-date. Andrus and Roth (2002) present excellent resources for low literacy educational materials, training programs, as well as health literacy Web sites.
Vulnerable Populations and Nursing Research
To advance nursing research, rehabilitation nurses need to include vulnerable populations in their studies. Vulnerable groups may be difficult to recruit for research studies because they fear lack of confidentiality and feel stigmatized by being grouped into a special population. They also may have limited time and energy to participate in research (Anderson & Hatton, 2000). Vulnerable persons may be harmed, manipulated, or coerced by researchers because of their decreased competence disadvantaged status (Sutton, Erlen, Glad, & Siminoff, 2003). The person’s right to decide whether to participate in research must be respected; informed consent in research is essential. The researcher must be willing to listen, demonstrate honesty and reliability, and be flexible (Julion, Gross, Barclay-McLaughlin, 2000). Potential research subjects must be treated fairly (Sutton, Erlen, Glad, & Siminoff). Collaboration between the researcher and the clinician may help to decrease distrust of potential subjects and facilitate recruitment of study participants.
Mr. Smith, a 49-year-old African American, came to a wound clinic because of an enlarging sore on his lower leg. He developed the sore about 6 months before, after he bumped his leg while helping to move furniture. He treats the sore by washing it with tap water and bar soap and trying to dry it out. He obtains wound care products at the emergency department of a nearby hospital. His insurance is through a Medicaid health maintenance organization (HMO). He was sent to the wound clinic by his primary care provider. His health history is negative except for hypertension and hepatitis C. He injected illicit drugs from 1980 to 2000; smokes cigarettes (1 pack per day), a habit he has had since the age of 12; and does not drink alcohol. He lives in a room he rents from a friend and does not have access to a refrigerator or stove. He eats if he has money to buy food. He works when hired by a friend’s moving company.
His wound is located in the region of the right medial malleolus. It measures 10 cm x 5 cm and has a red, crusted base with serous drainage. The wound is without odor, and there is no evidence of granulation tissue or epithelialization. The right lower extremity has evidence of stasis dermatitis, lipodermatosclerosis, hemosiderosis, and edema. Dorsalis pedis and posterior tibial pulses are strong. In the toes, the capillary refill is less than 3 seconds. He has considerable pain by the end of the day, when his leg swells. He has an ankle-brachial index of 0.9. A diagnosis of venous ulcer related to his history of injection drug use is made. The treatment plan requires the use of compression therapy.
Using the information provided about vulnerable populations, the nurse providing wound care for this person would need to consider the following:
Rehabilitation nurses provide care to people who belong to vulnerable populations. Many times these people have an acute or chronic wound. Rehabilitation nurses can be an important resource in wound care by helping their patients to understand their health insurance and the healthcare system, providing patient teaching that takes into consideration literacy level and learning style, developing wound plans that consider cultural issues, and performing complete health assessments. Rehabilitation nurses can learn about cultural aspects of care and participate in community programs to integrate available wound care services. They can participate as researchers to increase nursing knowledge about wound care for vulnerable populations.
About the Author
Barbara Pieper, PhD RN CS CWOCN FAAN, is a professor/nurse practitioner at the College of Nursing, Wayne State University, Detroit, MI, Address correspondence to her at the College of Nursing, Wayne State University, 5557 Cass Avenue, Detroit, MI 48202, or via e-mail to email@example.com
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