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When a leg ulcer becomes chronic : a phenomenological study of the older adult’s experience of living… Liebelt, Kathleen S. 1993

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WHEN A LEG ULCER BECOMES CHRONIC: A PHENOMENOLOGICALSTUDY OF THE OLDER ADULT'S EXPERIENCE OF LIVINGWITH A CHRONIC VENOUS LEG ULCERByKATHLEEN SUSAN LIEBELTB.S.N., University of British Columbia, 1984A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIESThe School of NursingWe accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAAugust, 1993© Kathleen S. Liebelt, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Department of  NtLys,."9.The University of British ColumbiaVancouver, CanadaDate  //U.guiji- 30, /9Q3DE-6 (2/88)iiABSIRACTWhen A Leg Ulcer Becomes Chronic: A PhenomenologicalStudy Of The Older Adult's Experience Of livingWith A Chronic Venous Leg UlcerChronic venous insufficiency has been recognized as one of the most commonhealth problems experienced by the older adult. Unfortunately, an all too frequentcomplication of this circulatory disorder is the development of a venous leg ulcer.Chronic venous leg ulcers can have a negative impact on the general well-being of theolder adult and costs to the health care system associated with the treatment of chronicvenous leg ulcers are substantial.A review of the literature revealed that no qualitative research studies have beenconducted in relation to the older adult's experience of living with a chronic venous legulcer. Rather, there are a few anecdotes in relation to the venous leg ulcer experiencethat have been written from a health care professional's perspective. Thus, in thecontext of chronic venous leg ulcers, the explanatory model of the client has not yet beendocumented.The purpose of this study was to gain an understanding of the chronic venous legulcer experience from the perspective of community-dwelling older adults. Thephenomenological approach to qualitative methodology was used for this study. Thisapproach seeks to describe human experience as it is lived. Six individuals, over sixty-five years of age, agreed to participate in this study; they were currently being seen orhad been seen on a regular basis by a home care nurse for treatment of their chronicvenous leg ulcers. Participants were each interviewed twice and these interviews wereguided by open-ended questions. Analysis of the data revealed that participants movedHithrough three sequential phases of a "living with a chronic venous leg ulcer continuum"as they lived with chronic venous insufficiency and chronic venous leg ulcers. In the firstphase of the continuum, participants experienced the effects of living with their chroniccirculatory disorder. They encountered losses in relation to physical endurance,gratifying activities, companionship, and predictability in their lives. In addition toexperiencing loss, the participants encountered a gain as a result of having a chronicvenous leg ulcer: the emotional support afforded them by home care nurses andhomemakers involved in their care. In the second phase of the continuum, participantsevaluated how significantly their chronic venous leg ulcers had affected their lives. In sodoing, the participants either appraised their leg ulcer as having been detrimental totheir quality of life, or inconsequential with regard to living a satisfying life. The keyfactor that influenced the appraisal that participants made of their leg ulcers waswhether or not their circulatory disorder had impacted on a primary source ofsatisfaction in their life. In the third and final phase of the continuum, the participantscoped with their circulatory disorder in one of two ways. Each participant either "puttheir life on hold" if they had appraised their leg ulcer as being detrimental to them, orthey "got on with life" if they had appraised their leg ulcer as being inconsequential.The implications for nursing practice, education, and research were identified in light ofthe research findings.ivTABLE OF CONTENTSABSTRACT ^  iiTABLE OF CONTENTS ^  ivACKNOWLEDGEMENTS  viDEDICATION ^  viiCHAFFER ONE: INTRODUCTION^  1Background And Significance Of The Problem ^  1Theoretical Framework ^  4Problem Statement And Purpose Of The Study  5Definition Of Terms  6Introduction To The Study's Methodology ^  7Assumptions ^  9Limitations  ^9Summary  10CHAFFER TWO: LITERATURE REVIEW^  11Introduction  ^11Living With A Venous Leg Ulcer ^  11Living With Other Types Of Wounds  15The Stoma Experience  16The Burn Experience  ^19Living With Chronic Illness  ^21Aging And Body image ^  23Summary ^  24CHAPTER THREE: METHODOLOGY ^  26Introduction  ^26Selection And Recruitment Of Participants  ^26Selection Criteria  ^27Recruitment Procedure ^  29Characteristics Of The Participants  ^32Data Collection  ^35Data Analysis  ^40Scientific Adequacy Of The Research  ^41Credibility And Fittingness  ^42Auditability  ^43Ethical Considerations  ^43Summary ^  46VCHAPTER FOUR: FINDINGS AND INTERPRETATION ^  47Introduction  ^47Experiencing The Effects Of The Chronic Venous Leg Ulcer ^ asEncountering Loss  ^49Loss Of Physical Endurance ^  49Loss Of Gratifying Activity  ^50Loss Of Companionship  53Loss Of Predictability  ^54Encountering Gain  ^55Evaluating The Significance Of The Chronic Venous Leg Ulcer ^ 58Appraising The Chronic Venous Leg Ulcer As Detrimental ^ 59Appraising The Chronic Venous Leg Ulcer As Inconsequential . . ^ 65Coping With The Chronic Venous Leg Ulcer^  70Putting Life On Hold  ^71Getting On With Life  ^73Summary ^  74CHAPTER FIVE: DISCUSSION OF THE FINDINGS ^  77Introduction  ^77Appraising The Significance Of The Chronic Venous Leg Ulcer ^ 83Coping With The Chronic Venous Leg Ulcer ^  87Summary ^  91CHAPTER SIX: SUMMARY, CONCLUSIONS, AND IMPLICATIONS ^ 94Summary ^  94Conclusions  ^96Implications For Nursing  ^97REFERENCES ^  104APPENDIX A  109APPENDIX B ^  110APPENDIX C  113APPENDIX D^  114APPENDIX E  115viACKNOWLEDGEMENTSMy sincere appreciation is extended to all of the individuals who agreed toparticipate in this study. They gave so generously of their time and energy so that othersmay benefit from their experience.My heartfelt thanks go to the home care nurses at the Burnaby HealthDepartment who did a wonderful job in assisting me with participant selection. A specialthanks to Susan Lanyon and Maureen Holley for enthusiastically supporting thisresearch and for their words of encouragement.I could not have asked for a more supportive and caring thesis committee. Tomy chairperson, Sally Thorne, thank-you for sticking by me no matter what. Yourstrength gave me strength, your words of encouragement inspired me, your belief in memade me believe in myself. Words cannot convey the depth of my gratitude. To RayThompson, thank-you so much for your expert counsel and for your incredible patience.I especially appreciated your easygoing manner and your wonderful ability to stay calmwhen things seemed to be a little crazy. I would also like to extend my thanks to GloriaJoachim for her valuable insights and for her support of this endeavour. And to CarolJillings, thank-you so much for caring enough to go the extra mile for me under verydifficult time constraints and for making every effort to put me at ease in a most unusualsituation.To my friends and colleagues at Douglas College's Department of PsychiatricNursing, I wish to express my sincere appreciation for their good wishes and words ofencouragement. A special thanks to Carol, Anna, and Lori for helping me "keep it alltogether" and for their support and reassurance.I am grateful to my friends for waiting so patiently for me to complete this thesisand for their understanding and support. I would like to especially thank Phyllis Huntfor her tremendous support during this long journey.Finally, I would like to thank my family for always being there for me. Dad,Mom, Karen, Brett, Tippy, Shelley, and Gramps, your love and support sustained me.You truly are my greatest blessing and joy in life.For Sally,who always believed in me.VII1CHAPTER ONEINTRODUCTIONBackground And Significance Of The ProblemChronic venous insufficiency of the legs has been recognized as a significanthealth problem in the general adult population (Coon, Willis & Keller, 1973; Lamont,1991) and as one of the most common health problems experienced by the older adult(Fitzpatrick, 1989). An estimated 5.9 percent of older adults in the United Statesexperience chronic venous insufficiency of the legs (Beauregard & Gilchrest, 1987).Unfortunately, an all too frequent complication of this circulatory disorder is thedevelopment of a venous leg ulcer (Fitzpatrick, 1989; Kunimoto, 1991; Prebble, 1990).Although writers such as Fitzpatrick (1989), Kunimoto (1991), and Prebble (1990)have noted that venous leg ulcers are a frequent occurrence in North American andEuropean adult populations, it is difficult to grasp the actual prevalence of this conditionfor a number of reasons. First, published estimates of the prevalence of venousulceration are few and the estimates that are available paint a confusing picture. Morespecifically, a search of the literature resulted in two greatly differing estimates of theprevalence of venous leg ulcers. David (1986) approximated the prevalence of venous legulcers in the general North American population as ten percent. Coon and colleagues(1973), in an earlier study conducted in the United States, found that between 0.1 and0.3 percent of their study population experienced venous ulceration. Similarly, Lamont(1991) estimated that between 500,000 and 850,000 individuals in the United States, orapproximately 0.2 percent of the population, have venous leg ulcers. Coon and2colleagues (1973) have also noted that it is difficult to accurately estimate the incidenceand prevalence of venous related conditions.Another reason for uncertainty in relation to the prevalence of venous leg ulcersis that a number of researchers have published estimates which group both arterial andvenous leg ulcers in the estimate (e.g., Callam, Ruckley, Harper & Dale, 1985; Dale,Callam, Ruckley, Harper, & Berrey, 1983; Prebble, 1990). In this type of statisticalreporting it is impossible to know what proportion of the leg ulcers are of venous origin.This story is made even more perplexing when authors such as Kunimoto (1991) citeestimates of the prevalence of venous ulceration from original studies (e.g., Dale, Callam,Ruckley, Harper & Berrey, 1983) that referred to leg ulceration in general (arterial andvenous leg ulcers combined) and not to venous ulceration in particular.When reviewing literature on the prevalence of venous leg ulcers, it is alsoimportant to note that writers have not specifically discussed prevalence of venousulceration among the older adult population. It is commonly thought, however, that thiscirculatory disorder is most prevalent among the elderly (e.g., Fitzpatrick, 1989; Merry,1989). Additionally, there is no sense of whether prevalence estimates refer to acute orchronic venous ulcers. Consequently, although it is widely believed that chronic venousleg ulcers are a significant problem among the older adult population, and although thisresearcher's clinical experience holds this to be true, it is difficult to support this beliefwith the statistics that are available. Future research findings in the area of wound carewill most likely support the notion that chronic venous leg ulcers are a significant healthproblem among the elderly.During the past few decades, there has been increased interest in documenting theincidence and prevalence of various types of tissue damage. Further, there has been a3tremendous growth in the number of allied health writings that relate to the care of theindividual with tissue damage. These writings, both theoretical and research based innature, have focused primarily on the assessment, classification, and local treatment ofthe tissue damage. For the most part, literature specific to the care of the individualwith a venous leg ulcer has provided detailed descriptions of the clinical presentation of avenous ulcer and associated pathogenesis, the differences between venous and arterial legulcers, and recommended treatment for the local tissue damage (e.g., Doyle, 1983;Fitzpatrick, 1989; Kunimoto, 1991; Lanyon, Van Nieuwenhuyzen & Wearing, 1987;Tretbar, 1987).Interestingly, a literature review that was conducted in relation to both acute andchronic venous leg ulcers showed no research in relation to psychosocial responses to thiscirculatory disorder and furthermore no research related to the lived experience of theolder adult with a chronic venous leg ulcer. The lack of research in this particular areahas implications for the community health nurse who often provides nursing care in ahome setting to older adults with chronic venous leg ulcers. Kleinman (1978), in anexplanatory model of transactions in health care relationships, notes that difficulties inhealth care relationships arise when the health care professional has a differentexplanatory model or view of a sickness episode than does the client. If the communityhealth nurse is to work effectively with the older adult who is living with a chronicvenous ulcer, it is essential that s/he have some understanding of what this experience islike from the client's perspective. In the context of chronic venous leg ulcers, theexplanatory model of the client has not yet been documented.4Theoretical FrameworkThe theoretical framework which provided direction for this study wasKleinman's (1978) explanatory model of transactions in health care relationships. In hisconceptualization of the health care system, Kleinman (1978) suggests that this system iscomprised of three sectors or social arenas within which sickness is experienced andresponded to: professional (health care professionals involved in traditional healingpractice), popular (individual, family, social network, and community), and folk (non-professional healing specialists). In each of these arenas, differing explanatory modelsmay be elicited in regard to a particular sickness episode. For example, the health careprofessional often understands the sickness episode within the context of a westernbiomedical science paradigm; the sickness is viewed in terms of a disease process withemphasis on malfunctioning or maladaption of biologic or psychophysiologic processeswithin the client. The client, on the other hand, views the sickness episode within thecontext of personal meaning, that is meaning that has been constructed from personal,interpersonal, and cultural reactions to sickness; the sickness is viewed primarily interms of illness, which is the everyday human experience of living with sickness.Kleinman (1978) urges health care professionals to explore the client'sexplanatory model in relation to a sickness episode and notes that difficulties in healthcare relationships arise when explanatory models conflict or when clinical realities areconstructed in differing ways. More specifically, when explanatory models among theprofessional and popular arenas, for example, are substantially dissimilar, there will beless effective communication in health care relationships and more clinical managementdifficulties. Furthermore, Kleinman (1978) notes that the health care professional must5consider the client's illness experience as well as the disease if holistic health care is to beprovided.The foregoing theoretical framework provided useful direction in relation tovarious aspects of this research study. More specifically, Kleinman's (1978) workvalidated the researcher's beliefs that it is essential for nurses to understand the olderadult's subjective experience of living with a chronic venous leg ulcer and that asignificant problem does exist if there is a dearth of knowledge in relation to this livedexperience. Thus, a research method aimed at describing human experience as it is livedwas thought to be ideal for such a study as the researcher wished to understand theparticipant's explanatory model and illness experience.Problem Statement And Purpose Of The StudyWithin the community setting, nurses are providing care to older adults who areliving with chronic venous leg ulcers. If the nurse is to work effectively with theseclients, there must be some understanding of what the client's experience is like. Morespecifically, the older adult's subjective experience with a chronic venous ulcer must beunderstood within the context of everyday living. To date, no research studies have beenfound which explore the experience of living with a chronic venous leg ulcer from theperspective of the older adult.Therefore, the purpose of this study was to explore and describe the experience ofthe older adult who is living with a chronic venous leg ulcer. This purpose wasaccomplished by answering the following research question: "What is the lived experienceof the older adult, residing in a home setting, who has been identified by a health careprofessional as having a chronic venous leg ulcer?"6Definition Of TermsA number of key terms used in this study were defined as follows:Older adult: a male or female individual, sixty-five years of age or older, who is residingat home and is visited by a Burnaby Health Department home care nurse at least onceper week for treatment of a chronic venous leg ulcer. The individual is able tocommunicate, in English, his/her experience of living with a chronic venous leg ulcer. Aswell, the individual must not be experiencing a coexisting physiological/psychiatriccondition that would significantly alter his/her perception of the experience of living witha chronic venous leg ulcer or impact significantly on the lived experience (e.g., delusionalthinking, paraplegia, chronic respiratory difficulty that the individual is continuallyaware of and trying to manage).Chronic venous leg ulcer/chronic venous ulcer: tissue damage, manifesting as anulceration or open lesion of the skin of a lower extremity, related primarily to venousinsufficiency. The diagnosis of a venous leg ulcer is made by a health care professionaland is based on clinical presentation and client history data that would indicate that theleg ulcer is related primarily to venous insufficiency. Additionally, as part of thediagnostic process, the possibility that the leg ulcer is related primarily to arterialinsufficiency is ruled out (see Appendix A for a summary comparison of characteristicsof arterial and venous leg ulcers). In terms of chronicity, the ulceration is of at least twomonths duration and has been treated by a Burnaby Health Department home care nurseat least once per week for a minimum of two months.Lived experience: the older adult's perception or subjective experience of everyday life.7Health care professional: a home care nurse (employed by the Burnaby HealthDepartment) or a physician (family practice, specialist) involved in the care of the olderadult who is living with a chronic venous leg ulcer.Introduction To The Study's MethodologyIn their discussion concerning the selection of a research methodology, Field andMorse (1985) noted that "For each question, there is a best or most appropriate method,and selecting the method is the most important decision in the research process" (p.29).According to these writers the researcher needs to consider a number of factors whenselecting the "best" or most appropriate method for a research study. Factors to beconsidered during selection of a research method include: (i) the nature of the researchquestion; (ii) expected outcomes of the research; (iii) constraints of the setting; (iv)characteristics of the participants; and, to a lesser degree, (v) resources available to theresearcher (Field & Morse, 1985).Phenomenology was the research method selected for this study subsequent to theresearcher's consideration of the aforementioned factors as well as the direction providedby the theoretical framework. The following discussion provides a rationale for theselection of phenomenology as the research method for this study. Further discussion ofthe phenomenological method and a description of the ways in which this method wasapplied are presented in Chapter Three.To begin, the expected outcome of this study was a description of the subjectiveexperience of the older adult who is living with a chronic venous leg ulcer. This outcomewas to be accomplished by answering the following research question: What is the livedexperience of the older adult, residing in a home setting, who has been identified by ahealth care professional as having a chronic venous leg ulcer? Both the expected8outcome of the study and the nature of the research question directed the researcher toselect a research approach which is qualitative in nature. In a discussion of thedifferences between qualitative and quantitative research, Knaack (1984) noted that thetraditional scientific method of quantitative research seeks to objectify human behaviorthrough the actions of "observing" and "explaining"; the phenomenon of human behavioris observed, quantified, and verified by independent observers. A qualitative approachto research, on the other hand, has as its aim the "interpreting" and "understanding" ofthe subjective meaning of human experience which is congruent with this study'sexpected outcome and research question (Knaack, 1984; Oiler, 1986; Ornery, 1983).Phenomenology was the specific qualitative research method thought to be mostappropriate for this study for a number of reasons. First, phenomenology has as its aimthe description of human experience as it is lived (Oiler, 1986). The phenomenologicalresearcher endeavours to understand phenomena from the perspective of those beingstudied (Riemen, 1986). Bruyn (1966) noted that "phenomenology serves as the rationalebehind efforts to understand individuals by entering into their fields of perception inorder to see life as these individuals see it" (p.90). Thus, the phenomenological aim wasconsistent with the researcher's goal in this study, that was, to explore and describe thehuman experience of living with a chronic venous leg ulcer. The phenomenologicalmethod was also consistent with the direction that this study's theoretical frameworkprovided. More specifically, the theoretical framework directed the researcher to select aresearch method which furthers understanding of the participants' explanatory models ofsickness and their illness experiences through exploration of their lived humanexperiences. Finally, the phenomenological method was found to be appropriate whenconsidering such factors as participant characteristics and resources available for thestudy. Specifically, participants in this study had the ability to share their experiencesand the researcher had both the time and resources required to conduct aphenomenological study.AssumptionsThe researcher assumed that each participant had a desire to share his/herexperience of living with a chronic venous leg ulcer. It was also assumed that eachparticipant's views represented reality for that individual and that this reality wasreported as accurately as possible. Further, the researcher assumed that while no livedexperience is the same, themes would emerge that were common to all of theparticipants' descriptions of living with a chronic venous leg ulcer.limitationsThere were a number of factors which served to limit the generalizability of thestudy's findings. To begin, participants in the study were selected from one specificurban area (area served by the Burnaby Health Department) and may, therefore,represent a specialized subgroup of the population. Additionally, all of the participantswere able to understand and speak English and participated in the study on a voluntarybasis. The lived experiences of these participants may not be representative of the livedexperiences of older adults, with chronic venous leg ulcers, who do not understand orspeak English or who did not volunteer to participate in the study. Finally, eachparticipant described his/her experience within the context of personal meaning, that ismeaning that has been constructed from personal, interpersonal, and cultural reactionsto sickness. The lived experiences of these participants may differ in significant waysfrom the experiences of other older adults with chronic venous leg ulcers who, forexample, are members of significantly different cultural and social systems.910SummaryThe community health nurse often provides nursing care to community-dwellingolder adults who are living with chronic venous leg ulcers. Yet, no research studies havebeen found which explore the experience of living with a chronic venous leg ulcer fromthe perspective of the older adult. This research problem was presented in thisintroductory chapter along with the purpose of this study, which was to explore anddescribe the experience of the older adult who is living with a chronic venous leg ulcer.The theoretical framework and methodological perspective, which provided direction forthe study, were also discussed in this chapter. Chapter One concluded with a review ofassumptions that were made by the researcher and limitations inherent in the study.In Chapter Two, selected literature relevant to the phenomenon under study isreviewed. Further discussion of the phenomenological research method and a descriptionof how this method was applied in this study is the focus of Chapter Three. The study'sfindings and interpretation of the data are presented in Chapter Four. Next, adiscussion of the findings is presented in Chapter Five. Finally, Chapter Six includes asummary of the study, conclusions derived from the research findings, and a discussionof the implications of the findings for nursing practice, education, and research.11CHAPTER TWOLITERATURE REVIEVVIntroductionIn order to further understand what the older adult's subjective experience ofliving with a chronic venous leg ulcer might be like, the researcher reviewed literaturethat was thought to be relevant to the phenomenon under investigation. First, literaturerelated to the experience of living with a venous leg ulcer was reviewed. When it wasdiscovered that there was a dearth of knowledge in this area, the researcher thenbroadened the scope of the literature review and examined writings related to theexperience of living with other wounds such as stomas and burns. Second, theresearcher briefly reviewed literature addressing the chronic illness experience as it wasthought that, quite possibly, the particular circulatory disorder that was the focus of thisstudy could be classified as a chronic illness although it had not been addressed as suchin the literature. Finally, writings in relation to the aging process and its impact on bodyimage were briefly examined as it was thought that the older adult's experience with achronic wound might be influenced by the way in which they perceived their aging body.In this chapter, then, literature that was reviewed in relation to the aforementionedsubject areas is presented.Living With A Venous Leg UlcerCurrently, there is no documented research related to the older adult's subjectiveexperience of living with a chronic venous leg ulcer. However, a few authors havebriefly described their own perceptions of what the individual with a venous leg ulcer12might experience (Fitzpatrick, 1989; Lamont, 1991; Rolstad, 1991). Fitzpatrick (1989), adermatologist, noted that chronic venous insufficiency and the complication of a venousleg ulcer can have a devastating effect on the well-being of the elderly individual. Hedescribed not only the possible financial hardship associated with extendedhospitalizations for treatment of a venous leg ulcer, but also suggested that it is the long-term impairment of ambulation that has the most profound effect on the person. In theenterostomal therapy arena, Rolstad (1991) provided a little more insight into thepsychosocial aspects of the chronic venous leg ulcer experience when she advanced theidea that chronic wounds, in general, may affect an individual's body image and self-concept. On a more specific note, she asserted that some individuals who are managingchronic venous leg ulcers feel discouraged with the leakage and odour that is oftenassociated with these wounds and can become disheartened when the ulcers fail to heal.Lamont (1991), another enterostomal therapist, also recognized that an individual's lifecan be dramatically affected by the presence of a venous leg ulcer but offered reasons forthis that were not addressed by the previous two authors. More specifically, she notedthat pain and discomfort associated with the ulceration are common problems which mayaffect an individual's quality of life and she commented that activities of daily living suchas bathing may be difficult because of the presence of a dressing and compressionstocking. Additionally, frequent visits by a health care provider can interfere with anormal lifestyle and the cost of wound care supplies can be an overwhelming burden.Finally, Lamont (1991) suggested that the venous leg ulcer experience may also involvethe management of associated complications. In particular, she noted that chronicanemia, hypoproteinemia, and shortening of the Achilles tendon with the development of13an equinus deformity that further reduces mobility are all conditions that may impact onthe individual's experience.In addition to the writings of Fitzpatrick (1989), Lamont (1991), and Rolstad(1991), three brief anecdotal accounts have been presented in the medical literature bywriters who discuss the leg ulcer experience in a more general way, not making thedistinction between venous and arterial leg ulcers. Prebble (1990) noted that someindividuals with leg ulcers may accept their condition more readily than others becausethey view their ulcers as being one aspect of the aging process or because the ulcers areseen as a way of ridding the body of "badness" (p.44). As well, Prebble (1990) suggestedthat an individual may become dependent on home care visits if the nurse is visitingfrequently to manage the leg ulcer. In another anecdote, Merry (1989) contended thatpeople with leg ulcers not only experience a loss of mobility but often the loss of a senseof independence and freedom as well. Callam and colleagues (1988) supported the ideathat a loss of mobility is a significant aspect of the leg ulcer experience and also notedthat work and leisure activities may be negatively affected by this condition.When considering the literature that has been described above, one cannot helpbut be surprised by the "piecemeal" nature of the information that is available regardingthe experience of living with a chronic venous leg ulcer. Each of the authors hascommented on only a few select aspects of the experience and in most instances theiropinions have not been substantiated because other writers have chosen to focus ondifferent aspects of the venous leg ulcer experience. When reviewing the literature onedoes get the feeling that this experience might negatively affect an individual's quality oflife and that impaired mobility may be particularly devastating but, for the most part,14the reader is left wondering how all the small pieces of the puzzle fit together andwhether all the pieces are in fact parts of this puzzle.There are issues, in addition to those mentioned above, that make the literaturerelated to the experience of living with a chronic venous leg ulcer problematic. Forexample, none of the authors have discussed, in any way, the basis for their perceptions.The reader does not know whether an author had actually cared for or talked with anindividual who had a chronic venous leg ulcer or whether the author's perceptions of theexperience were derived from the speculations of other health care professionals. Thus itis very difficult for the reader to evaluate the tenability of the writer's conclusionsregarding the chronic venous leg ulcer experience. As well, it is important to note thatan individual's lived experience may in fact be significantly different from the healthcare professional's perception of the person's experience (Kleinman, 1978).Another issue that makes the literature related to the experience of living with avenous leg ulcer problematic is that, with the exception of Fitzpatrick (1989), none of theauthors identified the characteristics of the individuals they were discussing. Morespecifically, the reader does not know what age group a writer was commenting on andwhether or not the individuals in question had venous leg ulcers which were short termor chronic in nature. The difficulty here is that the younger or middle aged person'sexperience with a venous leg ulcer may differ from the older adult's experience of thesame condition. Similarly, the lived experience of an individual with an ulceration thatis classified, by health care professionals, as chronic may differ from that of anindividual with the same condition that is not considered to be chronic.One final concern with regard to the literature reviewed in this section relatesspecifically to the writings of Callam and colleagues (1988), Merry (1989), and Prebble15(1990). As was mentioned previously, these writers discussed leg ulcers in a general wayand did not make a distinction between experiences associated with venous and arterialleg ulcers. Discussing leg ulcers in a generic way is problematic for this researcher asshe has found, in her own clinical practice, that clients with arterial leg ulcers havesignificantly more discomfort and impairment of mobility as compared to those clientswith leg ulcers that are related primarily to venous insufficiency. Accordingly, one canargue that it is likely that there is a difference between the venous and arterial leg ulcerexperiences and that writers who do not acknowledge that this is the case must beprepared to have the validity of their assertions brought into question.In sum, the literature reveals that knowledge in relation to the older adult'ssubjective experience of living with a chronic venous leg ulcer does not exist. A fewauthors have hypothesized about selected aspects of the experience of living with avenous leg ulcer but their conclusions were not based on research and are problematicfor a number of other reasons that have been addressed in this section.Living With Other Types Of WoundsThe finding that there is a dearth of knowledge related to the phenomenon understudy is supported by Albert and Moody (1990) who noted that there is very littleliterature concerning the lived experience of an individual with a wound and anyliterature that is found usually relates to the experiences of individuals who are livingwith chronic wounds such as stomas or burns. A review of selected literature wasundertaken in relation to an individual's experience of living with a stoma or burn as itwas thought that knowledge in relation to what it is like to live with other chronicwounds such as these might provide insight into the experience of living with a chronic16venous leg ulcer. A summary of the literature that was reviewed is presented in the nexttwo sections.The Stoma ExperienceA variety of clinical conditions exist which necessitate the surgical formation of astoma, an opening on the anterior surface of the body for the elimination of urine orstool (Klopp, 1990). As one might expect, the psychosocial impact of ostomy surgery andthe formation of a stoma can be profound (Shipes, 1987). Indeed, Klopp (1990) reportedthat individuals with stomas often have poor psychosocial outcomes that range fromfailure to resume employment, withdrawal from social and intimate contact, todepression and anxiety. These outcomes and other psychosocial aspects of living with astoma have been addressed in theoretical writings and research studies which are foundin the nursing, medical, and social sciences literature.Unquestionably, much of the comment and scientific inquiry that has beendocumented in the ostomy literature relates to body image changes that an individualwith a stoma experiences (e.g., Cohen, 1991; Gloeckner, 1984; Klopp, 1990). Thegeneral findings from the research that Gloeckner (1984) conducted in partial fulfillmentof her master's degree in nursing are consistent with many of the findings that aredocumented by other researchers who have investigated body image changes in relationto individuals with stomas (e.g., Orbach & Tallent, 1965; Sutherland, Orbach, Dyk, &Bard, 1952; Dlin & Perlman, 1971). Gloeckner (1984) investigated body image changeby examining individuals' perceptions of their own sexual attractiveness following ostomysurgery. Home interviews were conducted with sixteen women and twenty-four men,where the mean length of time since ileostomy or colostomy surgery had been 4.6 years.Data were collected by means of an investigator-developed questionnaire that used a17Likert scale to rate feelings of sexual attractiveness. Results indicated that sixty percentof subjects felt less sexually attractive one year after ostomy surgery than they had feltone year prior to the surgery. Many subjects made additional negative comments abouttheir body in that one year post surgery; they described feeling "ugly" and "disfigured."However, at the time of the interview 67.5% of subjects felt more sexually attractive thenthey had felt before surgery; this was possibly due to the fact that many of the subjectshad chronic inflammatory bowel disease and had experienced the unpleasant symptomsof this disease prior to surgery. It is noteworthy that this particular finding was notsupported by Klopp's (1990) finding that length of time since surgery did not contributeto statistically significant differences in either body image or self-concept. Anotherfinding of Gloeckner's (1984) study was that there was a significant difference betweensubjects who had management problems (e.g., leakage) with their ostomy and those whohad no problems or mild problems. Specifically, those subjects with markedmanagement problems viewed themselves as less attractive than the other subjects.Thus, Gloeckner's (1984) findings, which are generally representative of other bodyimage related findings in the ostomy literature, suggest that it is common for individualswith stomas to experience a body image disturbance. This disturbance in body imageexists initially after the formation of a stoma but then, as time passes, many individualsappear to adjust to the change in their body's structure and function. Furthermore,individuals who continue to experience a body image disturbance are often found to havehad difficulty with the management of their ostomy.In an effort to gain a more comprehensive understanding of the stomaexperience, Hurny and Holland (1985) conducted an extensive review of the ostomyliterature and found that there are certain problems that are commonly experienced by18people with ostomies. They grouped these problems into three categories: physical,emotional, and interpersonal. The first category refers to practical problems related tolearning to care for the stoma, irrigation, and managing minor crises such as applianceleakage and skin breakdown around the stoma. These practical difficulties often evokeemotional responses such as anxiety and fear. With regard to emotional problems, theseauthors found that individuals with stomas often have self-esteem problems associatedwith an altered body, experience depression and anxiety, and fear that they will besexually undesirable. Finally, Hurny and Holland (1984) noted that, from aninterpersonal perspective, individuals with stomas may experience alterations in sexualfunction and changes in relationships. As well, social isolation is a common problemwhich may be related to depression or to an individual's sense of stigma and low self-esteem.As one considers writings related to the stoma experience, the question arises asto whether this literature offers insight into the chronic venous leg ulcer experience. Itcertainly seems possible that some of the issues raised in this body of literature mightfurther one's understanding of the experience of individuals who are living with thisparticular circulatory disorder. For example, one can speculate that individuals withchronic venous ulcers might experience a body image disturbance and, hence, low self-esteem and anxiety or depression. One must acknowledge, however, that there are likelykey differences between the ostomy population and the chronic venous leg ulcerpopulation which could make the lived experiences associated with these two types ofwounds considerably different. More specifically, individuals with ostomy wounds mayhave a variety of issues to deal with that would not typically be part of the chronicvenous leg ulcer experience. For instance, the person with an ostomy has, in many19cases, been diagnosed with bowel cancer and, consequently, must cope with a potentiallylife-threatening disease. As well, this individual may be experiencing the effects of majorabdominal/perineal surgery and is most likely trying to cope with the stigma that oftenaccompanies an ostomy wound. The findings of this study are certain to shed some lighton how similar the ostomy and chronic venous leg ulcer experiences actually are.The Burn ExperienceBurns are considered to be another type of chronic wound as their healing time isoften prolonged. In terms of the burn literature, it is surprising to see that manyauthors have commented on the paucity of research in relation to the psychosocialoutcomes of burn injury (e.g., Browne et al., 1985; Ward et al., 1987; Watkins, Cook,May & Ehleben, 1988). Indeed, Browne et al. (1985) noted that the research emphasishas been on determining the pathophysiological sequelae of burn injury and theeffectiveness of different treatment modalities rather than on the psychosocial aspects ofthe injury. Authors have theorized, however, that clinical postburn depression may beone of the most common psychological disturbances following burn injury (Ward et al.,1987). Ward and colleagues (1987) did study the prevalence of depression and variablescorrelated with this psychosocial outcome in 139 burn injured adults. They found that9.4% of their subjects were mildly depressed, while 12.9% were moderately to severelydepressed. Interestingly, they also found that depression was not significantly associatedwith the extent and severity of burn injury but, rather, was most strongly linked to apast history of emotional disturbance. The researchers concluded that it is the person,rather than the burn injury, that best predicts postburn depression. Similarly, Browneand colleagues (1985) found that severity of the burn and time since the burn were notrelated to psychosocial adjustment in a sample of 340 randomly selected burn injured20adults. In their study, they discovered that "maladjustment" among burned adults wasrelated to variables such as avoidance coping behaviour, decreased participation inrecreational activities, and a perceived loss of family, friend, and peer support. Brownet al. (1985) noted that their findings tended to refute the commonly held view that post-burn adjustment is associated with burn severity, and instead, do support the idea thatpsychosocial adjustment after burn injury is a function of both coping responses andsocial resources.From a more theoretical perspective, authors such as Watkins et al. (1988) havefocused their energies on describing the stages of adaptation that post burn individualsappear to move through as they emotionally heal from their traumatic experience. Theseauthors believe that, for individuals with burns, a return to maximum independentfunctioning requires a gradual psychological adaptation to losses and changes resultingfrom the injury. The seven adaptive stages that Watkins et al. (1988) described are asfollows: survival anxiety, the problem of pain, the search for meaning, investment inrecuperation, acceptance of losses, investment in rehabilitation, and reintegration ofidentity. The authors have observed that some patients move through all of these stagesof adaptation while others skip one or more, but there has never been any variation inthe sequence of appearance of stages from that presented here.As with the literature addressing the stoma experience, it is difficult to know howmuch insight the writings in relation to the burn experience can provide the reader whois seeking further understanding of what it is like to live with a chronic venous leg ulcer.It certainly seems possible that depression could be associated with the chronic leg ulcerexperience. Further, it seems plausible that a person's successful adjustment to achronic wound may depend more on that individual's coping behaviour and social21support system than on the nature of the wound (e.g., severity or duration of thewound). The question that remains unanswered at this point is whether the traumaticand sudden nature of the burn injury could render that experience significantly differentfrom other chronic wound experiences, particularly in relation to the adaptation process.living With Chronic IllnessAs was mentioned, the researcher conducted a cursory review of some of theliterature related to the experience of living with a chronic illness as it was thought thatliving with a chronic venous leg ulcer might be a chronic illness experience of sorts. Theresearcher experienced some indecisiveness around this issue as chronic venous leg ulcersare not normally discussed within a chronic illness context in the literature. As well, thechronic illnesses that are typically referred to in the literature—illnesses such as arthritisand hypertension—are those that most often do not have a foreseeable end in sight.Thus, the goal is very often not to cure the illness but, rather, to live the best lifepossible with the illness. In terms of living with chronic venous leg ulcers, then, someindividuals have taken the view that their ulcers will probably never be cured and thatthey will simply follow a "maintenance" regime with regard to their care. Much morefrequently, however, the scenario is one of leg ulcers being treated in an aggressivemanner with the belief that they will eventually heal. Thus, one is left wonderingwhether this "cure" mindset precludes the experience from being one of chronic illnesseven though there is an underlying venous insufficiency that is likely chronic in nature.As with the burn and stoma experiences, it is probably not possible to make a decisionabout this issue until the findings of this study are examined.With regard to the chronic illness literature, the researcher did narrow herreview to select writings in relation to the impact of chronic illness on quality of life or22life satisfaction. One of the reasons for this was that it was beyond the scope of thisstudy for the researcher to consider the voluminous amounts of literature related toevery aspect of the chronic illness experience. As well, the researcher reflected on pastexperiences when she had cared for clients with chronic venous leg ulcers and determinedthat it was really the client's sense of well-being that was at issue in those situations.Curiously, assessment of factors that influence the perception of quality of life inthe chronically ill has received little attention from researchers until fairly recently(Burckhardt, 1985). As individuals in society have become increasingly concerned notonly with the length of life but with the positive and satisfying aspects of life, nurseresearchers have responded by conducting more research in relation to quality of lifeissues (Burckhardt, Woods, Schultz & Ziebarth, 1989). Further, researchers havesought to more fully understand the chronically ill clients' subjective feelings about thequality of the lives they lead while coping with chronic illness (Burckhardt, Woods,Schultz & Ziebarth, 1989).Life satisfaction and quality of life were the topics of three studies that theresearcher reviewed. In a study by Burckhardt (1985), ninety-four adults with variousforms of arthritis were interviewed with the use of a semi-structured questionnaire. Thepurpose of the study was to describe and explain the impact of physical, psychological,and social factors on the perception of quality of life experienced by people witharthritis. Burckhardt (1985) found that the factors that directly contributed to a higherquality of life for these subjects were: positive self-esteem, internal control over health,perceived support, and low negative attitude toward the illness. Laborde and Powers(1985) also studied life satisfaction in osteoarthritics. They found that, although thesubjects rated their usual pain as distressing, their degree of pain did not seem to impact23dramatically on their overall satisfaction with life. However, a positive relationship wasfound between life satisfaction and less joint pain. In addition, Laborde and Powers'(1985) findings supported Burckhardt's finding that life satisfaction was related to aninternal locus of control and better health perception. Finally, Burckhardt andcolleagues (1989) found that subjects with a variety of chronic conditions—diabetesmellitus, colitis, colon cancer, osteoarthritis, and rheumatoid arthritis—all used verysimilar terms to describe factors that were important to their quality of life. Theyreported that quality of life was enhanced by the following variables: independence,being physically active, ability to care for self, feeling healthy, having a sense of security,positive interaction and relationships with others, and feeling as though there wasmeaning in life. This final study provides one with a little more insight into the myriadof variables that likely contribute to life satisfaction.Aging And Body imageCurrently, there is a great deal of confusion in the medical, nursing, and socialsciences research literature with regard to the effects that the aging process has on one'sbody image (Janelli, 1986a). Specifically, there have been many dissenting opinionsvoiced with regards to body image changes that occur in the elderly, but the relationshipbetween age and body image has not been clearly demonstrated in the research that hasbeen done in the area (Janelli, 1986b). JaneIli (1986a) contends that uncertainty aboutthe relationship between aging and body image has arisen, in large part, because of thenature of the research methods that have been used to study body image in older adults.More precisely, human-figure drawings have been used in the majority of studies whichexamine the relationship between age and body image; older adults are asked to draw animage of themselves and then the image is analyzed by the researcher (Janelli, 1986a).24JaneIli (1986a) argued that this method is very subjective and its reliability could bejeopardized if extraneous variables such as drawing skill and cognitive impairment comeinto play. She also noted that difficulties have arisen because researchers use the terms"self-concept," "self-esteem," "body schema," "body precept," "body concept," and "self-image" interchangeably with the term "body image" and the meanings of all of theseterms are not the same (JaneIli, 1986b).From a more theoretical perspective, Esberger (1978) noted that older adultsoften experience various age-related physical changes as multiple losses and they grievethese losses as an integral part of the adjustment process. A chronic illness, or otherhealth problem, may represent losses that further intensify the older adult's existing lossexperience and, consequently, their grief. Interestingly there are authors who argue thatolder adults can overcome the despair that can be associated with aging, chronic illness,and disability if they are able to move forward in the developmental process towardexpanded self-boundaries (Haase, Britt, Coward, Leidy & Penn, 1992; Reed, 1991a;Reed, 1991b). In other words, it is suggested that these older adults can transcend theirchronic illnesses and natural physical decline and experience a sense of well-being if theycan reach out beyond self-concern (Haase et al., 1992; Reed, 1991a; Reed, 1991b).When reaching beyond themselves, older adults lose their self-preoccupation and becomecognizant of infinite possibilities or sources of purpose (Haase et al., 1992; Reed, 1991a;Reed, 1991b).SummaryThis chapter reviewed literature that was selected for the purpose of providinginsight into the chronic venous leg ulcer experience. The review revealed that there is apaucity of both theoretical and empirical information related to the experience of living25with venous leg ulcers. Further, the literature that is available is anecdotal in natureand does not offer a comprehensive view of what the venous leg ulcer experience mightbe like. Literature in relation to living with other types of wounds may or may not beapplicable to the phenomenon under investigation. If it is applicable to some degree, theparticipants in this study might describe such things as alterations in body image orfeelings of depression or anxiety. It would mean, as well, that the severity and durationof the participants' leg ulcers may not be a determining factor in how they respond totheir ulcers. It is not known whether the chronic illness literature will be applicable tothe chronic venous leg ulcer experience, but the researcher has gleaned insights into someof the factors that may determine whether the participants in this study feel as thoughthey have quality in their lives. Finally, the literature in relation to aging and its effecton body image paints a rather confusing picture. It suggests that participants maygrieve in relation to the leg ulcer which will represent another loss or, on the other hand,they may be able to transcend the health problem.26CHAPTER THREEMEMODOLOGYIntroductionPhenomenology was the research method selected for this study as this approachbest facilitates the exploration and description of the human experience of living with achronic venous leg ulcer from the perspective of the community-dwelling older adult.Further discussion of the phenomenological method, as it was applied in this study, ispresented in this chapter in relation to the following areas: participant selection, datacollection, and data analysis. In addition, the researcher provides a brief description ofthe strategies that were used to promote adequacy or rigor of the research. Finally, thischapter concludes with a discussion of the ways in which the researcher endeavoured toprotect the rights of the study's participants.Selection And Recruitment Of ParticipantsThe purposive method of nonprobability sampling was used to select theparticipants for this study. In this sampling design all participants are deliberatelyselected according to the theoretical needs and direction of the research (Morse, 1986).More specifically, the phenomenological research method requires that the study'sparticipants share information which will facilitate the researcher's understanding of theolder adult's experience of living with a chronic venous leg ulcer. To this end,individuals were purposefully selected based on their ability and desire to provideinformation that contributed to understanding and insight in relation to the phenomenonunder investigation. The following is a description of the criteria used for selection of27participants and rationale for this criteria, the procedure for recruitment of participants,and characteristics of the individuals who became participants in this study.Selection CriteriaThe following criteria for selection of participants were developed in order that asample of individuals be recruited who could best describe the experience of living with achronic venous leg ulcer from the perspective of the community-dwelling older adult.Each participant was to be:1. sixty-five years of age or older;2. residing in a house or apartment in the area being served by the BurnabyHealth Department;3. diagnosed as having a chronic venous leg ulcer by a Burnaby HealthDepartment home care nurse or a physician;4. visited by a Burnaby Health Department home care nurse at least onceper week for treatment of a chronic venous leg ulcer and has been visitedfor at least two months;5. free of coexisting physiological and/or psychological conditions that wouldsignificantly alter the individual's perception of the experience of livingwith a chronic venous leg ulcer;6. able to understand and speak English and is able to communicateexperiences.The rationale for selecting participants who were sixty-five years of age or olderwas twofold. First, venous insufficiency and the complication of a chronic venous legulcer are conditions which primarily affect the older adult. Second, participants werelimited to one developmental stage (older adulthood) because the experience of an illness28or disability may be influenced by stresses or demands specific to a particular stage ofthe life cycle (FaIvo, 1991). Hence, a young adult's experience with illness may differsignificantly from the older adult's experience with the same illness because of differingstages of development.In addition to an age criterion, it was specified that each participant reside in thearea being served by the Burnaby Health Department as this agency had consented toparticipate in the study. All participants were required to reside in an apartment or ahouse because the focus of this study was the experience of chronic venous leg ulcerationfrom the perspective of the community-dwelling older individual. Facility-dwelling olderadults experiencing chronic venous ulceration were not included in this study because itwas the researcher's belief that factors such as serious coexisting physiological and/orpsychiatric conditions which are usually present in this population and an institutionalmilieu might significantly influence the leg ulcer experience. Because community-dwelling individuals with chronic venous leg ulcers may also live with significant illnessesthat would affect the leg ulcer experience, it was stipulated in this study that acommunity-dwelling participant must not be experiencing a coexisting physiologicaland/or psychiatric condition that would significantly alter his/her perception of theexperience of living with a chronic venous leg ulcer (e.g., delusional thinking, paraplegia,chronic respiratory difficulty that the individual is continually aware of and trying tomanage). All participants were required to understand and speak English so that theycould comprehend the researcher's statements and express thoughts and feelings thatwould be understood by the unilingual English speaking researcher. In addition, it wasspecified that participants be able to describe what it is like to live with a chronic venousleg ulcer in order that the researcher be able to gain insight into the experience.29The decision that a venous leg ulcer would be considered chronic if it had beentreated by a home care nurse for at least two months was essentially an arbitrary one.Literature in relation to chronic venous leg ulcers did not provide any direction inrelation to length of time a venous ulcer needed to be present before it was consideredchronic in nature. What is known is that the inflammatory and proliferative phases ofwound healing (wound has closed but scar tissue is not necessarily mature at this time)are usually complete after approximately three to four weeks (Ignatavicius & Bayne,1991). Thus, a leg ulcer of at least eight weeks duration may be considered longstandingor chronic. It was also believed by the researcher that it may take this length of time foran individual with a venous leg ulcer to experience chronicity or persistence of thecondition. To ensure that participants were in fact experiencing venous ulceration, itwas stipulated that a diagnosis of this condition be made by a health care professional(home care nurse or physician) and that the diagnosis be based on clinical presentationand client history data that would indicate that the leg ulcer was related primarily tovenous insufficiency. Finally, it was specified that a participant be an individual whohad been visited by a home care nurse at least once per week for treatment of a chronicvenous leg ulcer. This criterion was developed to ensure that there were relativelysimilar experiences in relation to frequency of nursing visits.Recruitment ProcedureThe participants in this study were recruited by way of a specific procedure.First, the researcher provided the Administrator of Home Care Nursing for the BurnabyHealth Department with a copy of the research proposal which included a description ofthe selection criteria and recruitment procedure. After discussing the proposal with theresearcher, the Administrator communicated the nature of the study, participant30selection criteria, and the recruitment procedure to the home care coordinators who inturn conveyed this information to the home care nurses. In addition, an informationletter (see Appendix B) was distributed to the nurses.Over the course of two to three weeks, home care nurses determined which oftheir clients met the selection criteria. If a client was eligible for the study, the nurseexplained the purpose of the study and asked the individual for permission to becontacted by the researcher. Once an individual agreed to be contacted, the home carenurse referred his/her name to a home care coordinator who in turn submitted the nameand telephone number of the potential participant to the researcher. Following this, theresearcher contacted the potential participant by telephone and provided furtherexplanation of the study. If the individual was interested in participating in the study anappointment was made for the first home visit. Of the first six potential participantswho were contacted by the researcher, two declined to participate in the study. Oneman's daughter answered the telephone and told the researcher that her father's physicalcondition had deteriorated recently and he was not feeling well enough to be interviewed.Another potential participant became angry when the researcher called, stating that herphysician told her that she did not have to see any more people in regard to her legulcer. This incident was shared with a home care coordinator who reported that theclient did have a history of paranoia and, therefore, should not have been recommendedfor this study.At this point in the recruitment process the researcher determined that, in allprobability, the purpose of this study could not be achieved with a sample size of fourindividuals. Rather, it was thought that at least six to ten participants would need to beinterviewed for theoretical saturation to be attained and for the researcher to have a31comprehensive and accurate understanding of the chronic venous leg ulcer experience.For these reasons, the researcher procured the participation of two individuals who hadoriginally been excluded from the study as they were not being visited weekly by a homecare nurse at the time that recruitment of potential participants was taking place. Oneof these individuals was a gentleman who was well known to home care because of a longhistory of recurrent venous ulceration. Regular nursing visits for treatment of thisman's leg ulcers had ended a few weeks prior to the commencement of this study as hisulcers had healed. He was, however, being monitored on a regular basis over thetelephone as he was considered to be at high risk for recurrent ulceration. The otherindividual, who became the sixth participant in the study, was an elderly woman withchronic venous leg ulcers whose home care visits had ended three months earlier when itwas decided that she would be treated on a regular basis at the Vancouver GeneralHospital's Wound Healing Clinic. During the second interview this participant didinform the researcher that home care nursing visits would most likely resume as she hadbeen advised that she would soon be discharged from the Wound Healing Clinic. It isimportant to note that the aforementioned individuals were asked to participate in thisstudy because it was thought that they would be able to share valuable information aboutthe chronic venous leg ulcer experience even though they did not meet all of the originalselection criteria. The recruitment procedure varied slightly in this instance in that whenit was decided that these two individuals would be asked to participate in the study, eachwas initially contacted by a home care coordinator rather than by a home care nurse.In terms of recruitment procedure, it should also be noted that at the outset ofthe first home visit and prior to the initial interview, the researcher provided thoseindividuals who were interested in participating in the study with an Introductory Letter32(see Appendix C) and answered any questions that they had about the study. Theresearcher also formalized an individual's agreement to participate in the study byobtaining written consent (see Appendix D) before the interviewing began.Characteristics Of The ParticipantsThis description of the general characteristics of the study's participants wasderived from data that were collected from the participants themselves, the researcher'sobservations of the participants and their environments, and the Burnaby HealthDepartment's clinical records. As was mentioned previously, six individuals consented toparticipate in this study. These individuals, one man and five women, were allCaucasian and ranged in age from seventy-four to ninety-two years, with a mean age ofseventy-nine years. All of the participants were widowed and five of them lived alone ineither a self-owned apartment or house, or a government subsidized senior citizen'shousing project. The sixth participant lived on the main floor of a self-owned house andrented the top floor to a friend who routinely assisted him with care of his legs (e.g.,application of lotion and elastic support stockings). Five of the six participants receivedhome support services, the nature of which depended on their individual needs. Ofparticular note is the fact that three of these five participants attributed their need forhome support to the loss of mobility they were experiencing as a result of their chronicvenous leg ulcers. With regard to nursing visits for treatment of their ulcers, all of theparticipants had been or were being seen by a home care nurse at least once per week.In fact, at the time of this study four of the six participants were receiving home nursingcare two to seven times per week.All of the study's participants had been diagnosed by a health care professionalas having leg ulcers that were related primarily to venous insufficiency. In addition,33clinical records indicated that three of the participants were also experiencing somechronic arterial insufficiency. The foregoing finding suggests that it is probably notuncommon for both venous and arterial insufficiency to coexist in an individual, but thatone of these conditions is likely predominant. With regard to the actual ulcers, four ofthe six participants in this study had multiple venous leg ulcers, of varying sizes, whichwere situated on both legs. Differing from the majority of participants, was one womanwho had a single large venous ulcer on her right leg and one man who had experiencedreccurring venous ulcers only on his left leg.Interestingly enough, a few of the participants had some difficulty recalling howlong it had been since they had developed their first venous leg ulcer. One manremarked that it had been "more than five years" and that the "nurses would know"when his leg ulcers began. Another woman replied "too long" when asked how long shehad been dealing with leg ulcers. Other participants related their first leg ulcerexperience to a particular event in their lives and were able to recollect the number ofyears of venous ulceration by recalling how long ago the associated event had occurred.For example, one participant stated that "they [venous leg ulcers] broke out after myfirst son was born forty-six years ago." Another participant explained that a few yearsago she developed a "mess" after "squashing" her leg in a storm door. As far as theresearcher could determine, the participants in this study had been coping with venousleg ulcers for anywhere from two to fifty years. In addition, all of the participantsdescribed a situation in which there was an ongoing cycle of healing followed byrecurrence of the leg ulcers. As one woman noted, "It [venous leg ulcer] would heal upand then it would go away for two days and then it would come back ... it wouldn't stayhealed." Another participant remarked that some of her healed leg ulcers were "all34ready to break out again" and that the situation was like a "tea kettle that's not quite onthe boil." One woman differed somewhat from the others in that two of her venousulcers had never healed.During their many years of chronic venous ulceration, four of the study'sparticipants had undergone a myriad of topical treatments aimed at healing their legulcers. Hydrocolloid dressings, antimicrobial ointments, saline compresses, gel dressings,and a zinc paste bandage were some of the topical treatments that had been prescribedfor these individuals. It was not surprising that each of these four participants had losttrack of the number of different topical treatments that had been prescribed over theyears. One woman even commented that she felt like a "guinea pig" as a result ofhaving endured so many different topical therapies. Two of the study's participantswere not included as part of the aforementioned group as they indicated that they hadnot paid close attention to how their leg ulcers were being managed and thus could notcomment at all on the number and types of topical treatments that had been prescribedover the years. Clinical records for these two individuals were useful in the sense thatthey offered information about the most recent topical treatment that each had received(saline compresses), but they did not provide data in relation to the number and types ofprevious topical treatments.In addition to having their venous leg ulcers cleansed and dressed on a regularbasis by home care nurses, five of the study's participants had been hospitalized on atleast one occasion for more aggressive treatment of their ulcers. Three of theparticipants commented that their physicians had hospitalized them and prescribedbedrest and elevation of their affected legs for the purpose of enhancing their venouscirculation and decreasing peripheral edema. Several participants had undergone at35least two skin grafting procedures that have proven unsuccessful. Interestingly, only twoof the study's six participants had a history of vein ligation surgery, a surgicalintervention that is often performed when chronic venous insufficiency cannot becontrolled with more conservative medical therapy.All of the participants were surprisingly knowledgeable with regard tointerventions that promote peripheral venous return. For example, they described theimportance of elastic support stockings, regular exercise, and periodic rest periods withelevation of the extremities. The majority of participants were also aware of measuresthat can be taken to preserve intact skin on the legs, namely the application of lotion todry skin and the avoidance of trauma to the limbs. Having said this, it was curious tofind that a majority of the participants seemed to lack a basic and, in some cases,accurate understanding of the etiology of chronic venous leg ulceration. For instance,one man reported that he has recurring venous leg ulcers because "the skin is so weak ittightens up and then splits." Another woman commented that her ulcers started aftershe broke her ankle and then stated that she must have a "hereditary" condition as hermother "had bad legs way back." Two participants attributed their venous leg ulcers tothe effects of pregnancy but were unable to be more specific with regard to therelationship between pregnancy and venous ulceration. finally, one woman explainedthat when she was eighteen years old she sustained a "terrible sunburn" to her legs whichprobably damaged her "blood veins" and as she ages these veins "break down" andvenous leg ulcers develop.Data CollectionOmery (1983) noted that the phenomenological method is an inductive,descriptive research method which provides valuable direction to the researcher who is36exploring the meaning and perceived structure of any event or experience that affectshuman beings. Essentially, the data collection process that is associated with this methodrequires that the researcher enter into a participant's "world" or field of perception inorder that human experience be understood from the participant's perspective (Bruyn,1966; Knaack, 1984). The research data, from which the essential structure of anexperience is derived are, for the most part, events that are shared by a participant andthe subjective meanings that these events have for that individual (Ornery, 1983). Aswell, the researcher's field notes contribute to the data base with respect to observationsthat the researcher has made in relation to a participant's environment and behavior(Field & Morse, 1985).In this study, the researcher endeavoured to collect data in a manner that wasconsistent with phenomenological philosophy and method. This commitment on theresearcher's part to be as true as possible to the phenomenological approach hadsignificant implications for the way in which the researcher viewed the participants andthe manner in which she related to them during the data collection process. To begin, itshould be noted that the researcher viewed the study's participants as partners or co-researchers in this endeavour. The researcher found that this mindset was essential forthe development of trusting relationships with participants as it appeared that they feltmore comfortable sharing thoughts and feelings in an atmosphere that fosteredcooperative dialogue and mutual learning. Indeed, it was only within the context of agenuine and mutual "I-thou" relationship that the researcher could truly be "with" aparticipant and begin to understand that participant's world. This approach differssignificantly from the one advanced by the traditional quantitative method whereby theexperimenter is in a position of power and manipulates or controls the subject (Knaack,371984). In this scenario, the experimenter has an "I-it" association with the subject who isat arms length and is objectively observed, examined, and tested (Livingston, 1971).In order that the phenomenological researcher more fully understand themeaning that experiences have for participants, s/he must also engage in a processknown as "bracketing" (Davis, 1978; Knaack, 1984; Omery, 1983; Pallikkathayil &Morgan, 1991). More specifically, bracketing involves the setting aside of one's ownassumptions in order that the phenomena under investigation be met on their own termsand not be forced into a mold of preconceptions (Knaack, 1984). From a slightlydifferent perspective, Peck (1978) noted that bracketing involves the act of "temporarilygiving up one's self--putting one's self aside, so to speak--so as to make room for theincorporation of new material into the self" (p.73). In this study, the researcher madeevery effort to really hear what the participants were saying by consciously approachingeach individual with as open a mind as possible and centering her consciousness towardunderstanding the lived experiences as they were described by the participants. Inaddition, the researcher continually endeavoured to suspend any a priori preconceptionsor presuppositions as data were being analyzed and a description of the structure of thephenomenon under study was being developed. Field notes were found to be a valuableaid in the bracketing process as they helped the researcher keep track of the thoughtsand feelings she was experiencing in response to the participants' stories.Each of the six participants in this study were interviewed on two separateoccasions. A decision was made to conduct these interviews in the participants' ownhomes for a number of reasons. First, the researcher speculated that the participantswould feel more comfortable and secure in an environment that they were familiar withand because of this would be more at ease when discussing personal experiences. Based38on previous encounters with older adults who were living with chronic venous leg ulcers,the researcher also anticipated that some of the participants might be experiencingdifficulties with ambulation and would, therefore, be reluctant to leave their homes forthe purpose of an interview. Finally, it was thought that a home visit would provide theresearcher with some insight into the nature of the participants' environments and howthey functioned in these environments.The audiotaped in-depth interviews ranged in length from twenty minutes to oneand one-half hours and were, for the most part, unstructured so that participants weregiven the opportunity to discuss issues that were important to them. The researcher didhave a set of general open-ended trigger questions available (see Appendix E) and,typically, began the initial interview with a trigger question which, in most cases, eliciteda lengthy description of the chronic venous leg ulcer experience. With the exception ofone interview, open-ended questions were used throughout the interviews to encouragethorough and rich descriptions of the phenomenon under study. As well, the researcherasked clarifying questions whenever she had any difficulty understanding what was beingsaid or if more specific explanations were necessary in order that she could fully graspthe issues that were being discussed.In the initial interview with one of the study's ninety-two year old participants,the researcher did fail to facilitate a thorough and rich description of the chronic venousleg ulcer experience. This was due in large part to the fact that the researcher did notrespond in an effective manner to the participant's severe hearing impairment. When itbecame evident that the participant was having great difficulty hearing what was beingsaid to him, the researcher became uncomfortable with the situation and began to usemultiple, closed questions in a probing way and did not allow the gentleman much time39to think about or to respond to these questions. The following excerpt from the verbatimtranscript of the initial interview with this participant illustrates the difficulty that theresearcher was having interviewing this individual:R:^So you exercise then everyday?'P:^That's right.2R:^So you couldn't go swimming? And did that bother you at that time?P:^It sure did.R:^So you wanted to go swimming very badly but you couldn't?P:^That's right.R:^So you went walking but you didn't seem to enjoy that as much as yourswimming.P:^Oh no.Fortunately, the second interview with this gentleman was more in keeping with the kindof researcher-participant discussion that is characteristic of qualitative research. Indeed,a much more in-depth description of the chronic venous leg ulcer experience was elicitedfrom this participant when the researcher made every effort to speak loudly and clearlyand when she asked open-ended general questions and allowed ample time for responses.With regard to the data collection process, it should also be noted that secondinterviews were conducted approximately four weeks after the initial interviews. In asecond interview the researcher did take the opportunity to validate findings and clarifyinformation from the first interview to ensure that the data and the researcher's"R" is used to identify the researcher in the body of this chapter."P" is used to identify the participant in the body of this chapter.40interpretations of the data were accurate. As well, the researcher asked questionsrelated to the themes that were emerging as the data were being analyzed.Field notes were made following all home visits. In these notes the researcherdocumented observations related to each participant's physical appearance, mental status(affect, cognition, and mood), home environment, and ability to function in theirenvironment. Additionally, verbal information was documented that had not beenaudiotaped (e.g., comments that a participant would make before the interview began oras the researcher was leaving the participant's home) as were the researcher's thoughtsand feelings in relation to her experience with the participant. These field notes becamepart of the data base and helped facilitate interpretation of the data.Data AnalysisIn keeping with the phenomenological method, the process of data analysisoccurred simultaneously with data collection. Hence, data analysis began after the firstinterview with the first participant. Following the transcription of an interview by atypist, the researcher replayed the audiotape and compared it to the transcript.Transcription errors were corrected to ensure that the account was verbatim. Inaddition, the researcher made notes on the transcript with regard to changes in theparticipant's voice or tone and significant pauses or inflections which may have indicatedthat an issue was very meaningful or emotionally charged (Field & Morse, 1985).Following the initial steps that have been described above, the data from thetranscripts were analyzed with direction from the constant comparative method of dataanalysis (Hutchinson, 1986) and Georgi's (1975) interpretation of the phenomenologicalmethod. More specifically, a transcript was read through in its entirety so that theresearcher could gain a sense of the whole experience for that participant. Subsequent to41this, the transcript was read again in a purposeful manner and significant statements orphrases were extracted, reflected upon, and assigned meaning based on the researcher'screative insight, which remained faithful to the original data. Redundancies amongmeaning units were eliminated, the units were elaborated upon or clarified as necessary,and then these units were clustered into more abstract themes. Following this, theresearcher moved from one transcript to another for the purpose of identifying commonthemes and variations within these themes. At the same time, common themes andvariations that were emerging were validated and clarified with the study's participants.Finally, common themes, with identified differences serving as their boundaries, werethen "fleshed out" and synthesized into a description of the chronic venous leg ulcerexperience that was representative of all the participants' experiences with thisphenomenon. This description of the essential structure of the chronic venous leg ulcerexperience is presented in Chapter Four.Scientific Adequacy Of The ResearchEvery qualitative research study must address issues related to the rigor orscientific adequacy of the inquiry. Adequacy of the qualitative inquiry indicates that theresearch processes and outcomes are well grounded, cogent, justifiable, relevant, andmeaningful (Hall & Stevens, 1991). More specifically, the standard of adequacy isachieved when it is determined that the processes of the study were appropriate to theproblem being explored and when the researcher's description of what reality is for thestudy's participants corresponds to the reality that they actually perceive and experience(Hall & Stevens, 1991). In an attempt to deal with the standard of adequacy in a fairlyspecific way, Sandelowski (1986) proposes that Guba and Lincoln's (1981) criteria ofcredibility, fittingness, auditability, and confirmability be used to judge the rigor of a42qualitative research study. The following is a discussion of the ways in which theresearcher endeavoured to achieve credibility, fittingness, and auditability in relation tothe study at hand. Confirmability, the fourth criterion that Sandelowski (1986)addresses, relates to neutrality or freedom from bias in the research process andproduct. This criterion is achieved when credibility, fittingness, and auditability areestablished (Sandelowski, 1986). It is important to note that conclusions regarding thescientific adequacy of this inquiry are not possible until participants have had anopportunity to comment on the study's findings and colleagues provide feedback inrelation to the research findings and this scholarly report.Credibility And FittingnessCredibility and fittingness are criteria related to the truth value and applicabilityof qualitative findings (Beck, 1993; Sandelowski, 1986). Credibility is achieved when theresearcher presents a description of the phenomenon that is being studied and the study'sparticipants immediately recognize this description as being faithful to their own livedexperience (Beck, 1993; Sandelowski, 1986). As well, other researchers and nurses see"truth" in the analytic interpretations that are presented and find them to be meaningful(Sandelowski, 1986). Fittingness is achieved when readers of the research conclude thatthe researcher's analytic interpretations are applicable to contexts outside of the studysituation (Beck, 1993; Sandelowski, 1986). The following strategies were used toestablish credibility and fittingness in this study: (i) ensuring that selection criteria wereadhered to as much as possible so that the data are as representative as possible of theolder adult's experience of living with a chronic venous leg ulcer; (ii) conducting a secondinterview with each participant in order that patterns emerge and the researcher isprevented from "emphasizing a nonrecurring, idiosyncratic episode, statement, or43behavior" (Benner, 1985, p.11), and for the purpose of validating the researcher'sinterpretations of the data with the participants; (iii) documenting personal feelings andreflections throughout the research process in an effort to remain self-aware and toprevent bias when interpreting the study's findings; (iv) presenting data, from thetranscripts, that support the analytic interpretations in an effort to demonstrate that theresearcher has been "true" to the text and has "not read in meanings that are notsupported by textual evidence" (Benner, 1985, p.11); and (v) acquiring validation fromthesis committee members and clinical nursing experts that interpretations of the dataare supported by the text (Sandelowski, 1986).AuditabilityAuditability is the criterion related to the consistency of qualitative findings(Sandelowski, 1986). A study and its findings are auditable when another researcher orreader can clearly follow the thinking, decisions, and methods used by the originalresearcher and conclude that they are appropriate and logical (Sandelowski, 1986).Moreover, auditability is demonstrated when another researcher is able to arrive atsimilar or comparable, but not contradictory conclusions, given the researcher's data andmethodological perspective (Sandelowski, 1986). In this study, auditability is establishedprimarily through a written research report which clearly describes and justifiesdecisions made by the researcher throughout the research process. As well, the reportpresents analytic interpretations which are well founded in and consistent with the data.Ethical ConsiderationsThe following is a description of the ways in which the researcher endeavoured toprotect and promote each participant's right to respect, dignity, information, autonomy,and privacy.44Prior to data collection, written approval for the study was obtained from theBurnaby Health Department and the University of British Columbia's BehavioralSciences Screening Committee for Research and Other Studies Involving HumanSubjects. Ethical standards that were approved by the Burnaby Health Department andthe U.B.C. Screening Committee were adhered to throughout this study.To ensure that potential participants had the opportunity to make an informeddecision regarding their involvement in the research, each was asked to read anIntroductory Letter (see Appendix C) before agreeing to participate in this study. Theletter provided information about the purpose of the study, the nature of participantinvolvement, and participant rights. Interestingly, none of the potential participantsread the Introductory Letter. One woman told the researcher that she had misplacedher glasses and consequently could not read the letter. All of the other individualsglanced at the letter for a moment and stated that it appeared to be "OK", hence theywould not need to read it in any detail. It is not known whether this latter group ofelderly individuals had visual impairments which made it difficult for them to read therelatively small black print which was presented on a white background. To ensure thatconsent would be informed, the researcher read the Introductory Letter to each of theindividuals and answered any questions that they had. In order to further promote eachparticipant's right to information, all individuals who participated in this study wereverbally advised that they were welcome to study results after the research had beencompleted and the thesis written.In an effort to protect each participant's right to autonomy, the researcherensured that these individuals understood that involvement in the study was strictlyvoluntary and that non-participation would in no way affect current health care or45health care that may be required in the future. This information was documented inboth the Introductory Letter and the Participant Consent Form (see Appendix D), eachof which was read aloud to the participants. The foregoing documents also clearlyoutlined that, if an individual agreed to participate in the study, s/he could refuse toanswer any questions asked, request to have information removed from the audiotapes,or withdraw from the study at any time without jeopardizing current or future healthcare. Finally, the researcher required that each participant provide written consent (seeAppendix D) to participate in the study prior to the initial interview.In this study the researcher also endeavoured to protect each participant's rightto privacy in a number of ways. First, all of the audiotapes and transcripts were codedand only the researcher knew the identity of the participants. Second, access to theaudiotapes and transcripts was limited to the researcher, thesis committee members, anda typist. Third, participants were informed that audiotapes and transcripts were to bedestroyed when all scholarly reports had been written.Finally, it is important to note that the researcher made a moral commitment to,at all times, act in a manner which was considered to be in the best interests of each ofthe participants. For example, the researcher felt herself obligated to notify a home carecoordinator if information obtained from a participant was considered to have significanthealth-related implications or was viewed as life-threatening. In addition, the researcherwas prepared to listen and to respond therapeutically to a participant if discussion inrelation to the participant's leg ulcer experience elicited feelings such as sadness orhopelessness.46SummaryPhenomenology was the research method selected for this study as this method,unlike more empirical approaches, helps the researcher to more fully understand thenature of the chronic venous leg ulcer experience from the perspective of the community-dwelling older adult. Consistent with the phenomenological approach, the purposivemethod of nonprobability sampling was used to select six elderly individuals who wereable to describe the experience of living with a chronic venous leg ulcer from theirperspectives. Audiotaped interviews, which were transcribed by a typist, were conductedover a six week period in the participants' homes. The data from verbatim transcriptswere analyzed with direction from the constant comparative method of data analysis andGeorgi's (1975) interpretation of the phenomenological method. The result of the dataanalysis process was a description of the essential structure of the chronic venous legulcer experience which is presented in the next chapter.47CHAFFER FOURFINDINGS AND INTERPRETATIONIntroductionIn this chapter, the findings of the research are presented in the form of aninterpretive description of the older adult's lived experience with a chronic venous legulcer. This description evolved as the researcher utilized the phenomenological methodof data analysis to interpret the participants' explanations of their experiences. Hence,the description of the chronic venous leg ulcer experience that is presented in this chapterrepresents the collective experience of the study's participants as the researcherunderstood it. Essentially, the participants in this study described three distinct facets ofthe chronic venous leg ulcer experience, which together represent the essential structureof the experience. These three facets are presented as three sequential phases of a "livingwith a chronic venous leg ulcer continuum," as the participants in this study depicted thechronic venous leg ulcer experience as a linear passage, of sorts, with a beginning,middle, and an end.In the first phase of the continuum, participants experienced the effects of livingwith this particular circulatory disorder. They encountered losses in relation to physicalendurance, gratifying activities, companionship, and predictability in their lives. Inaddition, the participants experienced a gain as a result of having the leg ulcer, thatbeing the emotional support afforded them by certain health care workers. In thesecond phase of the continuum, participants evaluated how significantly their chronicvenous leg ulcer had made an impact on their lives. More specifically, they made a48judgment with regard to the overall effect that the losses, which were associated with thecirculatory disorder, had had on their lives. In so doing, the participants determinedthat their chronic venous leg ulcer had been either detrimental or inconsequential withregard to their quality of life. Then, in the third and final phase of the continuum, theparticipants coped with their circulatory disorder in one of two distinct ways. Eachparticipant either "put their life on hold" if they had appraised their leg ulcer as beingdetrimental to them, or they "got on with life" if they had appraised their leg ulcer asbeing inconsequential.As one final point, it is important to note that, in addition to validating findingswith the study's participants, the researcher did consult with two expert home carenurses with regard to her interpretation of the chronic venous leg ulcer experience. Thiswas deemed an essential step in the interpretive process when the data suggested that twoof the study's participants, although very similar amongst themselves, differedsignificantly from the other four participants in the study with regard to certain aspectsof the venous leg ulcer experience. The expert nurses were of the opinion that thisfinding was not an anomaly because, in their own clinical practice, they had frequentlyencountered clients with chronic venous leg ulcers who seemed to fall into one of the twocamps described here; they would either "survive" and "carry on" or become"victimized" by their leg ulcer experience.Experiencing The Effects Of The Chronic Venous Leg UlcerEach of the participants in this study explained that their chronic venous leg ulcerhad affected their life in a variety of ways. Some participants commented that they hadinitially been surprised by the many ways in which one's life could be impacted by thiscirculatory disorder as they had heard very little about the disorder before they began to49experience the effects of it. As one woman commented, "I never heard of [chronicvenous leg ulcers]. I asked around about it [and] nobody had heard of it either." Whentalking more specifically about the ways in which their lives had been affected by theirchronic venous leg ulcers, participants recounted the numerous losses that they hadencountered and, in addition, described a positive side to living with this circulatorydisorder.Encountering LossWhen asked about what it is like to live with a chronic venous leg ulcer,participants discussed ways in which their lives had been negatively altered or changed asa result of chronic venous insufficiency and the complication of a venous leg ulcer.Although each participant's story was unique, common themes emerged with regard tothe unwanted changes that had occurred in these individuals' lives. More specifically,they talked about a decline in physical ability, having to relinquish valued activities,feeling isolated at times, and having to now live with a medical condition that is sounpredictable. In essence, the participants were describing losses that they hadencountered as a result of their circulatory disorder. The following is a discussion of thestudy's findings in relation to the four types of loss that were described by theparticipants: loss of physical endurance, loss of gratifying activity, loss ofcompanionship, and loss of predictability.Loss Of Physical EnduranceMost of the participants in this study reported that their chronic venousinsufficiency and venous leg ulcers had contributed in a significant way to their inabilityto stand for long periods of time or to ambulate for more than short distances withoutresting. They identified leg discomfort, described as either a "pain" or an "ache" in the50leg, and muscle fatigue as the primary factors that limited their physical endurance orstamina. In terms of muscle fatigue, which was most often talked about in relation tothe leg muscles, several participants commented that they were "tuckered out" or"drained" after walking short distances in their homes. One woman effectivelycommunicated the impact that pain has had on her physical endurance when she relatedwhat she had told the doctor when he asked her about her ability to get around in herhome:I said I get up [and] walk across the floor and the pain is terrible. Youcan't get from [the bedroom] out to the kitchen. Oh, I sat down andsaid, "Oh my God. Put your feet up. Take that weight off your leg."And then [I'm] not satisfied yet.Another participant commented that because of her "tired and painful legs" she wasonly able to walk to a nearby mailbox before she had to sit down. For this same reason,she also had difficulty walking to her car in the underground parking lot of herapartment building.Several participants used mobility aids such as canes or walkers to help themwalk greater distances. They found that their leg discomfort and muscle fatigue werealleviated, to some degree, when they were able to shift some of their weight onto thesupportive device when walking. One woman, who normally used a cane or walkerwhen ambulating in her home, also found that because of her limited physical endurancethe use of a wheelchair was necessary when she left her residence.Loss Of Gratifying ActivityEach of the participants spent a considerable amount of time talking aboutactivities they could no longer participate in as a result of their circulatory disorder.Discussions centered around relinquished activities that participants wished they couldonce again engage in as they had been the source of a great deal of pleasure and sense of51accomplishment in the past; they were activities that had been gratifying and contributedto a sense of well-being. Participants talked most frequently about not being able towalk longer distances, shop in malls, travel, attend social functions, donate time as avolunteer, and partake in some of their favorite recreational activities. A few individualsalso said that they missed not being able to perform certain basic activities of daily livingsuch as cooking and cleaning.A lack of physical endurance was the reason given most often for a participant'sinability to engage in an activity that had once been gratifying. One woman explainedthat she couldn't "walk that well" and because of this "you're tied down, certainly. Youcan't do certain things. I'd love to be able to go out and shop in the stores and all and Ican't do that." Similarly, another participant expressed a strong desire to be able tostroll through a shopping mall. She had not been able to do this for many years as herlack of physical endurance had forced her to limit her shopping excursions to one storethat had handicapped parking nearby:Like I've never been in Metrotown [shopping mall]. Just like intoWoodward's cause you just go in and out and there's handicappedparking. I have a handicapped sticker of course. And as far as the restof the place [Metrotown mall], I've never been through it.Another woman, who had been very active in sports for most of her life but who wasnow having difficulty ambulating for even short distances because of the discomfortassociated with her leg ulcers, commented that she "can't get mobile, like operational"and that she wished she could do simple things like "just go outside and run or jump" or"walk out to the car with [the nurse] or anybody else that comes in." finally, oneparticipant provided an example of how her inability to stand for long periods of timemade it difficult for her to attend certain social functions:52I don't go to cocktail parties cause if I ever end up with a teacup in myhand...you know people standing around drinking tea...I can't do that.Everybody else is standing around talking. I have to go and get a chairand sit by myself because I can't stand on my feet and people don'tunderstand. They think I'm antisocial.This individual also commented that she really enjoyed being with people but feltembarrassed in social situations such as the one described above; it was this feeling ofembarrassment that contributed to her desire to avoid social activities altogether.Several participants explained that they had to forego certain activities becausetheir treatment regime interfered with the activities. For example, one gentleman wasnot able to go swimming—his favorite pastime—because it had been recommended that henot get his leg ulcer dressing wet. Another participant stated that she very seldom wenton a holiday because she found it too difficult to travel with a large box of dressingsupplies: "It's chiefly travelling [that I can't do]...you see, you've got to take all yourmedications and your medicines with you, your bandages and everything...a whole boxof things." For yet another participant, a more lengthy bus trip for senior citizens wasout of the question because of the recommendation that she keep her legs elevated asmuch as possible to reduce her edema and leg discomfort:Now today, I could have gone with the what they call a volunteer serviceand they had a trip out to Elwood Lake you know. And I thought, "Ohthat's too long" because [the bus] picked you up before noon and youwouldn't be back home before 4:30. And yes, I could take the wheelchairbut you see your legs are not elevated. ...[Your legs] are down all the timeyou're in [the bus] and it's quite a long trip.This woman also felt that if she could not adhere to the recommendation that she keepher legs elevated as much as possible, her legs would start "paining" and as a result shewould not feel "social" or "good" and would not enjoy herself on the bus trip.53Loss Of CompanionshipMany participants commented that at times they felt lonely and isolated as aresult of having to relinquish certain activities that had been a source of fellowship withfriends and acquaintances. One participant, who rarely left her home anymore,conveyed the impact that her circulatory disorder has had on her ability to socialize withothers: "Well, I've always been good at socializing with people. I've never had aproblem and now I'm strung up by the heels." Curiously, this woman reported thatsince she had become isolated in her own home she no longer had the ability to socializeas she once did even if given the opportunity to. For example, she had difficultytolerating more than a few people in her home at once:And also I don't like having too many people in the room at the sametime. It bothers me. ...Well, I get feeling as if I got noises in my head. Itaffects my ears. Geez, like having alot of bells ringing all at the sametime...buzzing in my ears.Another participant explained that when he was not able to go swimming everyweekday, he not only missed the activity but he missed seeing all his friends in theswimming group as well. It was evident that his relationships with his swimming buddieswere important to him as he even expressed concern for what they experienced when hewas unable to go swimming. "They just wonder why I'm not there. They miss me," hestated. For this man, then, his venous leg ulcer meant a loss of companionship not onlyfor himself but for his friends as well. As one final example of how the relinquishmentof a certain activity resulted in a loss of companionship with others, one woman talkedabout the sense of isolation and disconnectedness she had experienced when her friendswent travelling and she didn't feel that she could go with them: "Well the boatcruises...all my friends have been and I feel I can't and I shouldn't be on those and theygo out and do that." This participant refrained from travelling with her friends because54she felt as though she had too much difficulty getting around and it would have been tootroublesome for her to transport her large box of dressing supplies.Lass Of PredictabilityAll of the participants in this study explained that, in many respects, there was agreat deal of uncertainty or unpredictability associated with their chronic circulatorydisorder. The recurring nature of the condition was particularly difficult for theparticipants to come to terms with as they often felt vulnerable, as though they were justwaiting for the inevitable to happen. "You never know. It might go for a year ormore...but they'll break open some time or other because the skin is too weak," onegentleman stated. Another woman had this to say about the recurring nature of her legulcer: "And then it'll go away and maybe it'll come back and maybe it won't. ..you can'tsay." Some participants also commented that they were often surprised by the fact thata seemingly harmless occurrence could give rise to the formation of a venous leg ulcer.For example, one woman described feeling shocked when a leg ulcer developed after she"nicked" her skin when applying her elastic support stocking. Another woman explainedthat on one occasion her cat had scratched her leg and, as a result, she had developed avenous ulcer which took nine months to heal. Other participants reported that they hadbeen surprised when an ulcer developed after they had simply "knocked" their legagainst the corner of a chair or a cupboard door.In addition to not knowing when a venous leg ulcer might develop and what theprecursor to its formation might be, the participants had no idea how long their currentleg ulcers would take to heal or if they would heal at all. "I thought that [the currentvenous leg ulcer] would start healing right away but it didn't.. .so I don't know how longit will take," one woman remarked. This same woman also stated that she felt confused55as she did not know why a "little open spot" just above her leg ulcer had healed within afew days and, yet, her current ulcer had not healed in years. Another participantconveyed her uncertainty in relation to the healing process when she stated:I thought [the venous leg ulcer] looked as if it was actually getting to the[healing] point. [I thought] maybe in another week or two I'd have a skinon it.. .it's never happened. Mind you, it's filling in and it is improving.It's not that I deny the nurses when they tell me it's improving [because] Ican see that it is.. .but how long will it take to heal? Is it going to beChristmas before I'm going to be able to walk around without a bandage?This participant, like many others in the study, emphasized that one of the primaryreasons it was difficult to predict healing time was that there was such an air ofuncertainty surrounding the effectiveness of the various leg ulcer therapies. Many ofthese individuals described having had high hopes for a particular topical therapy, onlyto have had them dashed when their physician discontinued the treatment and prescribedanother that was thought to be more effective. In addition, a number of participantshad undergone skin grafting procedures that had been highly touted by their physiciansas being the "best solution to the problem," only to find that the grafts would not "take."On a final note, it was discovered that, as a result of having to endure many failed legulcer treatments, a number of the participants had become rather skeptical of theirphysicians' advice and abilities. One woman's comment about her experience at theWound Healing Clinic certainly illustrates the sense of disillusionment that a number ofthe participants felt: "[One doctor's] got so much he wants to do.. .then another guycomes along and he wants something else. They don't know bugger all. ...I said [to thedermatologist], 'I'm not going back to the Wound Clinic again."Encountering GainAs was mentioned, the participants in this study also reported that there hadbeen a gain associated with their chronic venous leg ulcer experience. Specifically, they56explained that their circulatory disorder had not been "all bad" because it had affordedthem the opportunity to receive emotional support from home care nurses andhomemakers who were involved in their care. Of import was the finding that most ofthe participants felt that the emotional support they had received from the home carenurses was of far greater importance to them than the physical care they had received inthe form of dressing changes to their leg ulcers. Indeed, these individuals wished thatthe home care nurses would visit more often "just to talk."When the participants were asked to be more specific about the nature of theemotional support they had received from the nurses, they talked, for the most part,about the fact that the nurses were "good listeners" and seemed to really care about theirwell-being. One woman stated that she had felt as though the nurses were genuinelyconcerned about her after her husband had died. She also commented that it had beeninvaluable for her to share her grief with someone on a regular basis: "[The home carenurse] would visit me in the morning and I'd have somebody to talk to...it helped me[after my husband died]." Another participant remarked that he always enjoyed seeingthe home care nurses because he liked their "presence." "I enjoy talking to them" and"[the home care nurses] are so happy and they listen," were some of the other remarksmade by participants as they explained why they appreciated having home care nursingvisits.Finally, it should be noted that one of the study's participants appeared to haveexperienced considerably more gain from her circulatory disorder than did the otherparticipants. This woman, who had become homebound and quite isolated in the lastfew years, reported that her home care nurses and homemaker fulfilled a "spiritualneed" that she had. She was unable to clearly articulate what she meant by the term57"spiritual need," but she did explain that a number of significant people in her life,namely her ex-husband and her mother, had not given her what she "needed." Whenshe made reference to her homemakers and nurses it was clear that she had become"attached" to them and thought of them in a very personal way. For example, shetalked frequently about how much she liked one of the home care nurses who wouldoccasionally come to change her dressing: "[The home care nurse] came out to visit andwe talked and she and I got along like a house on fire. She's an Aries like me so weunderstood each other." When this same nurse voiced her disagreement with theparticipant in regards to a certain issue, the participant felt hurt. "I was a little bit hurtwhen [the home care nurse] showed that she doesn't always understand me. I thoughtwe had a real thing going between us," she stated. Finally, the participant talked abouthow important her homemaker had become to her and how close she felt to this womaneven though she believed that the homemaker took advantage of her at times:Now [the homemaker] and I are good friends...I can't have anybodydoing things for me that is not my friend. ...I think [the homemaker]takes advantage of that and me but, nevertheless, I realize that she has avery bad background and she's overcome alot. ...I can't discard her as ifshe weren't good to me anymore. She's a person and I appreciate her....I respect and like [the homemaker] so much and love her as if she weremy own daughter, even if I get angry [at her].With regard to this participant, then, it appeared as though she had benefitedsignificantly from her chronic venous leg ulcer experience as she had been afforded theopportunity to develop the kinds of relationships with others that seemed to fulfill a"spiritual need" that she had.In sum, the participants in this study experienced various losses in relation totheir chronic venous leg ulcers. The losses pervaded many aspects of these individuals'lives and were often interrelated. For example, the loss of physical endurance often58resulted in loss of gratifying activity which, in turn, led to loss of companionship withfriends and acquaintances. In addition to encountering loss, the participants alsoexperienced a gain as a result of having a chronic venous leg ulcer. Specifically, theywere given the opportunity to have other individuals available who would listen to theirconcerns and care about their well-being, namely home care nurses and homemakers. Itis important to note at this point that even though there was a positive side to having achronic venous leg ulcer, the experience was still overwhelmingly one of loss. Following,is a discussion of the significance participants attributed to the effects of their chronicvenous leg ulcers.Evaluating The Significance Of The Chronic Venous Leg UlcerA particularly interesting finding of this research was that each of the study'sparticipants had made an evaluation of how significantly their chronic venous leg ulcerhad impacted on their life. Furthermore, the data suggest an apparent relationshipbetween the significance that a participant attributed to his/her chronic venous leg ulcerand the coping behaviour that was exhibited in relation to the circulatory disorder. Tobe more precise, the researcher interpreted the data to mean that the participants in thisstudy appraised their leg ulcers as being either "detrimental" or "inconsequential" withregard to what they termed "living a normal life" and then, based on their appraisal,coped with the circulatory disorder in one of two distinct ways. This section of thereport further explores findings in relation to the "appraisal" aspect of the chronicvenous leg ulcer experience. Subsequent to this section is a discussion of the ways inwhich participants coped with their leg ulcers.59Appraising The Chronic Venous Leg Ulcer As DetrimentalIn terms of appraising the significance of their chronic venous leg ulcers, two ofthe study's six participants concluded that developing leg ulcers was the worst thing thathas ever happened to them in their lives. "I've had a broken hip and I got over that.I've had a broken wrist. I've had a broken ankle. ...That wasn't bad. ...[But] I thinkthe ulcers are the worst," commented one woman who was evidently concerned about thefact that her leg ulcers had not healed as readily as her fractures had. This woman, whonow labelled herself as "disabled," also stated that her life had been "fairly good" andthat she had "enjoyed life" before she developed the venous ulcers. Now, her life was"not normal" and was, in fact, "miserable." The other participant talked at great lengthabout how her chronic venous leg ulcer had "ruined" her life because it had preventedher from "living a normal life." Surprisingly, this participant described her leg ulcer asbeing more devastating to her than the death of her young son in a plane crash manyyears ago.At this point in the discussion the reader may be wondering how an individualcould perceive of a chronic venous leg ulcer as such a detrimental force in their life.Interestingly, data from interviews with the two participants in this group does offerinsight into this matter. Essentially, both of these homebound individuals did not feel asthough they were living normally because they could not do what they wanted to do; theycould not partake in desired activities. As one woman remarked, "[It's] not a normallife because you don't do things you care to do." Similarly, the other woman commentedthat she had been "mentally psyched out of doing what [she] wanted to do" in lifebecause she always said to herself: "Oh, I can't do that [because] I'll have to stand."When asked about how her life would be different if she were living what she considered60to be a "normal life," this same participant responded by relating three wishes that shehad; dreams that would be fulfilled if she were able to live normally. First, she wouldtake a bus trip up north to Prince George to visit her son's grave because, as she stated,"I might not get another chance. ...I'm getting older and I know that." This woman alsoremarked that if she were able to live normally she would travel to Banff because shehad never seen the icefields or Lake Louise. Finally, this participant envisioned a"normal life" as one that included the occasional outing to a baseball game: "I [would] goto a baseball game. I get it through the TV but I'd love to go and see the Canadiansplay at Nat Bailey Stadium." When asked the same question, the other participantdescribed a life in which she could bowl and partake in a number of other recreationalactivities, one of which was jogging: "If I could get rid of the ulcers, boy you'd see meout jogging. You'd see me going down the street..."From the foregoing discussion, it is apparent that what the participants referredto as "having a normal life" is, in essence, what nurse theorists regard as "having a goodquality of life" or "experiencing life satisfaction." Thus, it would seem that these twoindividuals were conveying to the researcher their feeling that they no longer experiencedtheir everyday lives as having quality or as providing a sense of satisfaction and well-being. This does not seem surprising because for these participants a good quality oflife, or being able to live life to the fullest, was inextricably linked to their ability topartake in gratifying activities. Indeed, getting out and doing things is what theseindividuals believed life to be about. Consequently, when their venous leg ulcers made itdifficult for them to be involved in desired activities, they experienced life as beingmiserable and unsatisfying. From the perspective of these participants, then, their61chronic venous leg ulcers were highly significant in their lives as they were viewed as adetriment to the actual quality of their lives and to their well-being.Even though each of the participants in this group experienced a number ofdifferent losses as a result of their chronic venous leg ulcer—losses in relation to physicalendurance, gratifying activity, companionship, and predictability—only a few of theselosses were significant enough to the individual so as to be perceived as detrimental totheir quality of life. Specifically, the data suggest that the participants in this groupbelieved that losing their physical endurance and, hence, the ability to partake ingratifying activities had been ruinous to their lives, while losses in relation tocompanionship and predictability had not. It would seem, then, that companionship andpredictability were not at the heart of what made life satisfying for these individuals and,consequently, their loss was not perceived to be as injurious as the loss of physicalendurance and gratifying activity. Of course, one could argue that the loss ofcompanionship might have been equally as devastating for these individuals but thattheir energy had been directed toward lamenting the more tangible source of this loss,the loss of gratifying activity. Yet, this proposition seems somewhat unlikely as many ofthe activities that these individuals wished they could participate in were solitaryactivities. Furthermore, in their discussions they emphasized the "doing" aspect of alonged for activity more so than the "socializing" aspect of it.There are two other findings that offer insight into why this group of participantsregarded their chronic venous leg ulcers as such a detriment to their quality of life.First, these two participants differed from the other individuals in this study in that theyfelt that having the leg ulcers had stripped them of a sense of dignity they had onceexperienced when they did not require assistance with activities. "I hate like hell to be62helpless. ...I don't care to have somebody want to take care of me while I'm out oranything. I like to be independent, you know.. .more or less on my own," one womanremarked as she described how she felt when others had to push her wheelchair for heror help her ambulate with a walker. The other participant described feeling depressedand useless as a result of having to rely on homemakers to manage her home:Well one of the reasons I feel so terribly depressed [is that] I get theterrible feeling I'm sitting here, you might say, being subsidized by thegovernment. I can't pay for my homemakers and I have to have 'emseven days a week now. And so here I am. I'm a parasite on society.For these women, their chronic venous leg ulcers represented not only the losses thathave been previously discussed, but they signified a loss of independence and a loss ofdignity as well.It should be noted that, with regard to their loss of independence, both of theparticipants described above experienced a sense of frustration that was often manifestedas criticism towards their homemakers. For example, one woman explained howunhappy she was that her homemaker could not prepare as tasty a meal as she herselfhad once been able to prepare: "I don't know about you, but the way they cook, theydon't cook the way I did." The other participant conveyed her feeling of frustrationwith homemakers, who had worked for her in the past, when she made the followingremark:My experience has been with homemakers is that most of them are poorlyeducated or neurotic [and] can't get a job anywhere else. If there wereplenty of jobs, then I got the dregs of society.. .people who don't evenkeep themselves clean.This same participant was very fond of her current homemaker but had this to say abouther homemaker's housekeeping skills: "[The homemaker] comes in here.. .and rattlesaround in [the kitchen] and I hear things dropping and I know very well the next time I63go in that kitchen there's going to be one hell of a mess." Once again, this woman'scomment revealed the sense of frustration she was experiencing as a result of needingsomeone else to clean her kitchen, an activity that she herself had once enjoyed.The other finding, that sheds a little more light on why the participants in thisgroup appraised their chronic venous leg ulcers as detrimental, relates to their belief thatbecause of their leg ulcers they would have to endure a dismal future. One participant,who claimed that her venous ulcer was improving, still felt that she would never be"finished with" her circulatory problem and that she would never lead a "normal life."She described her future this way:And all along I knew what the end was going to be. I could almost seethe writing on the wall. I'm not psychic but I got a strong intuition and Icould see into the future. And yet, I said to myself "Now stop beingmorbid."...I just had a vision in my head about twenty, thirty years agoof maybe ending up in a wheelchair and it looks as if I'm heading thatway.The other participant explained that, because of her decreased physical endurance andinability to partake in many activities, her long-term care worker had placed her nameon a waiting list for admission to a "home." This participant was very resistive to theidea of entering a facility at this point in time but her comments to the researcherindicated that she had accepted that this may be her only alternative in the future."[The long-term care worker] said, 'Do you think you want to go into a home?' I said,'No I don't yet. As soon as I lose my marbles and I'm not copacetic I might, but fornow I'll stay here'," she stated on one occasion. It was also apparent that she was quitedistressed about the suggestion that she enter a facility that, in her mind, was for peoplewho were mentally incompetent. Another remark that she offered demonstrated theeffort she was making to resist succumbing to what she believed would be a dismalfuture: "[The long-term care worker] asks me when I'm going into the Old Folk's Home64and I say, 'When I lose my marbles I'll go.' But I don't think I'll go yet. I'm going totry and hang on for awhile yet." From the preceding discussion it is evident that theparticipants in this group experienced their chronic venous insufficiency and venous legulcers as a detriment to their quality of life not only in terms of the present, but withregard to their future as well.The emotional responses that these participants described and demonstrated werecertainly consistent with their belief that developing chronic venous leg ulcers is the worstthing that has ever happened to them in their lives. One participant cried frequentlythroughout the first interview when she described what it has been like to live with a legulcer. During this interview many of her comments were delivered in an angry andsomewhat fearful tone and at one point she even remarked: "I wish I never had [thevenous leg ulcers]. Why did I get them?" She also stated that she often felt "down" andthat "some days are a struggle." As well, this woman described feeling frustrated withmany aspects of the experience. "I am fed up with this," she stated. The otherparticipant in this group described emotional responses that ranged from fear, anger,and frustration to despair. She also commented that living with her leg ulcer had been a"combination of burden, hardship, and worry." The enormous emotional toll that thisexperience had taken on this woman was never so evident as when she explained howdepressed she had become as a result of having to live with her circulatory disorder forso many years:I have been so depressed this past year. This [current venous ulcer]started in September but I have been so depressed thinking back to theprevious three years. I've been so depressed and I hinted around toseveral of the nurses that I knew how to take my own life if I got to thatpoint. And I said to [the home care nurse], "You know I'm kind ofworried...I don't want to take my own life...I know it's a sin against Godand I'm not about to do that.. .but at the same time I'm afraid that in a65weak moment that I might and I know how to do it. ..I've got an easyway."In sum, two of the study's six participants appraised their chronic venous legulcers as having had a very significant impact on their lives. Indeed, each of theseparticipants regarded their leg ulcers as having been detrimental to their quality of lifeand well-being. Interestingly, the data suggest that these individuals were particularlydevastated by their circulatory disorder as it had rendered them incapable ofparticipating in many desired activities and, from the perspective of these participants,their quality of life was inextricably linked to their ability to partake in gratifyingactivities. As well, the chronic venous leg ulcers represented a loss of independence anddignity for these participants and were the primary reason these individuals envisioned adismal future for themselves. Curiously, the other four participants in this study viewedtheir chronic venous leg ulcers in a very different light. The following is a discussion inrelation to how this second group of participants appraised their venous leg ulcers.Appraising The Chronic Venous Leg Ulcer As InconsequentialIt was particularly intriguing, in light of what the other group of participants haddiscussed, to find that each of the four individuals in this second group had appraisedtheir chronic venous leg ulcer as being inconsequential with regard to what they alsotermed "living a normal life." "Just normal...I felt just normal," one gentleman statedwhen asked what it was like to live with a venous leg ulcer. Similarly, the otherparticipants described their lives as being "just normal" and not having changedsignificantly since they had developed their circulatory disorder. As with the other groupof participants, it was apparent that these individuals were using the term "living anormal life" in the same way that nurse theorists might use the terms "living a life thathas quality" or "living a satisfying life." Thus, it would seem that these four participants66were conveying to the researcher their feeling that they still experienced their everydaylives as having quality, or as providing a sense of satisfaction and well-being, despite thefact that they were living with a chronic circulatory disorder.At this point it should be noted that even though these participants viewed theirchronic venous leg ulcers as being of little consequence with regard to living a satisfyinglife, they did report that the leg ulcers were "annoyances" or "inconveniences" in theirlives. As one woman remarked, "The only thing I can say is that [the venous leg ulcer]is kind of annoying to have." When asked to elaborate on the annoying or inconvenientnature of their venous leg ulcer, the participants talked primarily about the losses theyhad experienced as a result of their circulatory disorder. Thus, for these individualslosses in relation to physical endurance, gratifying activity, companionship, andpredictability were considered to be annoying or inconvenient rather than devastating orruinous. It is also noteworthy that, in sharp contrast to the first group of participants,none of the individuals in this latter group indicated that they had experienced a loss ofindependence or dignity, or a sense of foreboding with regard to the future, as a resultof their chronic venous leg ulcers. Rather, they talked about episodically feeling"bothered", "disappointed", or "discouraged" with their leg ulcers. Additionally, a fewparticipants commented that they felt a little worried at times. "Well, [my venous legulcer] is not really a big worry you know...it's a little [worry]," one woman remarked.With regard to this second group of participants, then, it was evident that the emotionssurrounding their venous leg ulcer experience were much less intense and all-embracingas compared to the emotions experienced by the first group of participants. Thisdiscovery, that the latter group of participants did not appear to be emotionally67distressed as a result of their leg ulcers, certainly seems consistent with the finding thatthese individuals' lives had not been detrimentally impacted by their circulatory disorder.From the foregoing discussion the reader might assume that the participants whoappraised their chronic venous leg ulcers as having little consequence in their lives wouldhave less serious leg ulcers as compared to the participants who had appraised theirvenous ulcers as being detrimental to their lives. One might also assume that theindividuals in the former group would have fewer leg ulcers and that, most likely, theulcers were associated with less physical discomfort and limitation as compared to the legulcers that were endured by the latter group of participants. Surprisingly, theseassumptions did not prove to be true in every instance. In fact a few participants, in thegroup that appraised their venous leg ulcers as being inconsequential, had leg ulcers thatcould be classified as more clinically serious than those of at least one of the participantsin the other group. In addition, a few of the participants in the former group had moreleg ulcers than those individuals in the latter group and, as well, they reported similarexperiences with regard to ulcer-related physical discomfort and limitations. Finally, it isnoted that the individuals within each group varied with regard to how long they hadbeen coping with their circulatory disorder. Thus, a participant's appraisal of howsignificantly their venous leg ulcer had impacted their life was not necessarily related tothe length of time venous ulceration had been present, nor was it necessarily related tothe other factors that have been described above.At issue now is why the participants who appraised their chronic venous legulcers as being inconsequential in their lives were able to do so. Data from interviewswith these participants and from the researcher's field notes does, in fact, seem to offersome insight into why this may be the case. To begin, the data suggest that each of the68participants in this group derived a great deal of pleasure and satisfaction in life fromthe close and meaningful relationships that they had with family members. For example,one woman talked frequently and excitedly about how proud she was of her family andhow fortunate she was to have close relationships with her son, daughter-in-law, andgrandchildren. She had this to say about her son:My son is my lifeline cause he's just wonderful! ...I got a terrificson.. .you couldn't beat him. Everybody says, "Where did you get himfrom?" He's just like his father. His father was that type of caringperson, you know, and he takes after his dad. ...I look around me andthink, well I'm lucky.. .I'm so pleased at how he is!This participant explained that her son visited her frequently, as did her grandchildren."Oh, those children, he has wonderful little kids. They're so well behaved...they comehere and you don't even know they're here. They play, just play away. They're terrifickids," she remarked when describing how happy she felt when she was with hergrandchildren.The three other participants in this group also spoke enthusiastically about theirfamilies. In her second interview, one participant spent almost fifteen minutes discussingthe personalities of two of her sons and relating what each of her children were doing interms of their careers. As well, she showed the researcher numerous graduation picturesof her children and grandchildren and commented on how happy she was that one of hersons and his wife would be visiting her that evening. Another participant explained thathe talked to at least one of his children everyday on the telephone and that familymembers would visit frequently. His eyes would light up and he would chuckle as hetalked about the family dinners he attended every weekend. With regard to his homeenvironment, the researcher observed that this gentleman had surrounded himself withfamily memorabilia. For example, in his livingroom, directly across from a chair that he69frequently sat in, was a large console that was blanketed with many photographs of hischildren and grandchildren. Finally, the fourth participant in this group brieflycommented on the content of numerous photographs of her family members. On thewhole, she did not talk as much about her family as the other participants had but shedid state that her children were very important to her and that she always lookedforward to seeing them.The data suggest, then, that the meaningful relationships these participants hadwith family members were, very possibly, at the heart of what made life satisfying forthese individuals. Thus, for these participants a good quality of life, or being able to livelife to the fullest, was inextricably linked to their ability to have meaningful relationshipswith family members. Therefore, the implication is that the individuals within thisgroup may not have appraised their chronic venous leg ulcers as being detrimental toliving a satisfying life as the leg ulcers did not represent a loss that would havethreatened their quality of life; in particular, they did not signify the loss of meaningfulrelationships with family members. For these participants, then, their primary source ofsatisfaction in life remained unchanged by their leg ulcer experience and the losses thatthey did experience—losses in relation to physical endurance, gratifying activity,companionship with friends, and predictability—were perceived as "inconveniences" andof little consequence with regard to living a satisfying life. As a final point, it should benoted that the two participants who appraised their chronic venous leg ulcers as beingdetrimental to their lives had little, if any, family support. One of the participants wasdivorced and her only son had died many years ago; she spoke of no other familymembers. The other participant was widowed and had no children. This womanoccasionally contacted her nephew to ask him to drive her to an appointment, but she70did not see him socially. She made the following comment in relation to her brother andhis wife: "And as far as my people back home.. .1 get a little worried about them.. .butthat doesn't bother me too much because they didn't bother about me anyway toomuch." Thus, unlike the other four participants, it is doubtful that these twoparticipants derived much satisfaction in life from meaningful relationships with familymembers. Rather, their sense of well-being was dependent on their ability to partake ingratifying activities. As was mentioned previously, significant differences between thetwo groups of participants were not limited to the appraisal aspect of the chronic venousleg ulcer experience, but could also be found when one examined the ways in which theseindividuals coped with their leg ulcers.Coping With The Chronic Venous Leg UlcerAll of the participants in this study recounted ways in which they had tried tomanage their chronic circulatory disorder so that they could live as "normal" a life aspossible. In essence, these individuals were describing coping strategies they hademployed for the purpose of preserving or recovering their quality of life. Interestingly,the data revealed an apparent relationship between a participant's appraisal of thesignificance of their chronic venous leg ulcer and the types of coping strategies theyutilized. In other words, similar coping strategies were used by the two participants whoappraised their venous leg ulcers as having been detrimental, but these strategies differedsignificantly from those used by the other group of participants. Furthermore, thecoping strategies that were utilized by a group, when considered in combination,represented a more general coping behavior; a coping behaviour, then, being a behaviourwhich is comprised of an individual's coping strategies and enduring coping style.Hence, the individuals who appraised their leg ulcers as being detrimental used a more71general coping behaviour which the researcher has termed "putting life on hold." On theother hand, a coping behaviour, which the researcher has called "getting on with life,"was utilized by the participants who appraised their circulatory disorder as beinginconsequential. The following discussion in relation to coping is organized according tothe two general coping behaviours that were utilized by the study's participants.Putting life On HoldThe two participants who appraised their chronic venous leg ulcers as havingbeen detrimental to their quality of life appeared to have literally put their lives on holdin an effort to rid themselves of their leg ulcers. Indeed, both of these individualscommented that currently their primary concern in life was that their leg ulcers weremanaged in the best way possible in order that they would have a chance to heal. Ofnote is the fact that both of the participants repeatedly commented that they had been"battling" or "fighting" to eliminate their leg ulcers. "I've had to fight [the venous legulcers]," one woman remarked. In a very real way, then, it appeared as though theseparticipants had put their lives on hold in order that they could "go to battle" againstwhat they considered to be one of their greatest adversaries in life, that being theirchronic venous leg ulcer. Certainly, this aggressive stance in relation to their leg ulcerdoes not seem astonishing when one considers that, from these individuals' perspective,their leg ulcer had robbed them of quality in their life and had threatened their sense ofwell-being. What is a little surprising, however, is the fact that these participants hadwaged a battle against their leg ulcers for many years without ever having come to thepoint of accepting the chronic venous leg ulcers as being a part of who they are.In this "battle" to heal their leg ulcers, these participants utilized a number ofdifferent coping strategies which, when considered in combination, contributed to the72coping behaviour that the researcher has termed "putting life on hold." To begin, thedata suggest that both participants had become very cautious with regard to the activitiesthey would take part in. They talked about being "scared" that they would jeopardizethe healing process or cause a setback if they took part in certain activities. Of note isthe fact that, indeed, both of these participants had experienced what they believed weresetbacks as a result of participating in certain activities. For example, one participanthad become reluctant to ambulate for more than very short distances with her walker asshe had experienced a fall in the past which she felt had jeopardized the healing of herleg ulcers. "I'm trying to be extra careful now," she remarked when discussing why shewas now reluctant to ambulate. The other participant wanted to go and visit her son'sgrave in Prince George but had decided not to as she claimed that her leg ulcer hadstarted "leaking more" during the last bus trip that she had taken. Interestingly, herphysician recommended that she take the trip up to Prince George but as she stated, "Idon't feel it's worth taking any chances." This same woman also claimed that shewanted very badly to attend a tenants meeting in her housing complex but thought shemight decline in the end because the last time she tried to attend a meeting she becameso exhausted trying to get ready that she did not make it to the meeting. "It just wasn'tworth it," she said. Thus, the two participants in this group engaged in a strategy theresearcher has termed "playing it safe" because they did not want to risk losing groundagainst their leg ulcers. Ironically, the use of this strategy resulted in them notpartaking in some of the very activities that brought them enjoyment in life.In the "battle" to heal their leg ulcers, the participants also used a coping strategythat the researcher has termed "being vigilant." They were very watchful over theirulcers and demanded that the ulcers be cared for in the best way possible. This meant73that they were often critical of their physicians and home care nurses if they did not feelas though they were getting appropriate care. One participant conveyed the anger andfrustration she had felt when her home care nurse did not correctly apply a tensorbandage to her leg:The nurses that come in here, most of them don't know how to put abandage on. Well [the home care nurse] at first was resistant. Shethought that I was just a prattling patient. ...I got annoyed with her andsaid, "Look, I've had [the leg ulcer] for years and I've been [applying thebandage] for years. I know what I'm talking about. If you don't put iton right it's not going to be any good at all." So now I've taught her yousee. She listens.Being vigilant also meant that these participants were frequently monitoring thestatus of their leg ulcers and were phoning their physicians regularly to update them onthe status of their ulcers. It was interesting to note that both participants had phonenumbers for physicians and other health care agencies handy at all times and carefullykept track of when they had medical appointments or appointments at the WoundHealing Clinic. One woman even asked the researcher to call the physician to discuss thestatus of her leg ulcer. Thus, by "becoming vigilant" the participants had becomefocused on their leg ulcers and other things in their lives seemed to take a back seat orwere put on hold.Getting On With lifeThe four participants who appraised their chronic venous leg ulcers as havingbeen inconsequential to their quality of life simply got on with their lives. They wereable to do this by engaging in a coping strategy that the researcher has termed "doingthings differently." These participants could no longer do many things in the way thatthey once had but that did not seem to stop them; if they really wanted to do somethingthey would just go about doing it in a different way. For example, one participant had74enjoyed volunteering in a local hospital for many years but when she could no longermanage this, because of a loss of physical endurance, she volunteered to be on fourdifferent phoning committees. Thus, she still was able to participate in volunteer workwhich she found very gratifying. Another participant would go walking if he could notgo swimming because of his leg ulcer dressing. Ile missed seeing his swimming buddiesbut he got the exercise he desired. It was certainly evident that these participants hadaccepted the leg ulcers as being a part of them and were going to carry on in spite oftheir presence. The mindset that these participants had in relation to their chronicvenous leg ulcers was best expressed by one woman who had very severe leg ulcers: "Ican't understand having ulcers so bad they could stop you from doing anything."StumnaryIn this chapter the study's findings in relation to the older adult's subjectiveexperience of living with a chronic venous leg ulcer were presented. The findingsrevealed that the participants in this study moved through three sequential phases of a"living with a chronic venous leg ulcer continuum" as they lived with chronic venousinsufficiency and chronic venous leg ulcers. In the first phase of the continuum,participants experienced the effects of living with their chronic circulatory disorder.They encountered losses in relation to physical endurance, gratifying activities,companionship, and predictability in their lives. These losses pervaded many aspects ofthese individuals' lives and were often interrelated; one loss often gave rise to anotherloss. In addition to experiencing loss, the participants encountered a gain as a result ofhaving a chronic venous leg ulcer. Specifically, they had been afforded the opportunityto receive emotional support from home care nurses and homemakers who were involvedin their care. Participants enjoyed "just talking" with the home care nurse and felt that75they received emotional support from the nurse by way of being listened to and feeling asthough the nurse really cared about their well-being. With regard to the significance ofthis gain, the data suggest that even though there was a positive side to the chronicvenous leg ulcer experience, the experience for these participants was stilloverwhelmingly one of loss.In the second phase of the continuum, participants evaluated how significantlytheir chronic venous leg ulcer had impacted their life. More specifically, they made ajudgment with regard to the overall effect that the losses associated with the circulatorydisorder had had on their lives. In so doing, two of the study's participants appraisedtheir chronic venous leg ulcer as having been detrimental to their quality of life, whilethe other four participants appraised their leg ulcer as having been inconsequential withregard to living a satisfying life. The individuals who determined that their venous legulcers had been detrimental in their lives were particularly devastated by theircirculatory disorder as it had rendered them incapable of participating in many desiredactivities and, from the perspective of these individuals, their quality of life wasinextricably bound to their ability to partake in gratifying activities. Furthermore, thechronic venous leg ulcers represented a loss of independence and dignity for theseparticipants and were the primary reason these participants envisioned a dismal futurefor themselves. Conversely, the participants who determined that their venous leg ulcershad been inconsequential in their lives perceived of their leg ulcers as "annoyances" or"inconveniences" and were not emotionally distressed by their presence. Interestingly,there were no substantial differences between the two groups with regard to severity ofthe leg ulcers, ulcer-related physical discomfort and limitations, or length of time thecirculatory disorder had been present. However, the participants who appraised their76chronic venous leg ulcers as inconsequential did differ in one significant way from theother participants in this study. For these individuals, meaningful relationships withfamily members seemed to be at the heart of what made life satisfying; a good quality oflife, then, was inextricably linked to these participants' ability to have meaningfulrelationships with family members. Consequently, they did not appraise their leg ulcersas being detrimental to living a satisfying life as the leg ulcers did not represent a lossthat would have threatened their quality of life; in particular, they did not signify theloss of meaningful relationships with family members. For these participants, then, theirprimary source of satisfaction in life remained unchanged.In the third and final phase of the continuum, the participants coped with theircirculatory disorder in one of two distinct ways. Each participant either "put their lifeon hold" if they had appraised their leg ulcer as being detrimental to them, or they "goton with life" if they had appraised their leg ulcer as being inconsequential. Theparticipants who put their lives on hold did so because they were "playing it safe" and"being vigilant." Conversely, the participants who got on with their lives were able to doso because the things that they could not longer do as they once had, they just diddifferently.77CHAPTER FIVEDISCUSSION OF THE FINDINGSIntroductionIn this chapter the researcher will further explore some of the study's findings inrelation to the older adult's experience with a chronic venous leg ulcer. In particular,findings in relation to the appraisal and coping aspects of the chronic venous leg ulcerexperience will be examined. First, however, it is important to revisit some of theliterature that was presented at the beginning of this report as it represents, for the mostpart, the health care professional's explanatory model of the chronic venous leg ulcerexperience. What must be determined now is whether there are substantial differencesbetween this explanatory model and the participant's explanatory model of the leg ulcerexperience which was documented in Chapter Four.When one considers the complexity of the experience that was documented in thelast chapter, it seems clear that the literature that is currently available in relation toliving with a venous leg ulcer offers little to further the reader's understanding of theexperience at hand. Not only does it lack complexity but, based on the findings of thisstudy, it could be argued that some aspects of the literature may lack validity as well.For example, Merry (1989) asserted that individuals with leg ulcers not only experience aloss of mobility but often the loss of a sense of independence and freedom as well. Thedifficulty with this assertion is that a very complex idea is presented in such a simplisticmanner that it actually becomes misleading. What the reader of the statement may havedifficulty grasping is that the loss of a sense of freedom and independence may not78necessarily follow a loss of mobility and, in fact, may not ensue in the majority of casesif the results of this study are to be taken into account. Rather, the loss of a sense offreedom and independence will only be experienced if the individual perceives that theloss of mobility has been a threat to their freedom and independence. Thus, the ideathat individuals vary with regard to the meaning that they assign to a given situation hasbeen left out of Merry's (1989) conceptualization of the "mobility" aspect of the leg ulcerexperience. Lamont's (1991) statement that pain and discomfort, in relation to the legulcer, can affect an individual's quality of life is yet another example of how thecomplexity of the experience has been lost. Based on this study's findings, ulcer-relatedpain and discomfort give rise to a loss of physical endurance which, in turn, gives rise toa loss of gratifying activity, and it is this latter loss that is more likely to impact one'squality of life if the individual does, in fact, appraise this loss as a threat to lifesatisfaction. Thus, a great deal of the current literature in relation to the venous legulcer experience lacks complexity, to the point of possibly being deceptive.There are also some positive aspects of the literature that is available in relationto the venous leg ulcer experience. For one, it does convey that the experience is one ofloss even though authors have not necessarily used the term "loss" to describe thechanges that occur in an individual's life as a result of having a chronic venous leg ulcer.In the literature the loss of mobility is identified by a number of authors (Callam,Harper, Dale & Ruckley, 1988; Fitzpatrick, 1989; Lamont, 1991; Merry, 1989) as beinga significant loss associated with this experience. The study's findings support thisassertion with one qualification, that being that the loss could more accurately bedescribed as a loss of physical endurance or stamina. It is important to note that the79literature does not identify two of the losses that were described by participants in thisstudy, those being the loss of companionship and the loss of predictability in life.With respect to the venous leg ulcer literature, it is also noteworthy that a few ofthe assumptions put forth were not supported by the findings of this study. First, anumber of authors (Fitzpatrick, 1989; Lamont, 1991) assume that there is financialhardship associated with the venous leg ulcer experience. Certainly, because of asignificantly different health care system and a different system of social services thismay be the case in the United States, but the findings of this Canadian study did notsupport this assumption. One further point in relation to this assumption is that allparticipants in this study were well past retirement age and, hence, received a pensionfrom the government. If they had been younger, some may have experienced difficultieswith regard to employment and, consequently, experienced some financial hardship. Asecond assumption that proved untrue for the sample in this study was one put forth byLamont (1991). More specifically, she theorized that individuals with venous leg ulcerswould regard home care nursing visits as interfering with their daily lives. In fact, thestudy's findings suggest that this could not be further from the truth; indeed, theparticipants in this study welcomed home care nursing visits and perceived them to beone positive aspect of the chronic venous leg ulcer experience.After revisiting the literature in relation to the venous leg ulcer experience, it isevident that there are some significant differences between the health care professional'sexplanatory model, as presented in the literature, and the client's explanatory model ofthe chronic venous leg ulcer experience as presented in this report. For example,authors have not recognized that the loss of companionship and the loss of predictabilityin life are important aspects of the chronic venous leg ulcer experience. Further, they80have identified difficulties that a client with a venous leg ulcer may experience (e.g.,financial hardship) that were not evident with regard to this study's participants.Finally, the health care professional's explanatory model does not recognize thecomplexity of many aspects of the venous leg ulcer experience that are identified anddoes not address two integral aspects of the experience, those being the appraisal andcoping facets of the experience.At this point, one can also consider whether the related literature that wasreviewed did offer some relevant insight into the chronic venous leg ulcer experience. Tobegin, the findings of this study suggest that there are some similarities between thevenous leg ulcer experience and the stoma experience. Specifically, body imagedisturbances were evident in relation to two participants in the study who were "battling"their leg ulcers, conveying to the researcher, then, that they had not incorporated theirchronic circulatory disorder into their body image. But, unlike many individuals withstomas, the disturbance in body image was not resolved with time. The other fourparticipants in this study did not appear to experience body image disturbances. Withregard to the three categories of problems that Hurny and Holland (1985) identified—physical, emotional, and interpersonal—the findings of this study suggest that many ofthese problems are unique to the stoma experience, particularly problems related tomanagement of the ostomy wound and concerns regarding sexuality. Two of the study'sparticipants did experience social isolation but the causes for this were different fromthose that Hurny and Holland (1985) identified in relation to the individual with anostomy. More specifically, the two participants in this study experienced social isolationas a result of their loss of physical endurance and because they chose to "play it safe"and to not partake in many activities.81The burn literature also seems to have provided insights which are consistent withthe chronic venous leg ulcer experience as described by the participants in this study. Aswith many individuals who are living with burn-related wounds, two of the study'sparticipants talked about "feeling down" and one of these participants even describedfeeling "depressed." What is not clear, however, is whether the depression that may beassociated with the chronic venous leg ulcer experience is similar in nature to thedepression that can be associated with the burn experience. Another interestingsimilarity between the two experiences relates to the idea that psychosocial adjustment tothe wound may depend more on person-related variables than on the nature of thewound. In this study, ulcer-related variables such as severity, duration, and associatedsymptoms did not appear to be determining factors in relation to how the participantsappraised and then coped with their chronic venous leg ulcers. Rather, the data suggestthat it is the individual's perception of how significantly the leg ulcer has influenced theirquality of life that is a key factor in determining how the individual responds to his/herleg ulcer. Finally, in this study there was no evidence that participants had movedthrough distinct stages of adaptation such as those described by Watkins et al. (1988) inthe burn literature. This does not mean that participants in this study did not movethrough stages of adaptation but, rather, that further research needs to be conducted inrelation to the experience of living with a venous leg ulcer over time.With regard to the chronic illness literature that was reviewed, the researcher hasdetermined that there appear to be many similarities between the chronic illness andchronic venous leg ulcer experiences. Even though venous insufficiency and venous legulcers cannot be considered incurable in all instances, the findings of this study suggestthat after the onset of venous ulceration the scenario is primarily one of healing and then82recurrence of the leg ulcer over many years or, in some instances, the venous ulcerationmay never heal. In effect, then, the individual with a chronic venous leg ulcerexperiences a persistent condition, or a condition of long-term duration, that hascharacteristics typically ascribed to a chronic illness. For example, the participants inthis study described adaptive tasks that they engaged in that are consistent with thoseoutlined in the chronic illness literature. Specifically, the participants endeavoured to:(1) deal with symptoms; (2) manage health care regimens; (3) adjust to alterations inbody appearance, in many instances; (4) handle the uncertainty of the progression of thedisease process; and (5) revise personal and social goals (Lambert & Lambert, 1987).In terms of quality of life for the participants in this study, the data suggest thatthere was a significant variable related to these participants' life satisfaction that was notspecifically addressed in the literature related to chronic illness and quality of life:whether or not the chronic venous leg ulcer had had a negative impact on a primarysource of satisfaction in these individuals' lives. To be more precise, the study's findingssuggest that if the leg ulcer had negatively affected a primary source of satisfaction in aparticipant's life, then s/he experienced a life without quality. Finally, the literature inrelation to aging and body image indicates that the older adult may experience thephysical effects of a health problem or chronic illness as losses, just as age-relatedphysical changes are experienced as losses. In this study, the participants did experiencea decrease in physical endurance as a loss and the data suggest that two of theparticipants were in the process of grieving this loss in physical ability. It appeared asthough the other four participants in this study had come to terms with their loss inphysical ability; it is not known whether the process of self-transcendence had a part toplay in this acceptance of loss.83Appraising The Significance Of The Chronic Venous Leg UlcerAs was mentioned, a key finding of this study was the discovery that each of theparticipants had made an evaluation of how significantly the chronic venous leg ulcerhad affected their life and then coped in a way that was consistent with the appraisalthat they had made. The discovery that participants engaged in an appraisal process isconsistent with current thinking in relation to stress, coping, and adaptation. Lazarusand Follunan (1984), in a complex process-oriented theory of psychological stress andcoping, described cognitive appraisal as a process of judgment about the meaning orsignificance of a situation. In effect, the individual encounters a situation which isperceived as being stressful and makes a judgment concerning the significance of thesituation with regard to their well-being and, in addition, considers what might/could bedone to manage the demands that are appraised as stressful (1 azarus & Follunan, 1984).Even though each individual will appraise a stressful situation in a unique way, it iscommonly thought that an event is usually evaluated as either threatening or challengingand a judgment is made with regard to the magnitude of the threat or challenge (Cohen& Lazarus, 1983). Based on this appraisal, then, and factors such as personal and socialresources and situational determinants, the individual chooses a coping strategy whichultimately affects adaptational outcomes (Downe-Wamboldt, 1991).In this study, two of the participants appraised their chronic venous leg ulcers ashaving been detrimental to their quality of life. It is evident, then, that their judgmentwas that the leg ulcers had actually caused these participants harm, rather than simplyrepresenting a threat of harm. The other four participants appraised their leg ulcers ashaving been inconsequential with regard to their satisfaction in life. Of note is the factthat the data did not suggest that these participants construed their leg ulcers as a84challenge in their lives. Thus, the participants in this study did not appear to appraisetheir experience with chronic venous leg ulcers in a traditional way, that is either as athreat or as a challenge. Lipowski's (1969) work in relation to the psychosocial aspectsof disease does shed some light on this finding. More specifically, Lipowsld (1969)described the appraisal process as a process whereby the individual ascribes meaning toillness; meaning evolves from the evaluations and beliefs the person has in relation totheir illness and its likely consequences to their life and to the lives of significant others.Furthermore, the individual can interpret the illness as being insignificant, a threat, aloss, or a gain (Lipowski, 1969). In this study, the chronic venous leg ulcers representedsuch significant losses for two of the participants that they interpreted them as havingbeen detrimental to their quality of life. According to Lipowski (1969), the emotionalresponse to loss is a grief reaction which may at times assume a psychopathological formsuch as a depressive syndrome. Indeed, the findings of this study suggest that the twoparticipants who interpreted their leg ulcers as being detrimental were experiencing adepressive syndrome as a result of their chronic venous leg ulcer experience. Depressionoccurs, then, in relation to loss of such significance that the person feels overwhelmed, orwhen the number of losses exceeds the person's capacity to limit his or her experience ofhelplessness and hopelessness (Schneider, 1984). The interpretation of an illness as beinginsignificant as opposed to being a challenge was more consistent with what the otherfour participants in this study experienced. They had experienced losses in relation totheir leg ulcers but these losses did not influence their quality of life, so the chronicvenous leg ulcer experience was interpreted as being inconsequential or insignificant tothem. It is important to note that Lipowski (1969) does not suggest that an illness maybe interpreted as insignificant for the reason given above. Rather, he proposes that an85individual interprets an illness as being insignificant because of ignorance or indifferencein relation to the illness (Lipowski, 1969).A number of authors have speculated in relation to the factors that influence theappraised meaning of an illness (e.g., Craig & Edwards, 1983; Lipowski, 1969;McHaffie, 1992). Lipowski (1969) suggests that the following variables may affect theway in which an individual appraises an illness: (1) the client's personality type and pastexperience in general and with illness in particular; (2) the quality of the client'sinterpersonal relationships at the time of onset of the illness and during it; (3) theaesthetic quality of the client's surroundings as this variable will affect the client's mood;and (4) characteristics of the illness. With regard to the last variable mentioned above,Lipowski (1969) comments that the greater the value and significance that the body partor function affected by the illness has for the client, the more intense the psychologicalreaction is likely to be. Moreover, a given organ or biological function is especiallysignificant to a client when it provides a source of pleasure, pride, or self-esteem(Lipowski, 1969). Other authors such as Craig and Edwards (1983) and McRaffle(1992), note that appraisal of an illness is influenced by factors such as the backgroundand personal characteristics of the client, the illness and the degree of challenge or threatthat it poses, and the surrounding physical and social environment. In this study, theresearcher was not able to determine if and how all of the aforementioned variablesinfluenced the participants' appraisal of their circulatory disorder. However, thefindings suggest that there was one key variable that significantly influenced how theparticipants in this study appraised their chronic venous leg ulcers: whether or not theillness that they were experiencing had a negative impact on a primary source ofsatisfaction in their lives. Thus, participants appraised their circulatory disorder as86detrimental if it had negatively impacted a primary source of satisfaction orinconsequential if it had had little impact on a primary source of satisfaction. Thisvariable is equivalent to Lipowski's (1969) "characteristics of the illness" variable and isconsistent with his assumption that psychological reaction to an illness is more intense ifthe illness has affected a body part or function that is particularly valuable or significantto the client.What is particularly interesting about the foregoing finding is the fact that onesource of satisfaction appeared to be less vulnerable than another source of satisfactionwhen the individual was confronted with the circulatory disorder that was the focus ofthis study. More specifically, participants were able to maintain quality in their lives iftheir primary source of satisfaction in life was meaningful relationships with familymembers, as this source had not been negatively influenced by the chronic venous legulcers. Conversely, participants whose quality of life was inextricably linked to theirability to partake in gratifying activity experienced a life without quality, as theirprimary source of satisfaction had been negatively impacted by the chronic venous legulcer experience. Thus, it would seem that some primary sources of satisfaction, such asmeaningful relationships with family members, are less vulnerable than others to themany physical effects of chronic illness. Having said this, one cannot help but wonderwhether it would be possible for the two participants in this study, who had been robbedof their quality of life, to develop alternate sources of satisfaction. As a final point, it isnoteworthy that there has been much discussion in the literature about the positive rolethat social support plays in relation to an individual's ability to have quality in lifedespite the fact that a chronic illness may be present. Indeed, White, Richter, and Fry(1992) note that people cope more effectively with stressful life events if they have87support, and the lack of social support has been found to contribute to psychologicaldeterioration. Based on the findings of this study, it seems possible that an individualwho has a chronic illness may have a better quality of life if s/he has social supportbecause this support may be a primary source of satisfaction in life that is less vulnerableto the physical effects of an illness.In sum, the finding that participants in this study engaged in an appraisal processin relation to their circulatory disorder is consistent with current thinking in relation tostress, coping, and adaptation. Participants did not appraise their illness as being eitherthreatening or challenging but, rather, as detrimental or inconsequential with regard totheir quality of life. The key factor that influenced how the participants appraised theirchronic venous leg ulcers was whether or not their illness had impacted their primarysource of satisfaction in life in a negative way. The study's findings suggest that somesources of satisfaction (e.g., social support) may be less vulnerable to the effects ofchronic illness than other sources of satisfaction.Coping With The Chronic Venous Leg UlcerAnother key finding of this study was that participants had engaged in copingstrategies for the purpose of preserving or recovering their quality of life. The data alsorevealed an apparent relationship between a participant's appraisal of the significance oftheir chronic venous leg ulcer and the types of coping strategies they utilized. As withthe appraisal aspect of the chronic venous leg ulcer experience, both of these findings areconsistent with current thinking in relation to stress, adaptation, and coping. Lazarusand Follunan (1984) explain that based on their appraisal of a situation, and otherfactors such as social resources, individual motivation, and situational factors, anindividual will engage in problem-solving efforts in an attempt to preserve physical and88psychological integrity, to recover reversibly impaired function and/or to compensate forirreversible impairment. The outcome of a successful coping process, then, is adaptationwhich involves coming to terms with the reality of chronic illness as a state of being,discarding false hope and destructive hopelessness, and restructuring the environment inwhich one now functions (Craig & Edwards, 1983). From a slightly differentperspective, Feldman (1974) notes that adaptation is essentially the reorganization andacceptance of self so that there is meaning and purpose to living that transcends thelimitations that are imposed by the illness.In this study, it was interesting to find that the two participants who appraisedtheir leg ulcers as being detrimental to them engaged in coping behaviour that wasconsistent with the appraisal that they had made of their leg ulcers, but would not beeffective behaviour with regard to adaptation. Specifically, these participants engaged incoping behaviour that was characterized by vigilance in relation to their leg ulcer and a"playing it safe" approach with regard to activities. This behaviour certainly was notsurprising considering that the leg ulcers were perceived to be a very harmful force inthese participants' lives; the participants were endeavouring to preserve physical integrityand to regain lost function by "battling" against the leg ulcers. The problem, however,was that their coping behaviour gave rise to further loss in relation to gratifying activity,and it was the ability to partake in gratifying activity that was at the crux of whatquality of life meant for these individuals. Consequently, these individuals did not movetowards adaptation as they were unable to engage in reorganization and acceptance ofthemselves with their leg ulcers. Furthermore, their ongoing vigilance made it impossiblefor them to transcend their illness. It is not known why these individuals engaged in thistype of coping behaviour for so long especially when one considers that it did not serve to89reduce their anxiety or distress in the situation. In addition, the behaviour isparticularly perplexing when one considers that, according to Lazarus and Folkman(1984), the individual who is coping will periodically engage in a reappraisal process inorder to determine whether their coping behaviour has been effective in dealing with thestressful or threatening situation and, then, will usually make adjustments in copingbased on this reappraisal. The researcher can only speculate that, possibly, theseparticipants were engaging in coping behaviour that was consistent with their usualcoping style, which is their enduring disposition to deal with challenges and stressorswith a particular constellation of techniques (Craig & Edwards, 1983). Thus, it ispossible that these individuals only had a select repertoire of coping strategies that theyengaged whenever necessary and in this situation they were not effective. Indeed, Craigand Edwards (1983) note that each coping behaviour may not be appropriate in everycircumstance and behaviours which are beneficial for a short period may be harmful ifused excessively.The findings of this study also suggest that the other four participants hadadapted to their chronic circulatory disorder. Specifically, they had come to terms withthe reality of their chronic illness as a state of being and, hence, had accepted themselvesas they were; in effect, they had transcended their illness and experienced meaning andpurpose in their lives. As with the other group of participants, it is not known why theseparticipants were able to cope effectively and adapt to their chronic illness. Certainly, itis possible that these participants also had a repertoire of coping strategies that weredifferent from those of the other group but effective in the management of this particularsituation.90In trying to determine why four participants in this study were able to adapt totheir chronic circulatory disorder, one might also consider the theory of self-transcendence as explicated by Reed (1991b). This theory is an emerging middle-rangetheory that was developed through "deductive reformulation" whereby existingknowledge, derived from non-nursing theory, is reformulated using knowledge obtaineddeductively from a nursing conceptual model. With regard to the theory of self-transcendence, the aim was to construct a nursing theory that incorporated knowledgefrom life span theories on adult social-cognitive and transpersonal development withMartha Rogers' conceptual model for nursing. In this emerging theory, then, self-transcendence refers generally to a quality of developmental maturity whereby there isan enlargement of self-boundaries and a focus on broadened life perspectives andpurposes. More specifically, it involves the expansion of one's conceptual boundariesinwardly by way of introspective activities, outwardly through concern about others'welfare, and temporally by blending perceptions of one's past and future to enhance thepresent; the individual transcends their physical being and reaches out beyond self-concern. The five possible antecedents that have been identified in relation to self-transcendence are: (1) an inherent tendency of the person to move beyond their own selfinterest; (2) a spiritual perspective; (3) a pivotal life event or stressful stimuli; (4) humanwork that enlarges the goals and visions of a person; and (5) acceptance of aninescapable situation. Although the theory of self-transcendence is associated, in largepart, with the social-cognitive and transpersonal development of older adults, it isthought to provide important insights into the well-being and mental health of individualswho perceive themselves as facing end-of-life issues, whether through terminal illness, orother issues. Thus, with regard to the four participants in this study who "just got on91with life," one can only speculate that at least some of these individuals may haveexperienced self-transcendence as a normal part of social-cognitive and transpersonaldevelopment in older adulthood.In summary, the findings of the study suggest that the participants engaged incoping behaviour in relation to their chronic circulatory disorder and that their copingbehaviour was consistent with the appraisal that they had made in relation to thesignificance of their chronic venous leg ulcers. Two of the study's participants engagedin coping behaviour that was ineffective with regard to moving them towards adaptation.It is not known why this was the case, but the researcher hypothesized that they mayhave been using an enduring style of coping that was not effective in that situation. Onthe other hand, the other four participants in the study coped effectively with theirchronic venous leg ulcers as they had adapted to the circulatory disorder. It wassuggested that they may have utilized an enduring coping style that was effective in thatsituation and that, possibly, some of these individuals experienced self-transcendence inthe older adulthood stage of development.SummaryIn this chapter the researcher further explored some of the study's findings inrelation to the older adult's subjective experience of living with a chronic venous legulcer. It is evident that there are some significant differences between the health careprofessional's explanatory model, as presented in the literature, and the participant'sexplanatory model of the chronic venous leg ulcer experience as presented in this report.Even more important, however, is the fact that the health care professional's explanatorymodel of the chronic venous leg ulcer experience lacks the depth and complexity that isessential if one is to fully understand the experience.92With regard to the appraisal aspect of the chronic venous leg ulcer experience, itwas suggested that there was a key mediating factor present that affected the appraisalprocess: whether or not the chronic venous leg ulcers had negatively impacted on theseindividuals' primary source of satisfaction in life. For those participants whose primarysource of satisfaction was family support, their leg ulcers were perceived asinconsequential and they experienced quality in life even though they were experiencinglosses related to the chronic venous leg ulcers. On the other hand, individuals whoseprimary source of satisfaction was being able to participate in gratifying activitiesexperienced a life without quality since their source of satisfaction had become vulnerableto their circulatory disorder. The researcher hypothesized, then, that there are somesources of satisfaction that appear to be less vulnerable to the effects of chronic illness.It was also suggested that if this latter group of individuals could develop other sourcesof satisfaction that would be immune to the effects of their illness, then they might havea chance of experiencing some satisfaction in life. Another difficulty for these individualswas that they coped in a way that was consistent with their appraisal of the leg ulcers asharmful, but their coping behaviour contributed to a situation in which they experiencedmore losses and did not move towards adaptation. It was speculated that theseparticipants might be engaging in behaviours that reflected an enduring coping style thatwas not effective in the chronic venous leg ulcer situation. Finally, it was suggested thatfour of the study's participants had adapted to their chronic circulatory disorder andthat this may have been because they had a repertoire of coping strategies that wasdifferent from the other group but effective in the chronic venous leg ulcer situation. Inaddition, the researcher hypothesized that at least some of these individuals may haveexperienced self-transcendence as part of normal social-cognitive and transpersonaldevelopment in older adulthood.9394CHAP'rER SIXSUMMARY, CONCLUSIONS, AM) IMPLICATIONSSummaryThe purpose of this study was to gain an understanding of the chronic venous legulcer experience from the perspective of community-dwelling older adults. Chronicvenous insufficiency has been recognized as one of the most common health problemsexperienced by the older adult. Unfortunately, an all too frequent complication of thiscirculatory disorder is the development of a venous leg ulcer. Chronic venous leg ulcerscan have a negative impact on the general well-being of the older adult and costs to thehealth care system associated with the treatment of chronic venous leg ulcers aresubstantial.To date no research has been conducted in relation to the older adult's experienceof living with a chronic venous leg ulcer. Rather, the literature contains a few anecdotesin relation to the chronic venous leg ulcer experience that have been written from ahealth care professional's perspective. Thus, in the context of chronic venous leg ulcers,the explanatory model of the client has not yet been documented. If community healthnurses are to work effectively with these clients there must be some understanding ofwhat the client's experience is like.The phenomenological method of qualitative research was used for this study.This method was appropriate for this study as the researcher wanted to understand thechronic venous leg ulcer experience from the perspective of the elderly community-dwelling individual. To be as true as possible to the phenomenological approach, the95researcher viewed the study's participants as partners or co-researchers in the endeavourand related to them within the context of a genuine and mutual "I-thou" relationship sothat the researcher could truly be "with" a participant and begin to understand thatparticipant's world.Six individuals participated in this study who were or had been seen on a regularbasis by a home care nurse for treatment of their chronic venous leg ulcers. Twoaudiotaped in-depth interviews were conducted with each participant and the tapes weresubsequently transcribed verbatim. The interviews were unstructured, for the most part,so that participants were given the opportunity to discuss issues that were important tothem. The process of data analysis occurred simultaneously with data collection througha process of constant comparative analysis. As themes emerged in each transcript, theresearcher moved from one transcript to another for the purpose of identifying commonthemes and variations within themes. At the same time, common themes and variationsthat were emerging were validated and clarified with the study's participants. Finally,common themes were elaborated on and synthesized into a description of the chronicvenous leg ulcer experience that was representative of all of the participants' experienceswith this phenomenon.The findings of this study revealed that participants moved through threesequential phases of a "living with a chronic venous leg ulcer continuum" as they livedwith chronic venous insufficiency and chronic venous leg ulcers. In the first phase of thecontinuum, participants experienced the effects of living with their chronic circulatorydisorder. They encountered losses in relation to physical endurance, gratifying activities,companionship, and predictability in their lives. In addition to experiencing loss, theparticipants encountered a gain as a result of having a chronic venous leg ulcer: the96emotional support afforded them by home care nurses and homemakers involved in theircare.In the second phase of the continuum, participants evaluated the extent to whichtheir chronic venous leg ulcers had affected their lives. In so doing, the participantseither appraised their leg ulcer as having been detrimental to their quality of life, orinconsequential with regard to living a satisfying life. The key factor that influenced theappraisal that participants made of their leg ulcers was whether or not their circulatorydisorder had negatively affected a primary source of satisfaction in their lives. Thus, achronic venous leg ulcer was appraised as being detrimental if it had negatively affecteda primary source of satisfaction, or inconsequential if it had not affected a primarysource of satisfaction.In the third and final phase of the continuum, the participants coped with theircirculatory disorder in one of two ways. Each participant either "put their life on hold"if they had appraised their leg ulcer as being detrimental to them, or they "got on withlife" if they had appraised their leg ulcer as being inconsequential. Those who "put theirlife on hold" did so by "playing it safe" and "being vigilant." The participants who goton with their lives were able to do so because, the things that they could no longer do asthey once had, they just did differently.CondusionsThe study's findings suggest a number of conclusions about the experience ofliving with a chronic venous leg ulcer:1.^The changes in functional abilities, social contacts, and predictability inlife that accompany a chronic venous leg ulcer are experienced as losses;972. There is a possible gain associated with having a chronic venous leg ulcer,that being the emotional support afforded the older adult by nurses whoare treating the chronic venous leg ulcer;3. Older adults with chronic venous leg ulcers appraise the significance thatthe leg ulcers have had in their lives;4. The older adult may appraise their chronic venous leg ulcer as havingbeen detrimental to their life if it has negatively impacted a primarysource of satisfaction;5. The older adult may appraise their chronic venous leg ulcer asinconsequential to their life if it has had little impact on a primary sourceof satisfaction;6. Research findings of this study suggest an apparent relationship betweenthe significance that an older adult attributes to his/her chronic venous legulcer and the coping behaviour that is exhibited in relation to thecirculatory disorder;7. Research findings of this study suggest that the older adult will "put lifeon hold" if the chronic venous leg ulcer is appraised as being detrimental;and8.^Research findings of this study suggest that the older adult will "get onwith life" if the chronic venous leg ulcer is appraised as beinginconsequential.Implications For NursingA number of implications for nursing practice, education, and research arisefrom the finding that the older adult's experience with a chronic venous leg ulcer is a98very complex one. To begin, the complex nature of the leg ulcer experience means thatit is essential that the nurse make every effort to explore and understand the client'sexplanatory model in relation to his/her sickness. Without this understanding of theclient's explanatory model, the nurse may have difficulty communicating with the clientand may not be sensitive to the client's health care needs. In addition, the complexnature of the chronic venous leg ulcer experience implies that the nurse must recognizethat a holistic approach to the care of the older adult who is living with a chronic venousleg ulcer is essential. Thus, the elderly client requires psychosocial care in addition tocare of the leg ulcer itself.With regard to psychosocial care, the nurse needs to be aware of the fact that theolder adult who is experiencing chronic venous ulceration will be experiencing losses inmany areas of their life as a result of their circulatory disorder. Furthermore, theseulcer-related losses may compound a myriad of other losses related to the normal agingprocess. Thus, the elderly client may be grieving multiple losses and the nurse must beprepared to offer support that is appropriate to any stage of the grieving process. If thegrieving process becomes pathological in nature, as it seemed to have become in relationto two of the participants in this study, then the nurse must also be prepared to refer theclient to other members of the health care team (e.g., social worker, psychologist) if theyhave more expertise in relation to mental health issues.If the nurse is aware of the particular losses that are commonly associated withthis circulatory disorder then interventions can be implemented which serve tocompensate for some of these losses. For example, in relation to the loss ofpredictability, the community health nurse may need to talk with a client and theirphysician about a "maintenance program" for the care of the client's chronic venous leg99ulcer if it appears unlikely that the wound will heal. Too often, clients whose leg ulcersare unlikely to heal will be treated for many years in a very aggressive manner with theunderlying expectation that they will heal. As a result of this practice, the client mayexperience many highs and lows as treatments fail and new treatments are prescribedand, as well, their lives are filled with uncertainty. Thus, a "maintenance program" forclients whose wounds are unlikely to heal would allow them to step off of the emotionalroller coaster that they have likely been on for years.With regard to the loss of companionship, the nurse might consider arranging fora volunteer to visit with the elderly client as appropriate. In addition, the nurse couldensure that the client has appropriate equipment to enable him/her to attend desiredsocial functions outside of the home. For example, a wheelchair or walker may be ofgreat benefit to a client who is reluctant to leave home because of a loss of physicalendurance. From a somewhat different perspective, it behooves home care nurses tocarefully consider what the self-care movement may mean for the elderly client whoderives companionship, and a sense of being care for, from the home care nurse whovisits to provide ulcer care. Based on the knowledge that social support positivelyinfluences health outcomes, and considering this study's finding that elderly participantsregarded the nurse's companionship and emotional support as more beneficial thanphysiological care, it seems apparent that there could be a negative side to the practice ofshifting responsibility for ulcer care to the elderly client if there is no recompense for thepsychosocial care that the home care nurse provides. More specifically, elderly clientswith chronic illness may suffer more depression, for example, if they do not receive theemotional support they may need to effectively cope with chronic illness. Thus, homecare nurses must be cautious in their application of self-care philosophy in circumstances100where elderly client's are coping with chronic illness; they must carefully consider howthe client's need for emotional support will be met.This study's findings in relation to the appraisal aspect of the chronic venous legulcer experience indicate that the nurse must recognize that clients will perceive their legulcers in different ways; for one client they may be devastating, and not for another. Aswell, the nurse might be able to predict, to a certain degree, the meaning a client mightassign to a leg ulcer if s/he has done an assessment in relation to the client's sources ofsatisfaction in life. For example, the nurse can anticipate that a client might find a legulcer detrimental if that client derives a great deal of satisfaction in life from partakingin recreational activities and now is no longer able to do so.With regard to the study's findings in relation to the coping aspect of the chronicvenous leg ulcer experience, the nurse must recognize that clients will cope in differentways depending on the significance they have attached to their chronic venous leg ulcer.As well, their coping strategies might represent an enduring style of coping that may beeffective or ineffective in the chronic venous leg ulcer situation. If coping is ineffective,the nurse may need to help the client explore alternate coping strategies that may bemore effective for that individual. In terms of the specific coping strategy which theresearcher has termed "being vigilant", if a client is vigilant with regard to the care oftheir leg ulcers and, at times, critical of the nurse, the nurse needs to be aware that theclient is probably not involved in a personal attack against the nurse, but rather thecriticism is one aspect of that coping strategy. Finally, the theory of self-transcendenceprovides a rationale for the nurse to attend to the spiritual and psychosocial expressionsof self-transcendence in the older adult client (Reed, 1991b). Potential nursingapproaches to helping clients expand self-boundaries include making use of practices101such as meditation, self-reflection, visualization, religious expression, journal keeping,and life review (Reed, 1991b).To date, basic nursing education in relation to the client with a wound hasfocused primarily on treatment of the wound. The findings of this study indicate thatbasic nursing students need to be educated to approach the client with a wound in a veryholistic way; that is, they need to know how to assess and intervene in relation to boththe physical aspects of wound care and psychosocial aspects of the client's care. Withregard to learning what holistic nursing care would mean for the older adult with achronic venous leg ulcer, nursing students would benefit from a course that addressedissues related to the older adult's experience with a chronic illness. This course wouldneed to explore topics related to: the chronic illness experience, coping and adaptation inrelation to chronic illness, physiological changes associated with aging, social-cognitiveand transpersonal development in older adulthood, the theory of self-transcendence, andloss and grieving in older adulthood. In addition, students would benefit from examiningKleinman's (1978) explanatory model of transactions in health care relationships anddiscussing how the nurse explores the client's explanatory model in relation to a sicknessepisode. Clinical experiences in relation to care of the chronically ill elderly in home,intermediate care, and extended care settings would provide the student with insight intothe older adult's experience of living with a chronic illness.With regard to continuing education, the findings of this study suggest that homecare nurses might benefit, as well, from an exploration of Kleinman's (1978) explanatorymodel of transactions in health care relationships if they did not have an opportunity toexplore a theoretical framework such as this in their basic nursing program.Furthermore, workshops might be conducted in which home care nurses examine some102of the issues that appear to be relevant to the older adult's experience of living with achronic venous leg ulcer. For example, issues in relation to loss and grieving and self-transcendence in older adulthood could be explored.In terms of research, epidemiological studies need to be conducted with regard tothe prevalence of chronic venous leg ulcers in the older adult population as prevalenceestimates that are available paint a very confusing picture. As well, further research isneeded to achieve greater understanding with regard to the experience of living with achronic venous leg ulcer. For example, more qualitative studies such as this one need tobe conducted with the purpose of exploring the older adult's experience of living with achronic venous leg ulcer. It is recommended that larger sample sizes be used, however,in an attempt to ensure scientific adequacy of the research. Quantitative studies need tobe conducted in relation to the appraisal and coping aspects of the chronic venous legulcer experience. With regard to appraisal, the mediating factors that influence theappraisal process need to be further explored with particular attention given to themediating factor that was discovered in this study, that being whether or not the chronicvenous leg ulcer impacts negatively on a primary source of satisfaction. As well, itwould be of benefit to study older adults who are experiencing depression in relation totheir chronic venous leg ulcers to determine if, in fact, a primary source of satisfactionhas been negatively affected by their circulatory disorder, or if there are other significantreasons for their depression. Additional research also needs to be conducted in relationto coping strategies that are used by older adults who are living with chronic venous legulcers. For example, a quantitative study could be conducted which compares the copingstrategies of those older adults with chronic venous leg ulcers who have adapted to theirillness with those individuals who have not adapted. Furthermore, the notion that103individuals have enduring coping styles needs to be further explored. Finally, furtherresearch needs to be done in relation to self-transcendence in the older adult as thisphenomenon has the potential of significantly impacting the mental health and well-beingof elderly clients who are living with a chronic circulatory condition.In conclusion, this study has described the chronic venous leg ulcer experiencefrom the perspective of the older adult. The findings of this study will contribute tonurses' understanding of what it is like to live with a chronic venous leg ulcer and willenable them to provide nursing care that is sensitive to the client's needs.104REFERENCESAlbert, M., & Moody, K. (1990). Assisting elders to care for wounds. Home Health CareServices Quarterly, 11(3/4), 91-155.Beck, C.T. (1993). Qualitative research: The evaluation of its credibility, fittingness, andauditability. Western Journal of Nursing Research, 15(2), 263-266.Beauregard, S., & Gilchrest, B.A. (1987). A survey of skin problems and skin careregimens in the elderly. Archives of Dermatoloey, 123, 1638-1643.Benner, P. (1985). Quality of life: A phenomenological perspective on explanation,prediction, and understanding in nursing science. Advances in Nursing Science,8(1), 1-14.Browne, G., Byrne, C., Brown, B., Pennock, M., Streiner, D., Roberts, R., Eyles, P.,Truscott, D., & Dabbs, R. (1985). Psychosocial adjustment of burn survivors.Burns, 12(1), 28-35.Bruyn, S.R. (1966). The human perspective in socioloey. Englewood-Cliffs, New Jersey:Prentice-Hall.Burckhardt, C.S. (1985). The impact of arthritis on quality of life. Nursing Research,34(1), 11-16.Burckhardt, C.S., Woods, S.L., Schultz, A.A., & Ziebarth, D.M. (1989). Quality of lifeof adults with chronic illness: A Psychometric Study. Research in Nursing & Health, 12, 347-354.CaIlam, M.J., Ruckley, C.V., Harper, D.R., & Dale, J.J. (1985). Chronic ulceration ofthe leg: Extent of the problem and provision of care. British Medical Journal,290, 1855-1856.Callam, M.J., Harper, D.R., Dale, J.J., & Ruckley, C.V. (1988). Chronic leg ulceration:Socio-economic aspects. Scottish Medical Journal, 33, 360-362.Cohen, A. (1991). Body image in the person with a stoma. Journal of Enterostomal Therapy, 18(2), 68-71.Cohen, F., & Lazarus, R.S. (1983). Coping and adaptation in health and illness. In D.Mechanic (Ed.), Handbook of Health. Health Care and the Health Professions.New York: The Free Press.Coon, W.W., Willis, P.W., & Keller, J.B. (1973). Venous thromboembolism and othervenous disease in the Tecumseh community health study. Circulation, 48, 839-846.105Craig, H.M. &, Edwards, J.E. (1983). Adaptation in chronic illness: An eclectic modelfor nurses. Journal of Advanced Nursing, 8, 397-404.Dale, J.J., Callam, M.J., Ruckley, C.V., Harper, D.R., & Berrey, P.N. (1983). Chroniculcers of the leg: A study of prevalence in a Scottish community. Health Bulletin,41(6), 310-314.David, J.A. (1986). Wound management: A comprehensive guide to dressing and healing. London, England: Martin Dunitz.Davis, A.J. (1978). The phenomenological approach in nursing research. In N. Chaska(Ed.), The nursing profession: Views through the mist (pp. 186-196). New York:McGraw-Hill.Dlin, B.M., & Perlman, A. (1971). Emotional response to ileostomy and colostomy inpatients over the age of 50. Geriatrics, 26, 113-118.Downe-Wamboldt, B. (1991). Coping and life satisfaction in elderly women withosteoarthritis. Journal of Advanced Nursing, 16, 1328-1335.Doyle, G.E. (1983). All leg ulcers are not alike: Managing & preventing arterial &venous ulcers. Nursing83, 13, 58-63.Esberger, K. (1978). Body image. Journal of Gerontolo2ical Nursing, 4(4), 35-38.Falvo, D.R. (1991). Medical and psychosocial aspects of chronic illness and disability.Gaithersburg, Maryland: Aspen Publishers.Feldman, D.L. (1974). Chronic disabling illness: A holistic view. Journal of Chronic Disease, 27, 16-27.Field, P.A., & Morse, J.M. (1985). Nursing research: The application of qualitative approaches. Rockville, Maryland: Aspen Publishers.Fitzpatrick, J.E. (1989). Stasis ulcers: Update on a common geriatric problem.Geriatrics, 44(10), 19-31.Giorgi, A. (1975). An application of phenomenological method in psychology. In A.Giorgi, C. Fischer & E. Murray (Eds.), Duquesne studies in phenomenologicalnsycholoey: Vol.2. (pp. 83-103). Pittsburgh: Duquesne University.Gloeckner, M.R. (1984). Perceptions of sexual attractiveness following ostomy surgery.Research in Nursing and Health, 7, 87-92.Guba, E.G., & Lincoln, Y.S. (1981). Effective evaluation. San Francisco: Jossey-Bass.106Haase, J.E., Britt, T., Coward, D.D., Leidy, N.K., & Penn, P.E. (1992). Simultaneousconcept analysis of spiritual perspective, hope, acceptance and self-transcendence.IMAGE: Journal of Nursing Scholarship, 24(2), 141-147.Hall, J.M., & Stevens, P.E. (1991). Rigor in feminist research. Advances in Nursing Science, 13(3), 16-29.Hurny, C.H., & Holland, J. (1985). Psychosocial sequelae of ostomies in cancer patients.Ca-A Cancer Journal for Clinicians, 35(3), 170-183.Hutchinson, S. (1986). Grounded theory: The method. In P.L. Munhall & CJ. Oiler(Eds.), Nursing research: A qualitative perspective (pp. 111-130). Norwalk,Connecticut: Appleton-Century-Crofts.Ignatavicius, D.D., & Bayne, M.V. (1991). Medical-surgical nursing: A nursing process approach. Philadelphia: W.B. Saunders.Janelli, L.M. (1986a). Body image in older adults: A review of the literature.Rehabilitation Nursing, 11(4), 6-8.Janelli, L.M. (1986b). The realities of body image. Journal of Gerontoloeical Nursing,12(10), 23-27.Kleinman, A. (1978). Concepts and a model for the comparison of medical systems ascultural systems. Social Science and Medicine, 12, 85-93.Klopp, A.L. (1990). Body image and self-concept among individuals with stomas.Journal of Enterostomal Therapy, 17(3), 98-105.Knaack, P. (1984). Phenomenological research. Western Journal of Nursing Research,6(1), 107-114.Kunimoto, B.T. (1991). How to manage venous leg ulcers. The Canadian Journal of Continuing Medical Education, 3, 45-53.Laborde, J.M., & Powers, M.J. (1985). Life satisfaction, health control orientation, andillness-related factors in persons with osteoarthritis. Research in Nursing & Health, 8, 183-190.Lambert, C.E., & Lambert, V.A. (1987). Psychosocial impacts created by chronicillness. Nursing Clinics of North America, 22(3), 527-533.Lamont, L.J. (1991). Venous ulcers: A nursing challenge. Journal of the American Academy of Nurse Practitioners, 3(4), 158-165.Lanyon, S., Van Nieuwenhuyzen, J., & Wearing, J. (1987). Leg ulcers: Frustration orchallenge? The Canadian Nurse, 83(6), 33-36.107Lazarus, R.S., & Follunan, S. (1984). Stress, appraisal and coping. New York:Springer.Lipowski, Z.J. (1969). Psychosocial aspects of disease. Annals of Internal Medicine,71(6), 1197-1206.Livingston, J. (1971). Modern Christian thought. New York: Macmillan.McHaffie, H.E. (1992). Coping: An essential element of nursing. Journal of Advanced Nursing, 17, 933-940.Merry, G.M. (1989). Management of foot and leg ulcers. Drug Protocol, 4(6), 28-32.Morse, J.M. (1986). Quantitative and qualitative research: Issues in sampling. In P.L.Chinn (Ed.), Nursing research methodology: Issues and implementation (pp. 181-193). Rockville, Maryland: Aspen Publishers.Oiler, CJ. (1986). Phenomenology: The method. In CJ. Oiler and P.L. Munhall (Eds.),Nursing research: A qualitative perspective (pp. 69-84). Norwalk, Connecticut:Appleton-Century-Crofts.Omery, A. (1983). Phenomenology: A method for nursing research. Advances in NursingScience, 5(2), 49-63.Orbach, C.E., & Tallent, N. (1965). Modifications of perceived body and of bodyconcept. Archives of General Psychiatry, 12, 126-135.Pallikkathayil, L., & Morgan, S.A. (1991). Phenomenology as a method for conductingclinical research. Applied Nursing Research, 4(4), 195-200.Peck, M.S. (1978). The road less traveled: A new psychology of love, traditional values and spiritual growth. New York: Simon & Schuster.Prebble, S.M. (1990). The patient with leg ulcers: Essential points of nursing. GeriatricMedicine, 20, 41-44.Reed, P.G. (1991a). Self-transcendence and mental health in oldest-old adults. Nursine Research, 40(1), 5-11.Reed, P.G. (1991b). Toward a nusing theory of self-transcendence: Deductivereformulation using developmental theories. Advances in Nursing Science, 13(4),64-77.Riemen, D.J. (1986). The essential structure of a caring interaction: Doingphenomenology. In CJ. Oiler and P.L. Munhall (Eds.), Nursing research: Aqualitative perspective (pp. 85-108). Norwalk, Connecticut: Appleton-Century-Crofts.108Rolstad, B.S. (1991). Treatment objectives in chronic wound care. Home Healthcare Nurse, 9(6), 38-44.Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nursing Science, 8(3), 27-37.Schneider, J. (1984). Stress. Loss, and Grief: Understanding Their Origins and Growth Potential. Baltimore: University Park Press.Shipes, E. (1987). Psychosocial issues: The person with an ostomy. Nursing Clinics of North America, 22(2), 291-302.Sutherland, A.M., Orbach, C.E., Dyk, R.B., & Bard, M. (1952). The psychologicalimpact of cancer and cancer surgery. I. Adaptation to the dry colostomy:preliminary report and summary of findings. Cancer,  5, 857-872.Tretbar, L.L. (1987). Chronic venous insufficiency of the legs: Pathogenesis of venousulcers. Journal of Enterostomal Therapy, 14(3), 105-108.Ward, H.W., Moss, R.L., Darko, D.F., Berry, C.C., Anderson, J., Kolman, P., Green,A., Nielsen, J., Klauber, M., Wachtel, T.L., & Frank, H. (1987). Prevalence ofpostburn depression following burn injury. Journal of Burn Care &Rehabilitation, 8(4), 294-298.Watkins, P.N., Cook, E.L., May, S.R., & Ehleben, C.M. (1988). Psychological stages inadaptation following burn injury: A method for facilitating psychologicalrecovery of burn victims. Journal of Burn Care & Rehabilitation, 9(4), 376-384.White, N.E., Richter, J.M., & Fry, C. (1992). Coping, social support, and adaptation tochronic illness. Western Journal of Nursing Research, 14(2), 211-224.APPENDIX AARTERIAL AND VENOUS LEG ULCERS: A SUMMARY COMPARISON109Predisposing factorsAssociated changes in leg orfootUlcer locationUlcer characteristicsPainARTERIAL ULCERS• arteriosclerosis• advanced age• diabetes mellitus• thin, shiny, dry skin• thickened nails• absence of hair growth• temperature variations• pallor on elevation• dependent rubor• pedal pulses usually absent• between toes or at tip oftoes• over phalangeal heads• on heel• above lateral malleolus• (for diabetic persons) overmetatarsal heads, on sideor sole of foot• well-demarcated edges• black or necrotic tissue• deep, pate baseextreme: decreases with legdependency, increases withcool environment orelevation of legVENOUS ULCERS• history of deep veinthrombophlebitis• valvular incompetence inthe perforating veins• firm ("brawny") tissuerelated to long-standingedema and superimposedcellulitis• reddish brown discoloration• typical "bottle leg" orgaiter area• dilated and tortuoussuperficial veins• pedal pulses usuallypresent• anteromedial malleolus• pretibial area• uneven edges• ruddy granulation tissue• superficial• moderate: increases withLeg dependency, decreaseswith cool environment orelevation of legNOTE:Some arterial insufficiency may be present with venous leg ulcer but history and clinicalpresentation indicate that venous insufficiency is primary etiology.REFERENCE:Doyle, J.E. (1983). All leg ulcers are not alike: Managing & preventing arterial & venousulcers. Nursing83, 13, 58-63.110APPENDIX BINFORMATION FOR BURNABY HEALTH DEPARTMENT HOME CARE NURSESTitle Of Study:"When A Leg Ulcer Becomes Chronic: A Phenomenological Study Of The Older Adult'sExperience Of Living With A Chronic Venous Leg Ulcer"Purpose Of Study:The purpose of this study is to explore and describe the experience of the older adultwho is living with a chronic venous leg ulcer.Investigator:Kathleen Liebelt, R.N., M.S.N. Student, Phone: 100i-300iXFaculty Advisor (U.B.C. School Of Nursing):Sally Thorne, R.N., Ph.D., Phone: xxx -xxxxProcedure For Recruitment Of Participants:The home care nurse will:1. identify a potential participant for the study (see criteria for selection ofparticipants below)2. explain the purpose of the study to the potential participant and ask permissionfor the investigator to contact the client by telephone3.^inform the home care coordinator of a potential participant if the client agrees tospeak with the investigatorThe home care coordinator will:1.^contact the investigator with the name and telephone number of a potentialparticipant111Criteria For Selection Of Participants1. 65 years of age or older2. male or female3. resides in a house or apartment4. understands and speaks English and is able to communicate experiences5. has been diagnosed as having a chronic venous leg ulcer by a home care nurse orphysician (see definition of chronic venous leg ulcer below)6. is visited by a home care nurse at least once per week for treatment of a chronicvenous leg ulcer and has been visited for at least two months7.^does not have a coexisting physiological/psychological condition that wouldsignificantly alter the client's perception of the experience of living with a chronicvenous leg ulcer or impact significantly on the lived experience (e.g. delusionalthinking; paraplegia; chronic respiratory difficulty that the individual iscontinually aware of and trying to manage)CHRONIC VENOUS LEG ULCER:DefinitionTissue damage manifesting as an ulceration or open lesion of the skin of a lowerextremity, related primarily to venous insufficiency. The ulceration is of at least twomonth's duration and has been treated by a home care nurse at least once per week for aminimum of two months.DiagnosisThe diagnosis of a venous leg ulcer is made by a home care nurse or physician and isbased on clinical presentation and client history data that would indicate that the legulcer is relate primarily to venous insufficiency. Additionally, as part of the diagnosticprocess, the possibility that the leg ulcer is related primarily to arterial insufficiency isruled out.Diagnostic GuideSee attached document outlining a summary comparison of characteristics of arterial andvenous leg ulcers. This document may be used as a guide in the diagnostic process butits use is not required.DIAGNOSTIC GUIDEARTERIAL AND VENOUS LEG ULCERS: A SUMMARY COMPARISON112Predisposing factorsAssociated changes in leg orfootUlcer locationARTERIAL ULCERS• arteriosclerosis• advanced age• diabetes mellitus• thin, shiny, dry skin• thickened nails• absence of hair growth• temperature variations• pallor on elevation• dependent rubor• pedal pulses usually absent• between toes or at tip oftoes• over phalangeal heads• on heel• above lateral malleolus• (for diabetic persons) overmetatarsal heads, on sideor sole of foot• well-demarcated edges• black or necrotic tissue• deep, pale baseextreme: decreases with legdependency, increases withcool environment orelevation of legVENOUS ULCERS• history of deep veinthrombophlebitis• valvular incompetence inthe perforating veins• firm ("brawny") tissuerelated to long-standingedema and superimposedcellulitis• reddish brown discoloration• typical "bottle leg" orgaiter area• dilated and tortuoussuperficial veins• pedal pulses usuallypresentanteromedial malleoluspretibial area• uneven edges• ruddy granulation tissue• superficial• moderate: increases withLeg dependency, decreaseswith cool environment orelevation of legUlcer characteristicsPainNOTE:Some arterial insufficiency may be present with venous leg ulcer but history and clinicalpresentation indicate that venous insufficiency is primary etiology.REFERENCE:Doyle, J.E. (1983). All leg ulcers are not alike: Managing & preventing arterial & venousulcers. Nursing83, 13, 58-63.113APPENDIX CINTRODUCTORY LETTERMy name is Kathleen LiebeIt. I am a Registered Nurse and a student in the Master ofScience in Nursing program at the University of British Columbia. I am interested inlearning about the experience of older adults who are living with longstanding leg ulcers.It is important for nurses to understand what life is like for individuals in this situationso that appropriate nursing care can be planned.My study will involve:1. two interviews, each lasting from thirty to sixty minutes, conducted in your homeat your convenience;2. a discussion of what it is like for you to live with a longstanding leg ulcer;3.^audiotaped recording of the interviews.All the information that you share with me will be confidential. Your name will notappear on the audiotapes, any transcripts, or the completed study. Access to theaudiotapes and typed transcripts will be limited to my thesis advisors, my typist, and me.The audiotapes and transcripts will be destroyed when all scholarly reports have beenwritten.Your participation in this study is strictly voluntary and your refusal to participate willnot affect any care you currently receive or may require. If you agree to participate inthe study, you may refuse to answer any questions asked, request to have informationremoved from the audiotape, or withdraw from the study at any time. Again, this willin no way jeopardize the care that you currently receive or may require.If you have any questions about the study or the interviews, please feel free to contactme or my faculty advisor at the telephone numbers listed below.Thank you.Kathleen Liebelt, R.N., B.S.N.Kathleen Liebek, R.N., B.S.N , xxx-xxxxSally Thorne, R.N., Ph.D., Faculty Advisor, xxx-xxxx114APPENDIX DPARTICIPANT CONSENT FORM'title Of The Study:"The Older Adult's Experience Of Living With A Longstanding Leg Ulcer"Purpose Of The Study:The purpose of this study is for the investigator to explore and describe the older adult'sexperience of living with a longstanding leg ulcer.Investigator:Kathleen Liebelt, R.N., B.S.N. - Telephone: X70C-70:XXGraduate Student in Nursing; School of Nursing,University of British ColumbiaI understand the purpose of this study, as outlined above, and I understand thatthis study involves:1. two visits to my home by Kathleen Liebelt for interviews that will last from thirtyto sixty minutes each;2. discussion of what it is like for me to live with a longstanding leg ulcer;3.^audiotaped recordings of the interviews.I understand that the information that I share with the investigator will beconfidential and that my name will not appear on the audiotapes, transcripts, orscholarly reports. As well, I understand that all information will be destroyed oncescholarly reports have been written.I understand that my participation in this study is voluntary. I may refuse toanswer any questions asked, request to have information removed from the audiotape, orwithdraw from the study at any time. I understand that my refusal in any of these areaswould not jeopardize any care that I currently receive or may require in the future.I consent to participate in this study as explained by the investigator andacknowledge receipt of an introductory letter and a copy of this consent form.Date ^Signature115APPENDIX EINTERVIEW GUIDEI understand that you have been living with this leg ulcer for some time now.What has this been like for you?What has it been like to live with an ulcer that is taking a long time to heal?If you have looked at the ulcer, how do you feel about the way it looks?In what ways has this leg ulcer affected your daily life? If daily life has beenaffected, how does this make you feel? How have you dealt with the changes inyour life?Is there anything that you can't do now that you would like to do?What is your major concern now in terms of living with this leg ulcer?What is it like for you to talk with me about your experience of living with thisleg ulcer?

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