Reducing venous leg ulcer recurrence - The development of the Venous leg ulcer self-efficacy tool (VeLUSET)
Annemarie Brown, PhD, MSc, BSc (Hons), Lecturer University of Essex
Venus leg ulcer (VLU) recurrence rates are high; 26% - 69% [1-3]. While the literature suggests that that some self-care activities such as wearing compression hosiery, leg elevation and exercises may help to reduce recurrence, many patients are unable or unwilling to do these, or have received conflicting advice about such activities . Therefore, post-ulcer healing interventions should focus on minimising recurrence and enabling patients to adapt their lives to living with chronic venous ulceration (CVLU).
The conviction that the nursing care of patients with CVLU required change led me to complete a PhD study, the aims of which were:
- to conduct a literature review on the efficacy of prevention self-care activities
- to explore different health behaviour change models to identify a suitable model which may help VLU patients
- to develop a tool which would help clinicians identify those patients requiring extra support with self-care activities
The literature review  indicated that:
- lifelong wearing of compression hosiery can help prevent recurrence 
- increased mobility and moderate physical activity may benefit healing and help prevent recurrence 
- there is inconclusive evidence regarding the assumption that leg elevation while in compression bandages will enhance ulcer healing, although it can also reduce oedema, thus promoting healing and making the application of compression hosiery easier and less painful 
- exercises such as heel rises, flexion, extension, and rotation of the ankles, increase venous return 
However, merely telling people how to change their lifestyle or handing out information leaflets often does not work, so a simple effective health behaviour change model is required.
Self-efficacy – a health behaviour change model in chronic conditions
In response to the increasing impact of chronic condition management on National Health Service (NHS) resources, self-care programmes such as the Expert Patients Programme , underpinned by self-efficacy (SE) theory  have been introduced to enable patients to self-manage their condition with minimal input from clinicians.
Self-efficacy is ones belief in how confident you feel when tackling difficult tasks, and is not related to competence . It governs how people think, feel and act ; for example, people with high SE will attempt to perform challenging tasks; when setbacks occur, they will invest more effort, recover more quickly and remain committed to the goals set to them 11. People with low SE may not even attempt a task if they think it is too hard for them, giving up at the first hurdle if unsuccessful; “If you think you can – you might. If you think you can’t – you’re right!” 
While SE measurement tools are available for a number of chronic conditions, no one tool was applicable to VLU patients. Thus, part of this work was to develop such a tool.
Phase 1: Focus groups
In order to ensure that the difficulties experienced by both patients and clinicians were heard, ten focus groups comprising clinicians, patients and relatives/carers were convened. Patients had to be aged 60 years and over; have an open, healed or recurring ulcer, be English speaking, and willing and able to consent. Their contributions developed the statements to be included in the scale; data was categorised initially into 110 statements, then into sixty.
Phase 2: Pilot
- one hundred and eighteen patients from local leg ulcer clinics completed the tool
- statistical package SPSS V.19 was used to explain common themes, develop categories and reduce the number of statements
- statements were reduced 36, and the scale re-administered to a new patient sample of 86
- after further data analysis, statements were reduced to 30; five related to general self-care, 12 related to daily self-care tasks, four to normal living, six to developing expertise, and thereby avoiding trauma
In order to assess whether the VeLUSET was stable over time, it was administered to a sub-set of the previous patient sample 4 weeks later. The results were very promising and indicated that the VeLUSET is a valid, robust tool for use in clinical practice.
Layout of the VeLUSET
The VeLUSET is in a questionnaire format with 5 main categories; each category contains related items. Responses are presented on a Likert scale with 10 points ranging from completely disagree (0) to completely agree (10) (Box 1). Patients are given instructions on how to complete the tool.
Box 1: VeLUSET category example
Score each statement 1-10
I am confident that:
1. I understand why I need to wear my compression stockings for the rest of my life
2. I will be able to check my compression stockings regularly to make sure they still fit me
3. I will wear my hosiery even though my ulcer may come back
4. I will try to see my nurse every 3/6 months to get new hosiery
5. I understand why compression stockings will help stop my ulcer coming back
Clinical application of VeLUSET
VeLUSET can be administered when an ulcer is almost or actually healed. It gives clear, evidence-based guidance on the types of self-care activities that help to reduce recurrence. By providing clarity, the clinician can assess how confident the patient feels in their ability to perform these tasks, and for those patients who are not confident in certain tasks, clinicians can implement strategies to help. Examples include providing application aids for applying compression hosiery or demonstrating rotational ankle exercises. By obtaining a pre and post intervention score, the VeLUSET will demonstrate an increase in SE which provides an objective measure of the intervention.
The VeLUSET is the first SE tool to be developed for patients with VLU. Preliminary validation studies indicate that it is a robust and appropriate measure, is reliable over time and quick and simple to administer. It is currently only suitable for use for patients over 60 years of age, who have a reasonable amount of mobility and further validation studies are required with younger patients (<60 yrs) or those with poor mobility. Nevertheless, it provides an objective outcome measure for nursing interventions by clinicians, for example, well leg clinics or self-care programmes.
Copies of the VeLUSET are available free of charge from the author: firstname.lastname@example.org
If you think you can – you might.
If you think you can’t – you’re right!