Journal of Tissue Viability (2014) 23, 109e114

www.elsevier.com/locate/jtv

Clinical study

Feelings of powerlessness in individuals

with either venous or diabetic foot ulcers
S.A. de Almeida a, Geraldo Magela Salomé b,*, R.A.A. Dutra b,
Lydia Masako Ferreira c

a
Auditing, Private Practice, São Paulo, SP, Brazil
b
Professional Master’s Degree Program in Sciences Applied to Health,
Sapucaı´ Valley University (UNIVÁS), Pouso Alegre, MG, Brazil
c
Division of Plastic Surgery, Federal University of São Paulo (UNIFESP), São Paulo,
SP, Brazil

KEYWORDS Abstract Aim: To assess feelings of powerlessness in patients with either venous
Feelings; or diabetic foot ulcers.
Self-concept; Methods: This was an exploratory, descriptive, cross-sectional study conducted
Quality of life; from May 2010 to August 2012. Two hundred adult patients with either venous
Leg ulcer; leg ulcers (N ¼ 100) or diabetic foot ulcers (N ¼ 100) were consecutively recruited
Varicose ulcer; from an outpatient wound care clinic of a university hospital in the city of São Paulo
Diabetic foot (Brazil). Eligibility criteria included patients with type 1 and 2 diabetes and foot ul-
cers, and those with venous leg ulcers and ankle-arm index between 0.8 and 1.0.
Patients unable to respond to a questionnaire due to physical or cognitive deficit
were excluded. Two instruments were used for data collection: a questionnaire as-
sessing sociodemographic and clinical characteristics, and the Powerlessness
Assessment Tool (PAT) for adult patients.
Results: Most patients were women, aged 60e70 years, and smokers. Fifty-seven
patients (57%) with diabetes had had foot ulcers for 3e6 years and 55 (55%) patients
had had venous ulcers for 7e10 years. Wound odor and exudate were present in
most ulcers. The total PAT score was significantly higher (P ¼ 0.002) for patients
with foot ulcers (mean, 57.10) than for patients with venous ulcers (mean,
55.12). The highest mean scores for patients with venous and diabetic foot ulcers
were 58.09 and 58.10, respectively, on the “self-perception of decision-making
capacity” domain.

* Corresponding author. Av. Francisco de Paula Quintanilha Ribeiro 280, Apt. 134, CEP 04330-020 São Paulo, SP, Brazil. Tel.: þ55 11
5012 5704.
E-mail addresses: salomereiki@yahoo.com.br, geraldoreiki@hotmail.com (G.M. Salomé).

http://dx.doi.org/10.1016/j.jtv.2014.04.005
0965-206X/ª 2014 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
110
Conclusion: Patients with venous and diabetic foot ulcers had very strong feelings
of powerlessness, but these feelings were significantly stronger in those with foot
ulcerations.
ª 2014 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
Introduction
Problems in the lower limbs represent one of the
most important chronic complications in in-
dividuals with vascular disease and diabetes mel-
litus. In industrialized countries, ulceration is the
most common cause of non-traumatic lower-limb
amputations, and has been shown to be a great
public health problem worldwide. Therefore, due
to the high incidence, prevalence and complica-
tions, the socioeconomic impact on the quality of
life of these individuals is considered important. It
is known that the majority of leg ulcers (60e70%)
result from vascular causes [1,2]. The prevalence
of venous ulcers is from 0.6 to 3.6% in the general
population [1e3].
Foot ulcers and amputations are the main con-
sequences associated with morbidity among per-
sons with diabetes mellitus [4], and it is estimated
that 15% of diabetic patients are at risk for foot
ulceration [2]. Studies have shown that the annual
population-based incidence may range between 1%
and 4.1% and prevalence from 4% to 10% [5].
Ulcers cause pain, alteration in sleep patterns
and loss of functional mobility, affecting the in-
dividuals’ capacity to work and compromising their
daily life and leisure activities. Associated with
these factors, expenditure on treatment has a
negative impact on the quality of life of persons
and their family members [6,7]. All of these as-
pects make patients feel frustrated, dissatisfied,
insecure, fearful, powerless and out of control.
Individuals with wounds feel incapable of per-
forming daily activities, and frequently consider
themselves incapable of and impotent to play their
role in society [8e10].
The feeling of powerlessness may be seen as a
loss; the loss of control of running one’s own life
[11]. NANDA-I defined the feeling of powerlessness
as “the perception that one’s own action would
not significantly affect a result; a lack of control
perceived about a current situation or an imme-
diate happening” [12].
Professionals in the field of health have tech-
nical and human skills to provide care for people
with lower-limb ulcers and must be able to identify
feelings of powerlessness and the basic care needs
of this population. The assessment of feelings of
S.A. de Almeida et al.
powerlessness may contribute to the planning of
interventions aimed at creating positive feelings
and minimize the impact of lower-limb ulcers on
the daily life of these patients.
The aim of this study was to assess feelings of
powerlessness in patients with venous leg ulcers
and compare with that of patients with diabetic
foot ulcers to provide supportive evidence for
improving quality of care for this population,
directing interventions more satisfactorily toward
the individual needs of the patient with a wound.
Methods
This is an exploratory, descriptive, cross-sectional
study. The sample comprised 100 patients with
diabetes mellitus and foot ulceration, and 100 in-
dividuals with venous leg ulcers. All received care
at the Wound Unit in the Plastic Surgery Outpa-
tient Clinic of the Federal University of São Paulo
and in an outpatient wound care clinic of a hos-
pital complex in interior São Paulo.
Two groups of patients were included: with
Type 1 or Type 2 diabetes and foot ulcer and with
venous ulcer, persons over the age of 18 years.
Patients without physical and mental conditions to
answer the questions in the questionnaire were
excluded from the study.
Data were collected in the period comprising
May 2010 to August 2012, after approval from the
Research Ethics Committee of the Federal Uni-
versity of São Paulo (Protocol No.0383/10). Written
informed consent was obtained from all patients
prior to their inclusion in the study.
Two instruments were used for data collection:
a questionnaire assessing sociodemographic and
clinical characteristics, and the Powerlessness
Assessment Tool (PAT) for adult patients. Because
most participants had a low education level, the
questionnaires were administered as a structured
interview by the researchers.
The PAT was developed in Brazil and tested in a
population sample of 210 adult patients from
medical-surgical wards for item selection, reli-
ability and validity [11,13]. It shows good internal
consistency (Cronbach’s alpha coefficient of 0.80)
and test-retest reliability (P > 0.05) [11,13].
Feelings of powerlessness in individuals 111

The instrument consists of a 12-item measure of

Table 2 Sociodemographic characteristics of pa-
powerlessness rated on a 5-point Likert-type scale tients with venous and diabetic foot ulcers.
ranging from “never” (1) to “always” (5). The total
PAT score range from 12 to 60, with higher scores Variables DF (N ¼ 100) VL (N ¼ 100) P-valuea
corresponding to stronger feelings of powerless- N % N %
ness. Based on the total PAT score, feelings of Women 66 66 74 74 0.035
powerlessness can be rated as absent (12), mild
Age group (years)
(13e24), moderate (25e36), strong (37e48), and
<60 41 41 28 28 0.033
very strong (49e60). The 12 items are grouped into 60e70 58 58 68 68
three domains: (1) “capacity to perform behavior” >70 1 1 4 4
or perceived behavioral control, which assesses
the patients’ feelings regarding the degree of Smokers 67 67 76 76 0.041
control they have over their own behavior; (2) DF, diabetic foot ulcer patients; and VL, venous leg ulcer
patients.
“self-perception of decision-making capacity”, a
Chi-square test of independence (P < 0.05).
which measures the patients’ perception of their
ability to make their own decisions; and (3)
“emotional responses to perceived control”, which
assesses the patients’ feelings regarding their
Results
perceived loss of control over aspects of their life
(Table 1) [11,13]. Most patients in both groups were women, aged
The Statistical Package for the Social Sciences 60e70 years, and smokers, with significant differ-
(SPSS) 15.0 for Windows (SPSS Inc., Chicago, IL, ences between groups for all variables (Table 2).
USA) and Microsoft Office Excel software (Micro- Fifty-seven patients (57%) with diabetes had
soft Corp., Redmond, WA, USA) were used for data had foot ulcers for 3e6 years and 55 (55%) patients
analysis. had the venous ulcers for 7e10 years. Wound odor
The chi-square test was used to compare the and exudate were present in most ulcers (Table 3).
frequency distribution of categorical variables be- Eighty-seven patients (87%) with diabetic foot
tween groups. The KruskaleWallis test and the ulcers and 71 (71%) patients with venous leg ulcers
Spearman correlation coefficient were also used in reported very strong feelings of powerlessness
the statistical analysis. All statistical tests were (Table 4).
performed at a significance level of 0.05 (P < 0.05). The mean total PAT score was 55.12 for patients
with venous ulcers and 57.10 for patients with foot
ulcers, with a significant difference between
Table 1 Powerlessness assessment tool (PAT) [13]. groups (P ¼ 0.002). This shows that patients with
No. Items diabetic foot ulcers had stronger feelings of
powerlessness than those with venous leg ulcers.
Capacity to perform behavior
Both groups of patients had high scores on all PAT
1 The things I do can help in my recovery.
2 I feel I am capable of achieving my goal. domains. The highest mean PAT scores reported by
3 I feel I have the disposition to participative patients with venous and diabetic foot ulcers were
in my care.
4 I feel my opinions can contribute in the
decisions about my health. Table 3 Characteristics of the venous and diabetic
5 I feel capable of looking after myself. foot ulcers.
6 My body still obeys my command.
Variables DF (N ¼ 100) VL (N ¼ 100) P-valuea
Self-perception of decision-making capacity
7 My health conditions avoid me from making N % N %
decisions about my treatment. Age of the wound (years)
8 Nothing I do can change the situation I am in. 2 16 16 10 10 0.015
9 I feel I am not capable of making any decisions. 3e6 57 57 27 27
7e10 15 15 55 55
Emotional responses to perceived control
>10 years 12 12 8 8
10 I feel sad that I can’t control my body
functioning as I did before. Exudate 67 67 70 70 0.023
11 I feel sad when I think I need someone to Odor 67 67 62 62 0.029
help me. DF, diabetic foot ulcer patients; and VL, venous leg ulcer
12 I feel there is nothing I can to make the patients.
place I am in more pleasant. a
Chi-square test of independence (P < 0.05).
112 S.A. de Almeida et al.

Low education level may negatively affect the

Table 4 Total PAT score for patients with venous
and diabetic foot ulcers.
quality of information collected using self-
administered questionnaires, and therefore the
Total PAT DF (N ¼ 100) VL (N ¼ 100) P-valuea instruments were administered as a structured
score N % N % interview. In Brazil, the illiteracy rate is high and
30 2 2 4 4 0.013 over half of persons with venous problems has
31e40 4 4 8 8 incomplete primary education [23]. The low edu-
41e50 7 7 17 17 cation level may negatively affect the patient’s
51e60 87 87 71 71 ability to understand and follow self-care in-
DF, diabetic foot ulcer patients; and VL, venous leg ulcer structions and the treatment regimen, such as
patients. daily evaluation of the feet, use of prescribed
a
KruskaleWallis test and Spearman correlation coefficient medications and appropriate dressings [26e28].
(P < 0.05).
Lower-limb ulcers cause great impact on pa-
tients, leading to changes in lifestyle, chronic
pain, low self-esteem, and possibly depres-
58.09 and 58.10, respectively, on the “self- sion.[24] To live with the condition of having a
perception of decision-making capacity” domain chronic wound, which frequently is associated
(Table 5). with odor, exudation, edema and pain, may result
in a series of changes in the lives of patients and
their families.[25] These individuals feel uncom-
Discussion fortable, discouraged and powerless in the face of
losing control of their own lives. The lesion may
Feelings of powerlessness were assessed in 200 remove the patient from work and be the reason
adult patients with either venous or diabetic foot for early retirement of an individual who is still in
ulcers. Most patients (diabetic foot ulcers, 87%; the productive stage, due to the incapacitating
venous leg ulcers, 71%) had very strong feelings of nature of the disease [1,19,22,27,29,30]. The ma-
powerlessness. Total PAT score was significantly jority of the participants in this study were retired.
higher for patients with foot ulcers than for pa- Various studies conducted in patients with chronic
tients with venous leg ulcers. wounds have shown that over half of participants
Venous and diabetic foot ulcers are character- are retired or laid-off workers [23,26,29]. Lower-
ized by a chronic, painful process, with a negative limb wounds negatively interfere in the quality of
impact on the quality of life because they affect life of these individuals, leading to mobility limi-
mobility, the emotional state and functional ca- tation associated with decreased functional sta-
pacity of these patients. Lower-limb ulcers require tus, thus affecting activities of daily living and
proper local and systemic treatment performed by intensifying the dependency needs of these pa-
a multidisciplinary team. tients, and consequently increasing their feelings
The individuals most affected by this condition of powerlessness [19,31].
are women and those aged 60 years and over A previous study reported strong feelings of
[1,6,7,14e17], which is in agreement with our re- powerlessness (mean total PAT score, 47.83; range,
sults. Various studies have indicated that the pre- 51e60) in patients with venous ulcers [9]. Similarly,
dominant age group affected by leg ulcers ranges in this study, the majority of participants with
from 51 to 70 years [1,2,5,7,18e22]. venous and diabetic foot ulcers had very strong
The studied sample had a low education level, feelings of powerlessness (Table 5). Other study
with over half of the participants being illiterate. assessing feelings of powerlessness and hope in

Table 5 Mean total and subscale PAT scores of patients with venous and diabetic foot ulcers.
PAT domains DF (N ¼ 100) VL (N ¼ 100) P-valuea
Mean SD Mean SD
Capacity to perform behavior 55.1 7.301 53.09 7.209 0.002
Self-perception of decision-making capacity 56.78 6.980 56.09 6.03
Emotional responses to perceived control 58.10 7.578 58.09 7.523
Total PAT score 57.109 8.578 55.12 7.974 0.002
DF, diabetic foot ulcer patients; VL, venous leg ulcer patients; and SD, standard deviation.
a
KruskaleWallis test and Spearman correlation coefficient (P < 0.05).
Feelings of powerlessness in individuals
patients with either chronic venous ulcers or dia-
betic foot ulcers found that those with diabetic foot
ulcers had stronger feelings of powerlessness and
less hope for cure than patients with venous leg
ulcers, which is agreement with our results [10].
A study assessed the level of psychosocial
adjustment was assessed in 50 patients with
venous ulcers using the Roy Adaptation model in a
university hospital in Brazil [32]. It was found that
82% of patients reported maladaptation in the
role-function mode (leisure, pain, social, educa-
tional and transportation restrictions) and inter-
dependence mode (support in treatment) [32].
These factors may diminish the ability of these
persons to deal with situations, resulting in feel-
ings of powerlessness.
Individuals with chronic wounds must be helped
to understand that the lesion is a new condition to
which they have to adapt and not a restriction on
social and sexual life. Considering how difficult it is
to live under this circumstance, the aid of a pro-
fessional is required so that the patient feels
supported and motivated to seek help. Patient’s
participation in health care activities has been
linked to better health outcomes [11]. Patients
should be motivated to perform self-care and ac-
tivities of daily living, since feelings of power-
lessness may interfere with treatment adherence
and self-care, affecting recovery [7,11].
The results of this study highlight the need to
focus on other aspects of the health of patients
with lower-limb ulcers and the importance for
health professionals to identify feelings of power-
lessness and the basic care needs of patients who
live daily with this condition.
In view of the needs that have arisen during the
last few decades as a result of the increasing
incidence of chronic diseases associated with the
aging of the population in many countries, it is
equally necessary to redirect the academic
training and qualification of health professionals,
valuing not only the technical aspects of care, but
also the humanization of care. Actions that include
factors associated with chronic diseases and
mental health will certainly contribute to the well-
being and quality of life of individuals with chronic
ulcers, especially in the elderly population.
Conclusion
Our results indicated that patients with venous and
diabetic foot ulcers had very strong feelings of
powerlessness in the face of living with an ulcer,
but these feelings were significantly stronger in
those with foot ulcerations.
113
The results also provide supportive evidence for
improving quality of care for this population, and
may contribute to direct interventions more
satisfactorily toward the individual needs of the
patient with a lower-limb ulcer.
Conflict of interest statement
The authors have no conflict of interest, financial
interest or commercial association with any of the
subject matter or products mentioned in the
manuscript.
Role of the funding source
There was no external funding for this study.
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