Shaping the trajectory of patients with venous ulceration in primary care.

OBJECTIVE: To explore the patient's experience of venous ulceration and how it is shaped within primary care.
DESIGN: Qualitative grounded theory study. PARTICIPANTS AND
SETTING: Thirty-nine patients, 33 nurses and 14 general practitioners in a major health district in England.
RESULTS: The findings indicate that patients with the chronic condition of venous hypertension are handled in an anomalous way within primary care when they present with ulcers on their lower limbs. The trajectory projections for the patients are not developed from the usual basis of a medically defined condition-specific diagnosis but from a symptom-specific diagnosis. This leads to an unusual context of care where there is a serious but unrecognized conflict of focus between the nurses and their patients. The nurses in this study tended to set priorities related to the ulcer and to the underlying pathology, whereas the patients wanted help in pain management and in normalizing their lives. The patients eventually came to a position of 'guarded alliance'2 that in this study took one of three forms: adapting and enduring, emphasizing the positive, or negotiating for comfort.
CONCLUSION: The acute care approach applied to patients with this chronic condition led to a situation where the professionals usurped the self-care potential of the patients and navigated rather than piloted them through an acute phase of an underlying chronic illness. This in turn, led to poor quality of life for many of the patients and to frustration for the nurses who were failing to achieve the outcomes they desired. Both perspectives need to be encapsulated into the treatment approach for patients with this condition: healing the ulcer and normalizing the patients' lives can and should form the basis of care.