Patient experiences of people with leg ulcers during the COVID-19 pandemic

Chronic wounds (also referred to as hard-to-heal wounds) usually describes those that do not heal within 8 weeks. However, there are certain types of ulcers that are considered ‘chronic’ from their very beginning, such as venous and arterial leg ulcers or diabetic foot and pressure ulcers (Dissemond et al, 2017). Chronic leg ulcers (CLUs) have an estimated prevalence of 1.51 per 1000 people (Martinengo et al, 2019) and the most common types of leg ulcers are venous (80%) and arterial (15%); atypical ulcers related to other causes are rarer (5%) (Todhunter, 2019). CLUs are difficult to heal and tend to be recurrent, especially those of venous aetiology (Finlayson et al, 2018).

CLUs can have a moderate (Cunha et al, 2017) to high (Kouris et al, 2016) impact on people's quality of life due to both pain (Probst et al, 2021) and significant restrictions to daily activities (Ruseckaite et al, 2020). Pain tends to be exacerbated during the night, leading to considerable difficulty in sleeping for patients, increasing the debilitation caused by the illness (Green et al, 2018; Phillips et al, 2018; Ruseckaite et al, 2020). Pain varies in type, intensity and duration: for some patients it is more or less constant, while others have described alternating periods without pain and moments of sudden onset without apparent precipitating factors (Phillips et al, 2018). Furthermore, restrictions to daily living are mainly caused by pain and walking difficulties, but also by the use of compression bandaging that restricts movement (Green et al, 2018; Phillips et al, 2018) and by frequent appointments at the wound clinic to receive routine care (Weller et al, 2021). Restrictions to daily activities can also impact on the ability to perform and to maintain personal hygiene, and can limit the choice of clothing and footwear (Phillips et al, 2018). In addition, CLUs may produce malodorous exudate that can cause embarrassment and shame, leading people to avoid interactions with others, resulting in social isolation (Ruseckaite et al, 2020). Depressive aspects (Green et al, 2018) related to prolonged healing time and the idea of the impossibility of complete recovery (Ruseckaite et al, 2020) may be present in patients with leg ulcers, with some expressing anxiety related to fear of falling or injury, which may increase the risk of ulcer recurrence (Green et al, 2018; Phillips et al, 2018; Ruseckaite et al, 2020).

Beyond treatment, for people with CLUs, the healthcare relationship can be of unique importance. Nurses are often considered crucial as participants in ulcer health care and also as social support (Phillips et al, 2018), and many people with CLUs tend to describe this relationship as ‘friendly’ (Green et al, 2018) or ‘familiar’ (Hopkins, 2004). The quality of the healthcare relationship may result in physical and psychological improvements (Tollow and Ogden, 2019) or, conversely, resignation and loss of hope (Tollow and Ogden, 2019; Ruseckaite et al, 2020). In fact, negative healthcare experiences are not uncommon in this patient cohort, and often stem from communication difficulties with the medical team and treatment-related factors, such inconsistent treatments across time and between physicians that patients perceive as guided by a trial-and-error approach (Tollow and Ogden, 2019).

The COVID-19 pandemic forced governments around the world to reallocate healthcare resources to respond to the emergency, leading to the suspension of non-essential surgical and outpatient activities (Torri et al, 2020). In Italy, during the first lockdown (March to May 2020), people were not allowed to enter hospitals unless they needed urgent or emergency surgery, or oncological management (Sallustro and Florio, 2021). During this period a decrease in wound care visits and medications were reported, resulting in a worsening of ulcers in terms of size, depth, exudate and pain (Tinelli et al, 2020; Sallustro and Florio 2021). During the second and less restrictive lockdown (October to December 2020) some patients with leg ulcers were followed via telemedicine and no worsening of ulcers was recorded (Sallustro and Florio, 2021). Furthermore, the public health emergency has had a negative impact on the mental health of people with a long-term condition (Louvardi et al, 2020).

Nevertheless, the way people experience and interpret different events, such as a chronic illness or the COVID-19 pandemic, may be profoundly different. Personal construct psychology (PCP) is a theory of personality that enables deep psychological insight into people facing difficulties in their life (Kelly, 1955). It has been used in some studies to understand how people interpret their ilnness and healthcare experiences (Cipolletta and Amicucci, 2017; Cipolletta et al, 2017), as well as how patients coped with the COVID-19 pandemic (Cipolletta and Gris, 2021; Cipolletta and Ortu, 2021; Tomaino et al, 2021). However, currently no study has analysed these two aspects concurrently. Moreover, as yet, no study has analysed how people with CLUs faced the changes that occurred in the care of their illness during the COVID-19 pandemic.

The aim of this study was specifically to understand how people with CLUs attribute meaning to their experiences of illness, health care and the pandemic and the relationship between these meanings. Moreover, we wanted to identify different illness trajectories (Glaser and Strauss, 1968) to develop personalised strategies for the care of people with CLUs during a public health emergency.

Methods

Participants

Twenty people with CLUs (12 women, 8 men) aged between 91 and 52 years (mean=73.6 years, standard deviation (SD)=10.64) participated in the study. Demographic and clinical data are reported in Table 1.

Inclusion criteria comprised the following: presence of leg ulcer(s), referral to a wound clinic, and understanding of the Italian language and ability to interact in the interview. Exclusion criteria were non-knowledge of Italian language and inability to understand questions and answer in an appropriate way.

Convenience sampling was used and recruitment ended once theoretical saturation was reached, that is, when the researchers noted that themes became repetitive, thus suggesting that gathering more data does not lead to more information related to the research questions (Flick, 2009).

Participants were recruited at the leg ulcer clinic of a hospital in Northeast Italy during their check-ups. Each person was asked by the nurse if they were interested in participating in a telephone interview, and those who consented offered their telephone number to be contacted later by a researcher who was external to the clinic. Of the 34 people approached to take part, 14 declined to participate in the interview due to health reasons or unavailability to take part in the research.

At the beginning of the call, before proceeding with the interview, the interviewer introduced himself and specified that the contents of the conversation would be confidential, and that participation in the study was voluntary and fully independent of the care received at the clinic. After that, the interviewer read the informed consent form and asked whether or not the recipient agreed to participate in the study, the processing of personal data and the audio recording of the interview. All respondents gave their informed consent, and pseudonyms were used to preserve their privacy. The Ethics Committee for Psychological Research at the University of Padua approved the study.

Data collection

Semi-structured interviews were conducted from November 2020 to February 2021. Although flexible, the interviews followed a common guide, which was created ad hoc by the researchers based on existing literature and previous experience in similar studies. After a brief introduction presenting the study and interview procedure, the interviewer posed a general question focusing on the illness experience and participants' self-perception and more specific questions on their current and previous treatment experiences, and their ways of coping with the second wave of the COVID-19 pandemic. Clinical data were also collected during the interview by asking the participants directly or by spontaneous emergence. The full range of potential questions is reported in Table 2.

The average duration of the interviews was 33 minutes (SD=13.41). The interviews were conducted by telephone for two reasons: first, the hospital management did not allow face-to-face interviews during the medical emergency and, second, many participants were unfamiliar or uneasy with using videocalls, smartphones or computers.

Data analysis

The interviews were audiotaped and transcribed verbatim. Subsequently, each transcript was analysed, using the software Atlas.ti 9, based on the six-step model proposed by Braun and Clarke (2006) for thematic analysis. First, the text of each interview was read several times, and each quote of potential interest was coded, which allowed the quotes to be grouped by topic. In the second step, the different codes and their related quotes were categorised into superordinate themes and subthemes. As interviews went on and the material to work with increased, the codes and themes were reviewed and refined: each code, with its associated citations, was re-evaluated and refined against the whole dataset. Once the interviews were completed, two researchers conducted a second revision to refine each theme and subtheme. Finally, a report was constructed containing all the citations grouped by code, subtheme and theme.

Based on the themes identified through the thematic analysis, patients with similar experiences were grouped together to identify different trajectories based on the transitions elaborated within PCP as transitions are diagnostic constructs used to define the meanings people give to changes in their life.

The study was conducted according to the Consolidated Criteria for Reporting Qualitative Research checklist (Tong et al, 2007). Coherence and reliability were achieved by accurately reporting the administration and data analysis from the interviews, as well as the consistent use of quotations. Reflexivity was sought through repeated comparison of the themes with regard to the data, and discussions were held between the researchers on alternative interpretations of the results (Yardley, 2000).

Results

The thematic analysis identified 102 codes grouped into three themes to describe the content of 609 citations of interest for the research. Table 3 reports the themes and codes along with the number of interviews in which the themes were identified.

Within each theme similar experiences are highlighted and grouped together to identify the four trajectories presented in Figure 1 and explained in the discussion section referring to the transitions of aggression, threat, constriction and guilt. Aggression is defined as the active elaboration of one's own perceptual field (Kelly, 1955). This transition characterises the experience of the people who actively elaborate the situation and make the best of it. Threat is the awareness of an imminent comprehensive change to core structures, those central to one's identity; constriction is the reduction of one's perceptual field in order to minimise apparent incompatibilities in construing, and guilt is the dislodgement from one's core role, one's characteristic way of being (Kelly, 1955).

In this section, the results are presented by grouping them in the three main themes. To contextualise and support the themes, many quotations translated from Italian are used. To respect participants' anonymity, quotations are attributed using a pseudonym, alongside age and gender.

Illness experience

Participants largely talked about their illness experience, often spontaneously. First, the pain associated with ulcers was found to be salient; in fact, over half of participants referred to the perception of pain, with different nuances regarding intensity, duration and constancy:

‘I am always agitated, precisely because I get terrible pains […] This pain is a kind of electricity, a kind of, like banging a pipe.’

Marcella, F, 79 years

‘After I had my vein surgery I don't have as much pain as before. Yes, now I have some pain, sometimes, but mild stuff.’

Alice, F, 71 years

Several participants referred to various difficulties and discomfort related to CLUs, such as those related to wearing footwear due to swelling or bandaging, or to walking, driving or other daily activities. Other discomfort was related to the need to pay attention to avoiding leg injury, avoiding exposure to sunlight and preventing infection.

Participants indicated different ways to cope with CLUs, which were identified with the PCP's transitions. The participants who faced CLUs with aggression adapted to the illness and integrated it into their lives, taking this as a chance to rethink their outlook and their habits:

‘I consider myself lucky because most of the things I want to do – obviously not in terms of physical activity, but in terms of everyday life – in short, I can do them […] I know I have limits and I have to be careful not to exceed them because otherwise I'll pay.’

Filippo, M, 52 years

They were used to depending mainly on themselves to cope with difficulties and their illness, but also reported relying on others:

‘[The physicians] gave me permission to do self-medication between a check-up and the following one […] Self-medication and putting the elastic sock over it is something I can do on my own.’

Filippo, M, 52 years

Other participants – grouped in the trajectory labelled ‘threat’-resigned themselves to the illness and being in others' hands for receiving care. They relied on their family members, who helped them with medication and accompanied them to the wound clinic:

‘Because my wife has always followed me since 2002 and she has always come to the clinic, by now she is like the nurse who is treating my legs when I can't go to the clinic.’

Davide, M, 61 years

Conversely, the participants grouped in the trajectory of ‘constriction’ showed a tendency to minimise or deny the severity of CLUs and the impact on their life:

‘Well, I do medications twice a week and I try to keep myself as clean as possible and I try to cope, to carry on with my life as normally as possible.’

Raul, M, 55 years

They tended to avoid asking for help as much as possible because they preferred to rely mainly on themselves:

‘I did not want to go to the physician because [the ulcer] was so small that I said to myself, “I go to the physician and I disturb him for such a small thing!” Also … I am not used to disturbing physicians because I think that there are people with more severe injuries.’

Irene, F, 72 years

Finally, for the people grouped in the trajectory of ‘guilt’ the limitations imposed by CLUs implied a loss to their personal role that was based on relying mainly on themselves for doing things, and they tried to keep their role alive by coping with CLUs alone (eg, by self-medicating or attending the clinic alone, asking for help from no one):

‘I have a rather exuberant character, rather restless, let's say, I'm the kind of person who likes to do things, but I can't do them any more […] I've always worked, I was fine. Now that I'm at home in retirement, I would like to do things but I can't.’

Marcella, F, 79 years

‘I realise that the only thing I can do is to stay – how to say? – to rest and not to be a burden [because] no one can do certain things, only I can do them.’

Raul, M, 55 years

Healthcare experience

Participants described their healthcare experience mainly in terms of satisfaction. In fact, almost all participants (19) declared themselves satisfied with the treatment they were receiving. For some (10), satisfaction was related to improvement in their health status that they attributed to the efficacy of treatment, or resulting from comparison with previous (inefficacious) treatments in other clinics:

‘When I met the doctor I no longer had any pain; he started to treat my ulcers in his own way.’

Serena, F, 84 years

Satisfaction was also linked to the humanity, availability and kindness of heathcare workers that allowed participants to feel important and safe, especially those grouped in the trajectories of aggression and threat:

‘I am very happy with how they take care of you, with the people they are, with how they treat you.’

Alessandra, F, 78 years

‘[The healthcare team] always have a smile; they are never grumpy, they are never angry, even if they have their own problems. I don't know if they are tired, but they never show it to us: they always receive you with a smile and “How is it going?” or “Don't worry, we're here for it now”, a relationship like that: a relationship that relieves you of everything.’

Virginia, F, 71 years

Only one person within the trajectory of constriction did not express satisfaction. She suffered due to clinical distance, a lack of autonomy, a perceived burden on family members and homecare access impossibility:

‘For me, it's hard, but you have to overcome all the troubles. [I need] to be accompanied to go and medicate myself until it [the ulcer] is cured; this is my sorrow, to not be self-sufficient.’

Benedetta, F, 85 years

Participants used a variety of words to describe the healthcare team. The most frequently used attributes, especially within the trajectory of aggression, constriction and guilt, were ‘competence’ and ‘professionalism’, in terms of the team's knowledge, and were deduced from the effectiveness of treatments. Other attributes used were related more to health professionals' personal characteristics, such as kindness, solicitude and availability. The participants grouped in the trajectory of threat described the relationship with nurses using terms such as ‘friendly’ or ‘familiar’ – a relationship that crossed professional boundaries and was more personal and based on dependency:

‘I felt like he [the doctor] was my oldest son because, if I had something, I asked him and [he is] really a wonderful doctor. And [the nurse] I see her as if she was my daughter […] in the sense that I also confide in her, and if I have pain I tell her, and if I have an itch I tell her. […] There's a certain affection.’

Serena, F, 84 years

Conversely, some participants within the trajectory of constriction offered elusive descriptions of the medical team, merely listing a few adjectives without providing further details or references to their experience of care:

‘Ah well! Kind and good! For I see that I am almost completely cured. Very good!’

Elisa, F, 89 years

All participants stated that during both the first and second wave of the COVID-19 pandemic, the wound clinic never ceased service. Nevertheless, their healthcare experiences varied. Most participants stated that the changes due to the adoption of restrictive measures had not changed their experiences and opinions of the treatments received in the clinic, and that they were even more satisfied with the service provided owing to the reorganisation that the emergency had led to:

‘Maybe in the past you could go there and have ten people in front of you. You would wait half a day – I'm talking about half a day, like an hour or two or three. Now, with all this talk of COVID-19, everything is limited: having the appointment at 2 pm, I know that at 2 pm I wait very little, maybe it's much, much better. There's no queue, there's nothing. You get there, you wait your turn, but in no time at all, and you always get in on time, absolutely! Paradoxically, in this respect, COVID, in short, has helped.’

Filippo, M, 52 years

Other participants completely denied or made no explicit reference to the presence of any changes in healthcare services (constriction), not even referring to the adoption of anti-COVID-19 protocols:

‘I haven't found any change, absolutely, absolutely no change.’

Monia, 80 years

If these participants noticed any changes (eg, the reduction in frequency of the visits), they minimised them.

Pandemic experience

Participants offered various descriptions of their experiences during the COVID-19 pandemic. Some highlighted the need to accept difficulties and move on with their lives (aggression). They maintained relationships with their partners, relatives or friends via new or traditional media:

‘Despite the pandemic, I'm always trying to move forward […] It's very sad because just hearing the “war bulletins” [COVID cases updates] on television … is something that makes you even more sad. Well, but you have to face it, going ahead, trying to be careful and not to have contacts […] And the important thing is, I always say, we must give ourselves courage, don't let ourselves down.’

Alessandra, F, 78 years

A fear of COVID-19 was the prevalent experience among participants who faced the pandemic with threat, mainly expressed in terms of infection worries or one's relatives becoming ill:

‘If I were to catch the coronavirus, that was the worry, [one] is afraid to be in the hospital you know; you have to be a bit careful about what you do because you are in the company of other sick people and there are, among the sick and the sick are always there, there may be the one who is positive, but who knows it?’

Alfredo, M, 77 years

‘I'm afraid of this emergency here for the others, not for me, because I don't go away so much anymore, but I'm afraid for my children, for my grandchildren, that is.’

Serena, F, 84 years

Conversely, six participants tended to minimise the difficulties and worries associated with the COVID-19 pandemic (constriction) and declared that they intended to live through this period much as before, as they had led a withdrawn life before the pandemic:

‘I don't go to bars, I haven't been going to bars for years, many years. […] I don't miss anything. […] What I did before, I do now. As I didn't move before, I don't move now […] I don't even have worries.’

Marco, M, 68 years

Finally, four participants described their pandemic experience as a tragedy (guilt) because the restrictive measures implied strong limitations to their social life and needs, and they could find no way to maintain contact with others during the pandemic:

‘The worst thing is that you don't have human relationships anymore, and so that's the thing that's most, yes, that is more tragic.’

Raul, M, 55 years

These participants reported that they felt ‘locked in’ because of restrictive measures and that they needed far more freedom during this period:

‘The imposition of living as one imposes on you to live against your will, and this is a great negativity.’

Monia, F, 80 years

Discussion

The aim of this study was to understand the illness, healthcare and pandemic experiences of people with CLUs. The results show that pain is a salient aspect in the participants here, more than half referred to their perception of pain, indicating different intensity, duration and constancy. Some participants described various difficulties derived from CLUs, such as when wearing footwear or when driving or walking. Other participants were particularly attentive to avoid worsening the condition of their leg ulcer via exposure to sunlight, infections or injury. These results are in line with previous studies (Phillips et al, 2018; Ruseckaite et al, 2020). In contrast to their findings, no participants referred to the odour produced by CLUs and to personal hygiene difficulties, and only one mentioned exudate, reporting that treatment had stopped its release. Three hypotheses can be advanced to explain this observation:

• Patients considered odour as a given of their disease, so much so that they made no reference to it
• Being a topic causing embarrassment and shame, patients decided to omit this information in their reports
• Treatment was effective in minimising the presence of malodorous exudate, or patients found strategies to compensate for hygiene difficulties.

Regarding the healthcare experience, although not all participants stated that the treatment was always effective, almost all stated that they were satisfied with the care they were receiving at the time. The main factor that contributed to the high level of satisfaction was the competence of the clinic team, often reported by way of contrast to care by staff teams in other clinics, and the good-quality healthcare relationship, as already identified by Tollow and Ogden (2019). The most common characteristics attributed to the healthcare team were kindness, availability, flexibility and humanity. Some participants described professionals' solicitude and attention in encouraging and inviting them not to give up when facing difficulties. In line with previous studies (Hopkins, 2004; Green et al, 2018) the healthcare relationship was described by some participants as friendly and familiar.

In contrast to the studies conducted in Italy during 2020 that recorded a reduction in wound care visits due to the government-imposed restrictive measures causing a worsening in the conditions of some patients with leg ulcers (Tinelli et al, 2020; Sallustro and Florio 2021), participants in this study stated that the wound clinic was always operational during that period and that they continued to go there regularly for ulcer treatment. Although it is advisable to use telemedicine to reduce the risk of COVID-19 infection, there are some clinical scenarios that require in-person visits, including medical procedures. In these cases, it is important that clinical facilities adhere to physical distancing recommendations and other regulations set by local health authorities and that patients and staff are screened for symptoms of COVID-19 (Shanthanna et al, 2020). Given the satisfaction and good medical outcomes reported by the participants, the authors can suggest that the choice to continue to ensure provision of non-emergency healthcare services can prevent worsening of the health condition of patients with chronic non-cancer illness and promote their wellbeing.

Given these common features, the results of this study show different ways of living and interpreting CLUs, health care and the COVID-19 pandemic, which have been grouped into four trajectories, independent of length of illness and sociodemographic characteristics and, instead, associated with personal ways to deal with changes in life. For this reason, the trajectories have been described referring to the PCP's transitions of aggression, threat, constriction and guilt.

The first trajectory is dominated by the tendency of aggression, which was experienced by individuals who interpreted the illness as an opportunity to reconstruct their lives; they were able to rely on themselves and others (including health professionals) for help and tended to consider the pandemic as an event to cope with by rethinking themselves and their routines. All these participants reported the adoption of anti-COVID protocols at the clinic, but this did not interfere with the positive evaluation of health care; indeed, one participant reported an increase in treatment satisfaction.

Those who experienced illness as a way to overcome the threat of losing their significant relationships and mainly relied on others for help were predominantly concerned with the threat that COVID-19 could present to themselves and their relationships. These individuals presented themselves by focusing on their illness and healthcare experiences, to the detriment of other personal aspects. The clinic team were described in a positive way, in some cases this was close to idolatrous, and the relationship was maintained on a personal level, mainly based on dependence, similarly to their experience of the family relationship. Regarding the COVID-19 pandemic, restrictions were accepted by these participants only if they did not negatively impact their healthcare and dependence relationships.

The participants grouped in the trajectory of constriction tended to minimise the severity of the illness and avoid confiding in others; they had an inclination to minimise or even deny the difficulties associated with the pandemic or resigned themselves to these. They talked little about their illness and healthcare experiences. Despite stating that they were satisfied with their health care, these participants generally gave poor and generic descriptions of the healthcare team, referring to their competence and other attributes generally positively, but without mentioning significant episodes. These participants tended to minimise the illness and pandemic difficulties to exclude them from the construction of their identity and to demonstrate to themselves and others that their lives remained unchanged.

Finally, the trajectory of guilt characterised participants who described their illness and the pandemic as a tragedy, similar to an accident that had disrupted their lives and habits. They tended to rely more on themselves than on others for treatment, self-medicating and attending the clinic alone. They could rely on the clinic team and were satisfied with the health care they received, but they also reported a lack of trust in other areas (eg, difficulties in accessing other healthcare services or feeling abandoned by public health). In general, they described the healthcare team by referring to their competence and some positive attributes, but they were not always able to refer to specific events. The dimension of mistrust was also expressed in relation to the pandemic, with some of these participants berating the government and the measures taken to control the public health emergency. This could be a strategy to minimise the perceived danger of the virus, restoring a sense of security, or to attach meanings to this situation to escape uncertainty and identify an enemy to fight (Douglas, 2021; Cipolletta et al, 2022).

Limitations

The main limitation of this study concerns the interview modality; conducting them by phone prevented researchers from observing non-verbal signals and aspects (eg, odour or self-care issues) that could not be detected by phone. A second limitation is the small sample size, as it was composed only of people who attend the same clinic for CLU care, thus preventing researchers from obtaining knowledge about other healthcare experiences. A third limitation is linked to the recruitment process, which involved nurses asking participants to take part in the study. This might have made it difficult for some people to express negative opinions about nurses, although the interviewer informed the participants of the confidentiality of their interviews. The final limitation concerns the clinical data that could not be retrieved from participants' medical records for reasons of privacy and could be inferred only from the interviews, making it difficult for interviewers to obtain a complete overview of participants' clinical conditions.

Conclusions

Although the results of this study showed some commonalities among participants, consisting of difficulties linked to CLUs, satisfaction with the care offered by the clinic and a feeling of social distance associated with the COVID-19 pandemic, four distinct trajectories were identified linking participants' perceptions of the changes implied by the pandemic to their varied illness experiences and perceived social support.

These trajectories are in line with those of previous studies (Cipolletta and Amicucci, 2017; Cipolletta et al, 2017; Cipolletta and Gris, 2021; Cipolletta and Ortu, 2021; Tomaino et al, 2021) that involved people suffering from various chronic illnesses and people's experiences of the COVID-19 pandemic, and are now included in this innovative study on the particularities of the experience of people with CLUs and the combination of illness, healthcare and pandemic experience.

The results will prove to be useful to enact personalised intervention strategies to cope with CLUs and prevent long-term effects of any future health emergencies based on the different ways of experiencing illness and health care and of coping with a public health emergency such as COVID-19, which the present study has identified. More specifically, people with CLUs should be supported in finding a way to reconstruct their illness experience and themselves by accepting illness, but also by searching for new meanings and life plans to pursue, confiding in themselves but also using different resources to cope with the illness and large-scale emergency situations.

Future studies might explore whether the trajectories identified in this study can be found in different cultural and healthcare contexts and test the validity of the healthcare interventions set up on the basis of the suggestions derived from the results of the present study.

KEY POINTS

• The COVID-19 pandemic affected the care of people with a long-term condition such as chronic leg ulcers (CLUs)
• People with CLUs reported similar difficulties linked to their illness, satisfaction with the care offered by healthcare workers and a feeling of social distance associated with the pandemic
• Nevertheless, participants differed in their perceptions of the changes implied by the pandemic according to their varied illness experiences and perceived social support
• The choice to continue to provide healthcare services during the pandemic prevented the worsening of the health condition of patients with CLUs and promoted their wellbeing

CPD reflective questions

• How did the COVID-19 pandemic affect the life, illness and healthcare experiences of people with chronic leg ulcers?
• How can the differences in their experiences be understood?
• Consider how such differences could be used to lead intervention strategies to promote patients' wellbeing
• Reflect on the aspects that made the healthcare relationship most satisfying for the patients interviewed here. How does this relate to the interactions and healthcare relationships in your area of practice?