Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

FormalPara Box 8.1: Key Points

  • Social support can be defined as the emotional and practical support that individuals provide to others through their presence and behaviour;

  • Social support has a significant impact on both mortality and morbidly with a lack of support being detrimental to health;

  • Improved concordance with treatment, supporting healthy behaviours and providing emotional support are all routes through which social support can positively impact on an individual’s health;

  • There is evidence that wound healing can be promoted by the presence of social support, potentially through an improvement in concordance;

  • A number of social support interventions can be implemented which may result in improved psychological well-being, concordance and potentially healing;

  • Living with a person with a wound can bring with it a number of significant consequences not least on the individual’s health;

  • Both the individual with the wound and their immediate family may suffer psychologically and socially because of the wound.

Summary

The focus for most of the other chapters in this text has been on the person with the wound and the significant psychosocial problems that they may have to confront. However, in this chapter we explore the broader social situation and how this can impact on the individual with the wound and how, in turn, that patient influences it. The concept of social support is outlined, what it is, it’s relationship to health and how this relationship comes about. The relevance to wound care is articulated and how this information can be used to develop social support interventions that can improve concordance, psychological well-being and subsequently wound healing. One specific form of social support- that received from the family and the spouse or partner in particular is explored in detail. Not only are the positive benefits to the individual with the wound detailed but the burden that may result from providing this support outlined. Social support is an important element in wound care and its impact should be harnessed by the health care professional to enhance wound healing and psychological well-being. However, the health care professional should also remember not to neglect the broader family who may all be placed under considerable burden and stress by the presence of an individual with a wound.

Introduction

Human beings are social animals and the presence of others can be of considerable benefit to most- improving not only their mental but also their physical health (Thoits 2011). Indeed, much psychological, medical and sociological research has explored this phenomenon of “social support” (see Box 8.1). Thoits (2010) defined social support as an ‘emotional, informational, or practical assistance from significant others, such as family members, friends, or co-workers; and that support actually may be received from others or simply perceived to be available when needed’. Research has demonstrated that social support is important for maintaining positive physical and mental health (Ozbay et al. 2007). Indeed, social support has been shown to enhance psychological well-being; which may reduce the risk of unhealthy behaviours and poor physical health (Uchino 2004). For instance, patients with poor social support have high levels of anxiety and depression than those with higher levels of social support (Oddone et al. 2011). Social isolation and low levels of social support have been shown to be associated with increased morbidity and mortality (Berkman 1995; Umberson and Montez 2010).

Although the influence of social support has been recognised for many centuries, one of the first systematic studies completed in the 1970s identified that the risk of mortality was twice as high in those with fewer social ties (Berkman and Syme 1979). Indeed, some research has suggested that the effects of limited social support are more significant than the effects of obesity, smoking or hypertension (Sapolsky 2004). Furthermore, research has indicated that low social support may hinder the recovery of certain health conditions such as cardiovascular disease, atherosclerosis, cancer or cancer recovery and even slow wound healing (Ertel et al. 2009; Everson-Rose and Lewis 2005; Uchino 2006).

As well as this wound recurrences and poor healing rates have been associated with patients having limited social support (Moffatt et al. 2006), with lower levels of social support appearing to have a significant impact on the recurrence of a leg ulcer (Finlayson et al. 2011; Wissing et al. 2001). Consequently, social support may have a significant impact on patients’ healing, their psychological well-being and potentially costs for health care providers. This chapter seeks to explore the influence of social support on well-being and health before moving onto the converse: how can chronic wounds and their treatment impact on family and friends of the individual patient?

What Is Social Support?

Social support can be defined as the existence of people on whom we can rely, people who let us know that they care about, value and love us, and the support they provide for us (Sarason et al. 1983). There is a distinction between the existence of social relationships and the functions provided by these. That is, the structure would be based on ‘how many friends, colleagues, or family relationships’ you have and the functional aspect would refer to what these do.

Essentially you can have lots of friends but have no interaction with them which is not useful to us. Social support can come from a variety of different sources and a variety of types of support (Cohen et al. 2000), for instance, spouses, relatives, friends, neighbours, co-workers, or superiors. But it can also come from professional sources (e.g. the nurse or other health care professional) and this can help in reducing stress, thus becoming a useful and advantageous social interaction. The type and amount of social support an individual receives depends upon their social network but also on various demographic factors such as their age, sex, culture, socio-economic status and so on.

Generally social support comes in one of five types (see Fig. 8.1).

Figure 8.1
figure 1

Sources of social support

Full size image

To explore the concepts presented in Fig. 8.1 in more detail:

  • Instrumental support: Is practical support- people will help you out when needed. They will give you a lift to the clinic, or do the shopping for you and so on.

  • Appraisal support: The person is encouraged to evaluate their own health through information and they are then able to put the stressors in context. In this way, the stresses and strain of the treatment is put into context and the individual realises that they are able to complete any necessary changes.

  • Emotional support: A “shoulder to cry on” is the traditional descriptor for this form of social support. It is being loved, cared for, protected emotionally and listened to.

  • Esteem support: Is a feeling that you are valued or held in esteem by others. If you feel that you are a competent and skilful person you are more likely to be able to cope with the stressors.

  • Information support: Is support in the form of information or knowledge which can assist the person in doing the right thing to look after themselves- providing feedback on how well they are doing, for example.

For the main part, however, social support is frequently divided into either practical support or emotional support: either “help with the shopping”, or a “shoulder to cry on”.

There are a number of methods available to measure social support. Phenomenological studies have investigated social support (Brown 2005a, b; Victor et al. 2002) through a formal methodological interviewing approach. Although this has a number of benefits in terms of getting to the “real data”, it can be subjective and time consuming. In contrast to this interviewing technique there are a number of psychometrically developed questionnaires and scales. For example, the Social Support Questionnaire (SSQ-SF; Sarason 1986; Sarason et al. 1983, 1987). The SSQ-SF is based on two elements: the perception of the number of others available to whom a person can turn to in times of need and the degree of satisfaction with the support available. The Medical Outcomes Study: Social Support Survey (MOS-SSS; Sherbourne and Stewart 1991) is relatively brief (12 item abbreviated version) measure of social support. It assesses four components of perceived availability of social support, including (1) Emotional support/ Informational support, (2) Tangible support (including material support), (3) Positive social interaction (does person have friends that are available to have fun), and (4) Affectionate support (including loving and nurturing relationships). The Multidimensional Scale of Perceived Social (MSPSS; Zimet et al. 1988) is another relatively brief (12 items) measure. The MSPSS assesses both the perceived availability and adequacy of emotional and instrumental social support, across the three factors relating to the source of support (i.e., Family, Friends or Significant others). The Social Provisions Scale (SPS- Russell et al. 1984) assesses six dimensions of social support received within the context of interpersonal relationships: (1) Guidance (receiving advice and/or information), (2) Reliable alliance (feeling assured that one can rely on certain others for concrete assistance if necessary), (3) Reassurance of worth (feeling important to or valued by others), (4) Opportunity for nurturance (feeling needed to provide nurturing attention to others), (5) Attachments (receiving a sense of emotional security from close relationships), and (6) Social integration (feeling a sense of belonging in a group, which includes others with similar interests). All these measures of social support demonstrate both the complexity of social support and the many facets within it.

Finally, Social support has been measured from within the family with the Family Relationship Index (FRI; Moos and Moos 1981). There are also a considerable number of psychometric measures that assess family functioning and support.

How Does Social Support Protect Health?

There is mounting evidence for the relationship between social support and psychological stress, with a lack of social support potentially increasing a patient’s experiences of stress and consequently potentially affecting wound healing (Brown 2008; Solowiej and Upton 2010a, b). A number of theories have been suggested that support the link between social support, stress and its impact on wound healing.

The main effect hypothesis suggests that the more social support an individual has the better the quality of life, regardless of the person’s level of stress (Helgeson 2003). In other words social support is beneficial to health and it is the absence of social support that is stressful. The more social support you have the better because large social networks provide people with regular positive experiences in terms of both emotional as well as physical support. Hence, social support promotes healthier behaviours such as exercise, eating healthily and not smoking, as well as greater adherence to medical regimes.

The buffer hypothesis proposes that social support buffers the individual against the stressor. Rather than protect a person all the time against the minor hassles and stresses of everyday life, the buffer acts when it is needed most. For example, when a person with considerable social support has a diagnosis of an illness then they appraise it as less stressful because they know people to whom they can turn. In contrast, those with lower social support might be unable to turn to anyone (Cohen et al. 2000). In this way an individual’s social support network, such as friends and family, act as a defence against the negative impacts of stress, which, in turn, can improve wellbeing and consequently the healing of the wound (Solowiej and Upton 2010a, b; Brown 2008). Indeed, Brown (2008) suggests that aftercare to prevent social isolation and potential recurrence of the wound is important.

The social comparison theory suggests that individuals may evaluate their attitudes, beliefs and their abilities against those who are in a similar situation to them. Thus, for example, individuals with a leg wound are much more likely to compare themselves to others with a leg wound in a similar situation. Individuals may either have an upwards or downward social comparison. Those with an upward social comparison can improve the view of themselves, and create a positive perception (e.g. an individual may think that someone else wound may be close to healing and that their wound is similar to theirs). Whereas a downward social comparison occurs when an individual dissociate themselves with others who they consider to be worse off than themselves to make them feel better (e.g. an individual thinking that their wound situation is better than someone else’s wound).

Uchino (2006) outlined a more detailed model that demonstrated the potential pathways between social support and health. One pathway involves behavioral processes including health behaviors and adherence to medical regimens as outlined by social control and social identity theorists (Lewis and Rook 1999 ; Umberson 1987). It is suggested that social support is health-promoting because it facilitates healthier including better adherence to medical regimes.

The other major pathway involves psychological processes that are linked to appraisals, emotions or moods (e.g., depression), and feelings of control (Cohen 1988; Gore 1981; Lin 1986). A variable that has been investigated thoroughly is control – defined as the extent to which a person feels they are able to change their own circumstances. Broadly, the results suggest that the more control you have the less stressful it is (e.g. Troup and Dewe 2002; Gibbons et al. 2011). Obviously, there comes a point where you have more control but also considerable responsibility and this can be stressful as well. This has important considerations when exploring self-management by the patient with the wound. It is obviously important for the health care practitioner to ensure the patient is fully involved in their own wound management and takes control over his or her own condition and treatment. However, this needs to be balanced within the confines of the patient’s ability and circumstances. Responsibility and control without the ability to control leads to increased stress and all the consequences that result.

Finally, it is important for the health care professional to understand how the patient copes with their wound related problems. If the patient uses social support strategies, it may be useful to involve family and friends in their treatment. If a patient prefers a more active approach it may be useful for the patient to be given more information and become more involved with their treatments. In some cases patients may avoid dealing with their wound situation, in this case it may be helpful for the health care professional to help the patient face the facts that their wound needs treatment to heal (Vermeiden et al. 2009). It is important that health care professionals strengthen patients coping strategies as this may reduce stress and potentially improve healing.

The Impact of Social Support on Health

Living with a leg ulcer can have a detrimental impact on an individual’s daily life (see Chap. 1), which can leave the patient with feelings of being trapped, living a socially restricted life, and on the whole generally feeling socially isolated (Jones et al. 2008a; Parker et al. 2012). Indeed, patients can suffer from extreme social isolation as a consequence of their wound, and this has been linked to a number of factors both psychosocial and medical: including, malodour, lack of mobility, exudate, altered body image, pain and worry over further injury to their leg (e.g. Persoon et al. 2004; Parker et al. 2012; Herber et al. 2007). Furthermore, it has been suggested that patients with chronic leg ulcers often feel as if they are not fully part of society because of poor mobility, and a lack of empathy and peer support from others in their local community (Brown 2005a, b; Maida et al. 2009). Similarly, researchers have suggested that an individual may be embarrassed due to exudate and malodour, which others may perceive as poor hygiene, all of which can result in further social isolation and consequently reduced social support (Douglas 2001; Hopkins 2004a). Overall, this has negative consequences for the individual- including less socialising, which reduces the number of social contacts they may have, which again results in further isolation and a lack of social support.

Research has shown that supportive social relationships can improve health and psychological well-being. This relationship can just be one friend- as long as it is a close and supportive friendship- or a large series of good supportive relationships. Holt-Lunstad et al. (2010) reported that people who were less socially integrated had higher mortality rates. Studies have suggested that those with low levels of social support have higher mortality rates – from cardiovascular disease (e.g. Brummett et al. 2001; Frasure-Smith et al. 2000; Everson-Rose and Lewis 2005) or from cancer (e.g. Hibbard and Pope 1993) and infectious diseases (e.g. Lee and Rotheram-Borus 2001). Furthermore, an overview of longitudinal studies has shown a continuous increased mortality associated with a lack of social support and weak social ties (Quick et al. 1996). Subsequent studies have confirmed that reliable links exist between social support and better physical health (e.g. Uchino 2004; Holt-Lunstad et al. 2010).

In terms of wound healing a series of ground breaking studies in the 1990s and beyond have demonstrated a clear relationship between psychological stress and wound healing (e.g. Kiecolt-Glaser et al. 1995 and see Chap. 3). For example, in a classic study Kiecolt-Glaser and colleagues (1995) explored wound healing in two groups: a control group (healthy women) and a group (n = 13) of women caring for a demented relative. The assumption was that the care-givers were under more stress than the control group and this stress would delay wound healing. Wound healing was explored using a punch biopsy- a method used to create a small wound- and the time taken to heal recorded. There was a significant difference between the two groups with those care-givers taking 25 % longer (approximately a week) than the control group. These studies have been repeated on many occasions (Kiecolt-Glaser et al. 2002) and the relationship between stress and wound healing is well recognised.

In contrast to these deleterious effects of stress on wound healing a number of studies have indicated that social support can improve wound healing. However, many of these are with animal models of stress and social support (e.g. Detillion et al. 2004) and the link to relevant human studies, particularly those with chronic wounds is lacking. Charles (2010) did explore the influence of social support on leg ulcer healing. In a group of patients with venous leg ulcers they found that social support through a community nurse was not related to healing. However, although social support was assessed through a questionnaire route, social support was not enhanced or developed. Furthermore, many of the patients were socially isolated due to their leg wounds and the findings appeared to support the suggestion that a visit to an isolated individual by community nurses did not meet the clients’ needs for social support, information exchange and empathy. Consequently, there may be a need for more formal social support interventions (Lindsay 2000, 2008; see next section).

Similarly, supportive social relationships have been demonstrated to be fundamental in patients adapting to illness as well as recovering from it (e.g. Keeling et al. 1996). However, not all social support is equally beneficial and it has been demonstrated that there are sometimes negative consequences of social support- dependency or the inhibition of recovery due to a lack of control and desire to take control of their own illness (e.g. Toshima et al. 1990). Indeed, some health care professionals wonder whether a proportion of patients want to keep their ulcers to maintain contact with their social support- their community nurses- for social contact and support (Brown 2003; Wise 1986; Brown 2005a, b; Moffatt et al. 2009). For instance, it has been suggested that some patients will deliberately delay their wound healing (e.g. take their bandages off after being treated the nurse) so their social contact with the district nurse can continue. However, it is not clear how many patients may do this, and needs to be further explored along with the underlying reasons and potential solutions for any significant problem identified. Furthermore, it has been reported by Charles (2010) that patients do not see nurses as social support contacts nor do they want to keep their ulcers in order to maintain this contact. Finally, it is also important to note that not all social support should be provided by nurses and other health care professionals- the support from significant others, such as family members, friends, or co-workers is also crucial for those suffering with chronic wounds and this will be subject to further discussion later in this chapter.

Social Support Interventions

Health care professionals are usually aware of the benefits of social support interventions for individuals with leg ulcers, even if they understand that the interventions themselves do not produce healing as a direct result (Brown 2010). It has been suggested that health care practitioners should encourage patients to become more involved in self-management, through such social support self-help groups to reduce both pain and the consequent stress it causes (Price et al. 2007; Moffatt et al. 2009; Brown 2010). ‘Leg clubs’ can provide individuals with an environment whereby those with similar problems can socialise in a supporting, information-sharing environment (Edwards et al. 2005). There have been a number of ‘leg club’ interventions set up within a community setting that have been developed which aim to improve an individual’s well-being, some of these include, ‘Lively legs’ programme (Heinen et al. 2012); ‘Look after your legs’ support group (Freeman et al. 2007); and the ‘Lindsay leg club’ ® (Lindsay 2013).

Furthermore, due to the isolation and depression experiences by ulceration patients, the Lindsay Leg Club model of care was established (Lindsay 2004). It is based in a non-medical setting such as a community, church or village hall, where those with leg wounds can have collective treatment and share their experiences, there is also open access, meaning that no appointment is required. Community based interventions also provide patients with information about their wound and how to care for their wound as well as a number of strategies with living with a wound and overcoming practical difficulties from health professionals and other patients who have similar wound related problems (Edwards et al. 2005). Here, the reintegration of leg ulceration sufferers into the social domain is encouraged, whilst the clubs have also proved successful in progressing the removal of the negative stigma associated with such ulcerations. These clubs can conclude in a number of benefits for both the patient and their carer in that not only has treatment concordance been found to improve, but recurrence rates can decrease with overall positive healing outcomes (Lindsay 2004). This club care model supports the assumption that through the fostering of therapeutic relationships, patients can be empowered and encouraged to engage with their care, leading to improved healing rates and overall reduced ulceration reoccurrence. As such, is important for clinicians to incorporate such notions within their would care regime, focusing on patient involvement, communication and health promotion, in turn, enabling patients to become actively involved in their treatment regime.

Edwards et al. (2005) evaluated a pilot community-based ‘leg club’ with a sample of 33 patients with venous leg ulcers. Patients were randomized to two treatment conditions, which were either the community based leg club or treatment in their own homes. Data from both groups were collected at 12 weeks, finding significant improvements in healing in the community based ‘leg club’ condition compared to the home group. Furthermore, those who attended the community based leg club were able to share information with ‘fellow sufferers’, not only about their leg ulcers but their other similar health conditions. Therefore improved healing rates in the leg club setting group could include the beneficial effects of social interaction, peer support and the opportunity to share information with others who have similar conditions. However, the small sample used in this study limits the generalizability of the findings, also patients who were unable to travel, due to being too physically disabled or those who were unable to drive were excluded. Edwards et al. (2009) conducted another study to determine the ‘leg clubs’ effectiveness on a number of different outcomes, which included quality of life, morale, depression, self-esteem, social support, healing pain and functional abilities of those with chronic venous leg ulcers. Sixty-seven participants were referred for care in the community, these patients were randomised to either the ‘Lindsay Leg Club’ ® model of care or to home visits. Data was collected at baseline, 12 and 24 weeks. Results identified that those who received care under the ‘Leg Club’ model had significant outcome improvements in quality of life, morale, self-esteem, healing, pain and functional ability. This suggests that the ‘Lindsay Leg Club’ Model of care has the potential to improve the well-being of those with chronic leg ulcers.

Overall, the ‘leg club’ environment may encourage an improved motivation for compliance to treatment, as patients may be able to see the direct positive effects of the treatment on others attending. As well as this the sharing of information among members attending the ‘leg club’ of how to overcome difficulties, such as increases in exudate or malodour, may improve compliance to treatment. ‘Leg clubs’ have also shown to provide significant costs for health care providers, provide holistic care for patients, a forum for health promotion and education and an accessible setting for opportunistic early detection of wounds and their treatment (Lindsay 2004). Community ‘Leg clubs’ may also have the propensity to develop new ways to deliver evidence-based practise in partnership with patients and colleagues (Lindsay 2013).

It has been reported that when leg ulcers are treated at community based ‘leg clubs’ healing times appear to be reduced, and therefore suggesting that management of psychosocial factors as well as effective evidence based treatment are effective to promote successful wound healing and prevent recurrence. A small number of evaluations have been completed to determine the effectiveness of ‘leg clubs’, for instance. Leg Clubs provide a space for social activities and social engagement with separate areas for wound care treatment. In this way individuals can get their treatment whilst being able to communicate and interact with others.

Despite the positive case studies and small reports (e.g. Lindsay 2013; Shuter et al. 2011) there is little evidence from randomised controlled trials (RCTS)- the so called “gold standard”- of wound healing benefit from social support interventions (e.g. Weller et al. 2013). Despite this, social support community based interventions do appear to improve a number of significant factors, such as wound care concordance and well-being (Gordon et al. 2006; Harker 2000; Edwards et al. 2009).

Family Considerations

One key element of social support is the family- the partner or spouse in particular- and they have a key role to play supporting the patient. This may be physical support- providing care and management for the wound, or emotional support for the pain, stress, or any psychological problems that the patient may be experiencing. Indeed, there is some evidence that being in a relationship may improve wound healing (Kiecolt-Glaser and Newton 2001). Moffatt et al. (2006) reported that patients who live alone were significantly more likely to have leg ulceration than those living with a spouse, although this was a cross-sectional study and hence no direct causality could be determined.

The informal carer is a considerable resource for both the individual and the country. For example, it is suggested that there are over six million carers in the UK who provide unpaid care to someone who is ill, frail or disabled (Buckner and Yeandle 2011). This contribution to care accounts for £199 billion annually. This figure equates to £2.3 billion per week, £326 million per day, £13.6 million per hour or £18 473 for every carer in the UK (Buckner and Yeandle 2011). The support they provide is fundamental to the success of the individual patient in not only successfully managing their condition physically but also psychologically. Their support is central to adaptation to chronic illness.

Conversely, of course, the experience of the family member may also be of concern. Living with an individual may bring with it significant psychosocial concerns which may be detrimental to health for the partner or family member (Bennett et al. 2013). Indeed, the impact of chronic illness on the whole family can be significant and result in increased morbidity, impaired family dynamics and ultimately family break-ups, psychological morbidity and ill-health. This section will explore these two elements of the family involvement in wound care.

Family caregivers are recognised as an important component of support for individuals with chronic conditions (Spence et al. 2008). Many take on a supportive role with little or no training, yet are involved in an array of complex and challenging tasks, such as symptom assessment, as well as assisting with activities of daily living or helping with wound management (Aranda and Hayman-White 2001; Thomas et al. 2002). The ongoing and frequent nature of some of these wound-related routines requires family adaptation, and patients’ success at maintaining these routines benefits from effective family support. Moreover, family members can take an active role in helping adults with chronic illness execute complex self-management tasks, make disease-related decisions, and cope with disease-related stress (Gleeson-Kreig et al. 2002). Partners or spouses are frequently involved in their partners’ chronic health conditions (Ell 1996), often by seeking to promote greater adherence to treatment regimens. Spouses are uniquely positioned to notice such non-concordance, and as such, often are directly involved in monitoring and influencing many of their partners’ health related behaviours (Trief et al. 2003).

In contrast to the positive support that the family and spouse/partner may provide they may experience some costs for their involvement. However, relatively little research has examined whether spouses incur any costs from involvement in their marital partners’ chronic woundcare and most of the evidence comes from either other conditions or as a by-product of other research into the patient experience. For example, in a study by Upton and Andrews (2013a, b), respondents were asked to consider the level of sleep disturbance they experienced as a direct result of NPWT with their findings suggesting that NPWT treatment itself directly impacts on patients’ sleep, particularly due to noise. However, it was also noted in this study that spouses also experienced sleep disturbance due to their partners’ treatment. The impact of NPWT on family and carers is therefore another area which should be explored. Research on caregiving with other chronic illnesses (e.g. diabetes) suggests that providing care to an ill family member may lead to feelings of burden as a result of the chronic stress it elicits (Vitaliano et al. 2003). This burden may stem from the time and effort spouses devote to helping their partners, as well as from potential adverse effects on their psychological or physical health (e.g. Coyne and Smith 1991). Spouses’ feelings of burden also could stem from the disruption of their own routines or the drains on their energy from having to monitor and seek to influence their partners’ health behaviors on a daily basis (see Sales 2003).

Hopkins et al. (2006) reported on participants with a pressure ulcer who described their worries about their families, the impact of the ulcer on the families and their sense of gratitude towards them. Based on the findings from a study on carers by Baharestani (1994), they were right to be worried: pressure ulcers do have an enormous impact on spouses. Other studies exploring issues for patients in relation to their partners also found this essence of a ‘sense of indebtedness’ towards the carer (White and Greyner 1999).

Indeed, family caregivers in many studies report that the care they have to provide is one of the most significant issues for those with family members with chronic conditions and this burden may lead to the caregiver postponing their own needs (Manne and Zautra 1990; Rees et al. 2001; Riemsma et al. 1999; Baanders and Heijmans 2007). The effect on family caregivers across most chronic illnesses can be grouped into changes in social, economic, physical and mental status (Glasdam et al. 2010; Johansson and Fahlstršm 1993; Oehlenslaeger 1998; Soubhi et al. 2006). The burden of care is one of the main consequences for family caregivers with chronic illness. The patient’s close family members may experience poor psychological well-being (depression, anxiety), decreased satisfaction in relationships, caregiver burden and poorer physical health (Glasdam et al. 2010). Similarly, often in significant cases the carer has to give up work which can lead to significant financial problems for the whole family.

Although the term “caregiver burden” has been used extensively and documented in a number of conditions such as HIV/AIDs, cancer, heart disease and dementia (e.g. Munro and Edwards 2010; Woods 1999; Aoun et al. 2005) little has been written about care-giving for those with a chronic wound. As Ousey et al. (2013) write there “is little investigation into the impact of an acute wound on the possible psychological impact this may have on patients’ and carers’ quality of life” (p. 3). The authors then went on to suggest that there was a need for both investigations and recommendations into how best to support both patients and carers:

There needs to be clear guidelines developed on how health and social care practitioners can meet the needs of these patients and their caregivers. Participation and involvement of patients and caregivers in the development of these guidelines are essential to ensure that the patient and their caregivers are at the centre of care. (p. 6)

Given the fundamental role that unpaid carers play in the support of individuals with chronic conditions and the overall value to the country that this is estimated to bring it is surprising that little research exploring carer burden with those with a chronic wound has been reported. This is important for a number of reasons. Firstly, the heath of all should be a concern for the individual health care professional. There are many anecdotal reports of the carer suffering health difficulties themselves (including premature death) and this is something that all should try and avoid. Secondly, of course, individual carers provide valuable care and support and without them the psychological and physical health of the individual wound sufferer may deteriorate. Finally, of course, without this support more health care resources would be required which would lead to greater economic burden for all. A number of theoretically driven psychological support programmes may prove beneficial. For example, the development of coping strategies, social support networks or resilience training have all been shown to be of benefit for carers (e.g. McDonald and Hayes 2001; Li et al. 2012).

Obviously, it has to be remembered that in any caregiving situation it is not just about the burden of care. Buckner and Yeandle (2011) reported that carers do find the role positive in that is provided a sense of family, community and friendship. It is therefore important that the positives of caring for a loved one are not overlooked and the valuable care they provide is recognised, encouraged and actively supported. This may mean a number of different things- from respite, to provision of support networks of their own, to a simple word of acknowledgment and appreciation from professionals.

Conclusion

Health care professionals may overlook psychosocial aspects of an individual with a wound due to the main focus being on the clinical aspects of wound care. However, this oversight may be problematic as social support can improve healing, mental and physical health, acts as a buffer against stressors, and improves patients’ well-being. Hence, improving the social support opportunities for those with a wound may prove beneficial not only for the psychological health of the individual patient but also for their physical health. Furthermore, as the number of individuals with chronic wounds may be on the increase community based intervention may be preferable and could contribute to overall management of those with a wound. The promotion of social support will not only enhance psychosocial well-being but may also improve wound healing rate. A number of such models are available and show promise but need to be formally investigated in order to be widely introduced for this reason alone.

In contrast, there is limited research that explores the impact of chronic wounds on the family and, in particular, to the partner of the individual with the wound. This is unfortunate given the key role that family members play in supporting successful adaptation to chronic disorders. Although parallels can be drawn from other conditions this is an area that warrants further investigation. Drawing from other chronic conditions it would appear that there could be significant burden on the spouse or other family members which may bring with it significant physical and psychological morbidity which needs to be addressed in order that not only that their health can be protected but the individual patient can continue to be supported with their own health concerns.