International Journal of Nursing Studies 51 (2014) 865874

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Current practice in the management of wound odour:

An international survey
Georgina Gethin a,*, Patricia Grocott b,1, Sebastian Probst c,2, Eric Clarke d,3
a

School of Nursing and Midwifery, National University of Ireland, Galway, Ireland

Kings College London, James Clerk Maxwell Building, Room 1.34, Waterloo Road, SE1 8WA London, United Kingdom
c
Departement Gesundheit, Institut fur Pege ZHAW Zurcher Hochschule fur Angewandte Wissenschaften Technikumstrasse 71, Postfach,
CH-8400 Winterthur, Switzerland
d
Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Ireland
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 10 April 2013
Received in revised form 16 October 2013
Accepted 16 October 2013

Aim: To determine from a multi-disciplinary and international perspective current

practice in the management of wound odour.
Background: Malodour is cited by patients and carers as one of the most distressing and
socially isolating aspects of their wounds. The absence of a standardised approach to
assessment and management underscores the need to collect baseline data to support
guideline development.
Design: On-line survey.
Methods: A study specic questionnaire in English, Spanish, Italian and German was
emailed to wound care organisations worldwide, palliative and oncology nursing
organisations, and known contacts with a special interest in wound management, for
distribution to members between December 2011 and February 2012.
Results: 1444 people from 36 countries responded. 12% assess odour with descriptive
words being the most frequent form of assessment. Charcoal and silver based dressings
were the most frequently used odour management agents, yet, only 48.4% and 23%
respectively reported these as being very effective. Antimicrobial agents were cited as
most effective but were not the most frequently used. 8% use aromatherapy oils direct to
the wound, and 74% combine a range of dressings to try and manage odour. Odour, pain
and exudate management were the greatest wound management challenges facing
patients and clinicians. 46.7% of respondents encounter patients with MFW on a monthly
basis and 89% agreed there is a need to develop guidelines in this area.
Conclusion: A trial and error approach to odour management exists with low overall
satisfaction with current practice. There is a need for research and education on means to
assess odour and odour management options.
2013 Elsevier Ltd. All rights reserved.

Keywords:
Odor
Guidelines
Management
Palliative wound
Wound symptoms
Nursing

* Corresponding author. Tel.: +353 91 492018; mobile: +353 86 8560053.

E-mail addresses: Georgina.gethin@nuigalway.ie (G. Gethin), Patricia.grocott@kcl.ac.uk (P. Grocott), prob@zhaw.ch (S. Probst).
1
Tel.: +44 0207 848 3629.
2
Tel.: +41 58 934 65 14; fax: +41 58 935 65 14.
3
Tel.: +353 1 4022477.
0020-7489/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijnurstu.2013.10.013

866

G. Gethin et al. / International Journal of Nursing Studies 51 (2014) 865874

What is already known about the topic?

 Acute and chronic wounds affect up to 2% of the
population and account for up to 4% of total health care
expenditure.
 Of all wound symptoms, odour is cited by patients and
carers as the most distressing, causing social isolation,
depression and revulsion.
 Best practice in wound assessment advocates for
assessment of odour, yet, there is no consensus on
methods of assessment or management strategies and
the lack of an evidence base to guide practice necessitates the need for collection of baseline data.
What this paper adds
 This study demonstrates an important theory-practice
gap as only 12% of clinicians assess odour, yet it is
advocated for in wound assessment tools.
 Topical antimicrobials are cited as being the most
effective odour management agents but are not the
most widely used for odour management.
 Trial and error prevails in the management of odour at
the wound bed and in the patients environment.
1. Introduction
Consistent research ndings demonstrate the negative
impact wounds, and their associated symptoms, have on
the quality of life of the individual in physical, psychological, spiritual and social domains. Of all wound related
symptoms, odour is cited by patients and professionals as
the most distressing, contributing to a contracted life of the
individual, social isolation, depression, feelings of guilt and
repulsion (Chase et al., 2000; Grocott, 2007; Probst et al.,
2009). Chronic wounds as well as palliative wounds may
be associated with a profound odour problem and some
patients report feelings of being totally isolated by the
effects of their wound attributing the odour as the main
causative factor (Probst et al., 2013a,b). These feelings of
isolation also result in patients and carers struggling in
their attempts to manage the physical elements of the
wound while simultaneously coping with the psychological impact of its appearance and in the case of malignant
fungating wounds (MFWs) the reminder of underlying
disease (Probst et al., 2013a,b).
Living in a body with a chronic or palliative wound that
leaks and smells is a big challenge for patients and leads to
signicant emotional, physical and social distress (Grocott
et al., 2005; Probst et al., 2009). Most of the patients are
using trial and error methods to cope with their
unpredictable and unbounded body that cannot contain
uids and odours and leads to feelings of shame and
frustration (Probst et al., 2013a,b). The problem of odour
may also have a detrimental effect on sexual expression,
leading to relationship problems (Haughton and Young,
1995).
Malodour arises from a combination of factors including bacteria, necrotic tissue, high levels of exudate and
poorly vascularised tissue (Gethin, 2010). It is caused by a
cocktail of volatile agents that includes short chain organic

acids, (n-butyric, n-valeric, n-caproic, n-haptanoic and ncaprylic) produced by anaerobic bacteria (Moss et al.,
1974), together with a mixture of amines and diamines
such as cadaverine and putrescine that are produced by the
metabolic processes of other proteolytic bacteria (Thomas
et al., 1998). This odour has been linked to the smell of
rotting meat (Price, 1996). More recently Dimethyl
Trisude has been identied in malignant wounds as a
source of odour (Shirasu et al., 2009). This compound has
also been found in volatiles emitted from certain
vegetables, fermented milk and aged food or drinks and
is also produced by aerobes such as Pseudomonas
aeruginosa (Shirasu et al., 2009).
Smell is difcult to research as any given odour may be
made up of hundreds of different chemicals. Humans can
distinguish 10,000 or so odours, but research suggests that
our olfactory receptors are stimulated by different
combinations of a more limited number of olfactory
qualities (Tortora and Derrickson, 2011). While it is
believed that individuals can become accustomed to
certain odours, this is not the case with putrescine and
cadaverine which cause a gagging reex among individuals
(Van Toller, 1994).
Assessment of wound odour remains an important goal
as there is currently no internationally agreed method of
assessment and the inter-rater reliability of some methods
is very poor (r = 0.2) (Gethin and Cowman, 2007). Variation
in the use of visual analogue scale (VAS) for assessment is
reported with scales ranging from a two point, to four
point, ve point, 10 point and 100 point scale; yet there is a
dearth of research, which has evaluated the reliability of
any of the scales.
2. Background
Wounds and their management are a signicant
problem affecting approximately 2% of the general
population, accounting for up to 4% of total health care
expenditure and approximately 68% of community nurses
time (McDermott-Scales et al., 2009; Posnett et al., 2009;
Sen et al., 2009). Chronic wounds such as venous, arterial
and diabetic foot ulcers have a protracted course of healing
and are associated with a recurrence rate of up to 70%
(Milic et al., 2009; Sen et al., 2009). While availability of
precise gures for MFWs is limited, it is estimated that of
those people with metastatic carcinoma approximately 5
10% experience skin involvement occurring during the last
612 months of life (Lo et al., 2008). A MFW occurs by an
inltration of the skin by a tumour or metastasis (Grocott,
2007). Population projections would suggest that the
prevalence of all wounds will increase signicantly in the
next 20 years due to a range of factors including increased
life expectancy, lifestyle changes, increased prevalence of
chronic illness and increased survivorship from major
traumas and surgeries (Posnett et al., 2009; Sen et al.,
2009).
The problem of wound odour extends across wound
aetiologies and geographical boundaries and is currently
an under researched and poorly managed phenomena
while simultaneously being the most distressing aspect of
a wound. Yet, odour management was not identied as a

G. Gethin et al. / International Journal of Nursing Studies 51 (2014) 865874

priority area for research or education in wound healing

(Cowman et al., 2012). In the absence of evidence to
support best practice, this study aims to describe current
practice in order to guide future research and to contribute
to the development of clinical practice guidelines. We are
not aware of any previous research, which has addressed
this issue at a local, national or international level.
3. Aim
The study aimed to determine, from an international
audience, current practice in the management of wound
odour and to determine the self-rated level of efcacy of
such management. Additionally, the survey aimed to
determine the level of agreement for the development
of guidelines on the management of odour and management of malignant fungating lesions.
4. Research design
A descriptive, cross-sectional, on-line survey.
5. Population and sampling
Prior assumptions of what denes a given research
population, and thus assumptions of representation,
present considerable challenges in obtaining a sample
where individual opinions or judgments are required. We
considered that as odour is a global problem, population
characteristic would be reasonably similar across countries. We therefore included those clinicians specically
involved in wound management or cancer care. Health
professionals with a recognised interest in wound care
(registered members of wound care organisations) and
those professionals who would be likely to encounter
malodorous wounds (palliative and oncology nursing
organisations) were invited to participate (see acknowledgements list). As we did not have a sampling frame from
which to select a study sample, we targeted members of
these groups by sending an email invitation to the
organisation, requesting them to forward this to all their
members. This method of self-selection has advantages as
individuals can select whether to participate or not. The
survey can be completed at a time of their choosing and it
removes the possibility of paper based survey being lost or
mislaid. As the study was a scoping exercise to include all
possible management practices for wound odour, we did
not set a limit on sample size but rather set a time limit for
close of the survey. A strength of this approach is the ability
to gather information across jurisdictions, health care
systems and cultural backgrounds, consequently providing
a rich source of data. Thus, we included a non-probability
purposeful sample.
Data collection was completed between December
2011 and February 2012. Two email reminders were sent
during this time.
6. Questionnaire design
Questionnaire design was guided by previous work
(Cowman et al., 2012; Probst et al., 2009), which

867

incorporated both on-line and paper based formats. The

nal questionnaire included 28 questions, of which 21
were closed questions; four incorporated a 3-point Likert
scale, one a ranking of items, one free text question, one
question to provide gures related to activity rates and a
nal question which invited comments or feedback. The
questionnaire sought minimum pertinent demographic
information including country, area of practice, profession
and years qualied. Other single response items included:
history of third level qualication/training in wound
management and management of MFWs, frequency with
which one encounters patients with wounds and percentage of working week dedicated to wound management.
In an attempt to see how often respondents encountered patients with MFWs we sought information in
relation to frequency of encounter, age prole of such
patients, location of wounds and whether they had
training in the management of MFWs.
A list of the fteen most frequently cited wound
products in the literature, and from anecdotal evidence for
the management of malodour, was presented to participants who were then asked to identify rst if they used any
of the products and, secondly, to rate how effective they
considered them to be on a 3-point Likert scale. It should be
noted that although aromatherapy agents are not currently
licensed medical devices for wound management, many
clinicians report using them and as such these agents were
included in this list. Similarly, a list of agents used within
patients rooms was collated from the literature and from
anecdotal evidence and presented to participants to
identify if they used them. Respondents were asked to
provide up to ve words they use to describe odour. In
addition, respondents were invited to provide examples of
dressings they use to manage odour. Finally, participants
were asked if they believed there was a need for clinical
practice guidelines to assist in this area of practice.
The chosen web based survey tool facilitated the
application of skip logic where questions are selectively
displayed to the respondent based on responses to
previous items. The application of skip logic in a web
based survey is embedded in the survey software and the
respondent sees only a smooth transition from one item to
the next and, overall, a shorter instrument to complete
(Oppenheimer et al., 2011).
7. Validity
The design of each question followed an iterative
process between the authors and consideration of previously used questionnaires (Cowman et al., 2012; Probst
et al., 2009). Validity was achieved by subjecting the
questionnaire to review from a methodological and
content perspective by experts in each of these areas.
Face and content validity was assessed by wound care
experts including tissue viability nurse specialists (n = 3),
palliative care nurses (n = 2), university lecturers (n = 3)
one surgeon, and one podiatrist. The study design was
descriptive in nature and therefore a key criterion for the
reviewers was to determine if the questions were broad
enough and unambiguous to allow participants from a
range of health care settings, professional backgrounds and

G. Gethin et al. / International Journal of Nursing Studies 51 (2014) 865874

868

study was voluntary. Return of the questionnaire was

taken as consent to use the data.

languages to respond. Additionally, the questions had to

cover as many elements of the practice of odour management as possible. Changes made to the questionnaire
during this process were returned to the group for reassessment. No gold standard questionnaire existed to
facilitate comparison to the nal design thus limiting the
possibility of determining criterion validity.
Recognising the international perspective of the study
and the need to make it suitable for easy translation, it is
recommended that web based studies have high usability
(Oppenheimer et al., 2011). This is because paper-based
layouts may not necessarily transfer to web based formats.
We pilot tested the nal questionnaire among ten nurses
with a special interest in wound care. The aim of the pilot
phase was to test for clarity and understanding of the
questions and to check the time required to complete the
survey. Members from one region of one wound care
organisation were invited to complete the on-line pilot
study. The nature and purpose of the study, together with a
statement of ethical approval, were included in the email
to participants and on the start screen for the study. No
revisions to the questionnaire were made following the
pilot study and the time to complete was less than 20 min.
Once the English version was pilot tested, it was
translated into German, Italian and Spanish. Each translation was cross-checked by a second individual and pilot
tested with three nurses. It was important that the literal
meaning of a word was translated during the translation as
well as its relationship to the context (Esposito, 2001).

10. Data analysis

Descriptive statistical analysis was conducted on the
quantitative data using SPSS version 17. Data from Likert
scales were treated as ordinal data while descriptions of
frequencies of encountering of wound types were analysed
as categorical variables. International differences were
explored with the chi-squared statistic. Information
provided through the free text comment section were
read and collated and reviewed by all team members.
11. Results
As we cannot determine how many people received the
survey, actual response rate cannot be provided. 1444
professionals from 36 countries representing primary and
secondary care settings participated, the majority, 83%
(n = 1195) of whom were nurses (see Table 1). Responses
by language were; English 41%, German 21%, Italian 18%,
and Spanish 20%. Respondent proles showed that 36%
(n = 527) had undertaken some form of formal or third
level education programme specic to wound care with
10% (n = 144) educated to Masters level (Table 1).
Sixty ve per cent (n = 926) encountered patients with
wounds on a daily basis and overall 68% (n = 635) spend up
to 25% of their working week dedicated to wound
management (see Table 2). The frequency with which
respondents encountered patients with MFWs was 46.7%
(n = 595) on a monthly basis. Of these patients, there was
an age related increase in prevalence with 50% (n = 855)
being between 60 and 79 years of age (Table 2). The
majority, 26.9% (n = 27), of MFWs were on the extremities.
Interestingly, 52.3% (n = 506) of respondents have had
training in how to manage these wounds.

8. Data collection
Data were collected using a commercially available
online survey tool (http://wwwsurveymonkey.com). SSL
(security sockets layer) encryption is used by the service to
protect data during transmission ensuring a secure
connection between a client (participant) and the server.
The tool is hosted off-site from the host institution.

12. Wound management practices

9. Ethical considerations
The wounds cited as being most associated with odour
in descending order were; MFWs (n = 811), pressure ulcers
(n = 307), leg ulcers (n = 132), diabetic foot ulcers (n = 116),
burns (n = 23), no response (n = 55).
With regard to the assessment of odour, 12% (n = 187)
stated they assessed odour. Of these only 4.5% (n = 66) used

Approval to conduct the study was gained from the

research ethics committee of the Royal College of Surgeons
in Ireland. To ensure anonymity, questionnaires did not
have codes and personal information was not requested,
apart from basic demographic details. Participation in the
Table 1
Prole of respondents.
Profession n (%) n = 1444

Nurse
Surgeon
Doctor
Podiatrist
Physical therapist/
Physiotherapist
Pharmacist
Other
Missing

1195
70
69
56
20

(83)
(5)
(5)
(4)
(1.3)

7 (.5)
23 (1.6)
4 (3)

Undertaken formal or 3rd level

education in wound management
n (%) n = 1444

Years since
qualication
n (%) n = 1444

Short course
Certicate
Diploma
Batchelor degree
Post-graduate diploma

15
610
1120
>20
Missing

Masters
Doctoral level
Other
None

70 (5)
69(5)
13 (<1)
33 (2)
63 (4)
144
9
126
917

(10)
(<1)
(9)
(64)

Country of respondents
n (%) n = 1444
111
144
380
800
9

(8)
(10)
(26)
(55)
(1)

Italy
Spain
Australia
Germany
USA

267(18.4)
266(18.4)
215(14.8)
195(13.5)
166(11.4)

Switzerland
United Kingdom
Ireland
Other

105(7.2)
103(7.1)
60(4.1)
67 (4.63)

G. Gethin et al. / International Journal of Nursing Studies 51 (2014) 865874

869

Table 2
Level of engagement in wound management practice.
Frequency with which you
encounter patients with
wounds
n (%) n = 1444

Frequency with which you

encounter patients with
MFWa n (%) n = 1444

Percentage of working
week dedicated to wound
management

Age prole of your patients

with MFW n (%)b

Location of
MFW (%)c

Daily
Weekly
Fortnightly
Monthly
Never
Missing

Daily
Weekly
Fortnightly
Monthly
Never
Missing

125%
2650%
5175%
76100%
Not applicable
Missing

<20 years
2039 years
4059 years
6079 years
80 years

Extremities
Neck
Head
Genitalia
Chest
Back

a
b
c

926
261
47
152
33
25

(65)
(18.4)
(3.3)
(10.7)
(2.3)
(2.3)

69
233
103
595
273
171

(5.4)
(18.3)
(8.1)
(46.7)
(21.4)
(12)

635 (68)
113 (12)
40(4)
26 (2.8)
116 (12.5)
514 (35.5)

18(1.05)
116(6.8)
497 (29)
855 (50)
224(14)

27
19
19
14
12
9

Malignant fungating wounds.

More than one age group could be selected.
More than one option could be selected.

a rating scale. These scales ranged from presence or

absence of odour (n = 29), 3-point scale (n = 11), 4-point
scale (n = 10), TELER scale (n = 4). A further 121 respondents stated they assessed odour using words (n = 63) or
distance from the wound at which they can detect odour
(n = 6) or other methods which were not-stated (n = 52).
A total of 3671 words were provided as examples of
how respondents describe odour. These were collated,
translated and merged to provide a list of the top 20 words
and the frequency which whey they are cited (Table 3).
The most frequently applied dressing(s) were charcoal
followed by silver based dressings, yet, only 48.8% (n = 516)
and 23% (n = 240) respectively reported these as being
very effective. metronidazole was only used by 56.9%
(n = 655), of these, 87.9% (n = 570) reported this as being
somewhat effective or very effective. Of the top ve most
frequently used dressings, antimicrobials accounted for
40%. However, of the top ve rated very effective
dressings, antimicrobials accounted for 100% of these
(see Table 4).

Table 3
Top 19 words used to describe odour.
Word

Frequency n (%)
Total number of
words = 3649

Foul
Malodorous
Sweet
Pungent
Strong
Smelly
Offensive
Moderate/mild/medium/minimal
Putrid
Acrid
No/No Odour/odourless
Intense
Nauseating
Foetid
Unpleasant
Faecal
Rotten
Pseudomonas
Penetrating
Odour
Other

281
261
243
216
163
160
151
113
100
79
75
74
73
72
71
64
62
53
48
41
1399

(7.7)
(7.1)
(6.6)
(5.9)
(4.4)
(4.4)
(4.1)
(3.1)
(2.7)
(2.2)
(2.0)
(2.0)
(2.0)
(2.0)
(1.9)
(1.7)
(1.7)
(1.4)
(1.3)
(1.1)
(35)

Seventy four percent (n = 1068) of participants combined a range of dressings and topical agents in an attempt
to manage malodour but cited these as being only
somewhat effective. A huge variety of dressing combinations were provided but there was no pattern or any one
combination that emerged and reected a trial and error
approach to odour management. It is worth noting that
there was doubling up of many dressings and agents for
example: silver based dressings plus silver secondary
dressing, charcoal dressings to the wound plus as a
secondary dressings; silver plus charcoal; honey plus
charcoal; hydrogels plus silver.
Eight percent (n = 115) of respondents currently use
aromatherapy oils to the wound bed the most commonly
cited oil being lavender 49% (n = 57), followed by lemongrass or lemon oil 37% (n = 41), peppermint oil 25% (n = 29),
orange oil 14% (n = 16), tea tree oil 13% (n = 15), bergamot oil
7% (n = 10). Other oils which were cited but for which less
than 10 people used them were: eucalyptus, coffee,
rosemary, nilodour, mint, patchouli, sandalwood, vanilla,
almond, cholophyll, clove, corpito, and grapefruit. The selfreported level of being very effective ranged from 20 to 38%.
Respondents were asked to identify the clinical concerns expressed by their patients in relation to their
wound; the top two being odour 85% (n = 1227), and social
concerns 72% (n = 1039) (see Table 5). The top three
greatest challenges reported by clinicians were: odour 83%
(n = 1198) and containment of exudate and pain 70%
(n = 1010) (Table 5).
13. Environment practices
In an attempt to manage odour in the patients
environment (patients rooms) a vast range of products
and materials were reportedly in use (see Table 6). Of
these, 17.2% (n = 166) named specic commercially available products while others relied on strategies including
cat litter, shaving cream and perfumes. Other items for
which less than 20 people reported using included:
citronella, eucalyptus, orange oil, incense, bergamot, mint,
shaving foam, and tea tree oil.
In the nal section 89.2% (n = 1053) indicated there was
a need to develop guidelines to assist in the management
of wound odour, and 90.6% (n = 1069) agreed there was a
need for guidelines to assist in the management of MFWs.

G. Gethin et al. / International Journal of Nursing Studies 51 (2014) 865874

870

Table 4
Participants use of, and self- rated level of efcacy of topical wound agents.
Type of Dressing

Do you use any of

the listed items?

Activated charcoal - dressings

Topical metronidazole gel (Flaygl)
Alginate with silver dressing
Hydrober dressings with silver
Iodine based dressings
Foam with silver
Honey
Hydrogels
Alginate dressing
Hydrocolloid dressings
Hydrober dressings
Foam dressings
Foam dressing silicon
Transparent dressing
Gauze

No n
(%)

Yes
n (%)

189(15.1)
496(43.1)
160(13.3)
218(18.8)
371(32.9)
283(24.7)
609(53.8)
188(16.9)
145(12.9)
275(24.6)
244(22.2)
174(15.5)
283(25.4)
398(36.3)
380(34.1)

1066 (85)
655(57)
1039(87)
943(81)
757(67)
861(75)
522(46)
923(83)
983(87)
842(75)
855(78)
949(85)
832(75)
699(64)
736(66)

Table 5
Challenges in managing wounds.
Item/theme

Odour
Social concerns
Containment of exudate
Pain
Emotional stress
Bleeding
Functional Compromise
Nutritional deterioration
Oedema
Difculties with t to location
Difculties with t
Difcult to keep clean
Mismatch between size of
wound and size of dressing
Peri-wound skin problems

Cited by
clinicians
n (%) n = 1444

Cited by patients
(according to
the clinician)a
n (%) n = 1444

1198
0
1010
1010
0
750
0
0
0
750
693
548
404

1227
1039
1010
1010
967
490
490
389
274
0
0
0
0

(83)
(70)
(70)
(52)

(52)
(48)
(38)
(28)

86 (6)

(85)
(72)
(70)
(70)
(67)
(34)
(34)
(27)
(19)

Not primary data from patients. These are what the patients
complain of according to the clinician.

Total (numbers
who replied)

1255
1151
1199
1161
1128
1144
1131
1111
1128
1117
1099
1123
1115
1097
1116

If yes to using the product(s), how effective to you

consider them to be?
Not effective
n (%)

Somewhat
effective n (%)

Very effective
n (%)

31(2.9)
85(12.9)
148(14.2)
239(25.3)
228(30.1)
267(31.0)
222(42.5)
709(76.3)
576(58.5)
669(79.4)
570(66.6)
700(73.7)
588(70.6)
604(86.4)
669(90.8)

519(48.6)
250(38.1)
651(62.6)
531(56.3)
404(53.3)
479(55.6)
218(41.7)
157(17.0)
352(35.8)
129(15.3)
245(28.6)
210(22.1)
210(25.2)
67(9.5)
51(6.9)

516(48.4)
320(49.8)
240(23.0)
173(18.3)
125(16.5)
115(13.3)
82(15.7)
57(6.1)
55(5.5)
44(5.2)
40(4.6)
39(4.1)
34(4.0)
28(4.0)
16(2.1)

Table 6
Most frequently used environmental agents (agents in the patients
room).
Environmental agents used

Number who use

these n (%)
Responses n = 965

Named commercial products

Air freshener/room sprays
Aromatherapy oils (names not specied)
Lavender oil
Lemon/lemon oil
Cat litter
Coffee
Peppermint/peppermint oil
Charcoal
Perfume/cologne/deodorant
Candles
Citronella/citrus oil
Eucalyptus
Orange/orange oil
Incense
Bergamot oil
Mint
Shaving foam
Tea Tree oil
Other

166 (17.2)
140 (14.5)
65 (6.7)
56 (5.8)
45 (4.7)
43 (4.5)
35 (3.6)
34 (3.5)
33 (3.4)
27 (2.8)
22 (2.3)
21 (2.2)
20 (2.1)
19 (2.0)
16 (1.7)
11(1.1)
11 (1.1)
10 (1.0)
10 (1.0)
180 (18.6)

14. Discussion
This is the rst study to synthesise the current practice
in the management of wound odour and provides
important insights for clinicians, researchers and industry.
It has highlighted the lack of assessment and presents a
trial and error approach to the management of odour,
which is reported as being the most difcult aspect of
wound management. Participants did not have condence
in the measures they currently use, as demonstrated
through the self-reported low levels of efcacy for many of
the agents.
15. Assessment
A signicant and unexpected nding of our study was
that only 12% (n = 68) of respondents currently assess

odour and of these only 4.5% (n = 66) use a scale. The

implications for this are unclear at this time, but it should
be acknowledged that the challenges faced in managing
this distressing symptom are not being tackled through
any form of systematic assessment but rather through
subjective description using over 3500 different words.
The choice of words would indicate repulsion to the odour
and that people struggle to dene and describe it.
The challenges of assessment are inuenced by the fact
that one is trying to describe, in an objective manner, an
entity that we cannot see, touch or measure. It is also
compounded by the fact that odour is both a sign and a
symptom of an underlying problem. A symptom is dened
as a subjective experience reecting changes in the bio
psychosocial functioning, sensations, or cognition of the

G. Gethin et al. / International Journal of Nursing Studies 51 (2014) 865874

individual (Dodd et al., 2001). Alternatively, a sign is

dened as any abnormality indicative of disease that is
detectable by the individual or by others (Harver and
Maher, cited in (Dodd et al., 2001)). This is particularly
relevant in cases of infection where odour may be the rst
sign of a problem (Gottrup et al., 2013).
The use of visual analogue scales (VAS) offers potential
for widespread adaptation in odour assessment. Such
scales are used successfully in the assessment and
management of pain, are inexpensive, and easily understood when incorporating faces, words and numbers to
overcome the limitations of language and literacy (Stuppy,
1998). They have been incorporated into wound assessment tools in palliative care including the Toronto
symptom assessment system for wound (TSAS-W) (Maida
et al., 2009) and wound symptoms self-assessment chart
(WoSSAC) (Naylor, 2002) but require further validation in a
greater range of wound aetiologies.
Alternatively, the TELER system is a generic method of
making clinical notes, which includes clinical indicators to
measure patient outcomes. This system aims to overcome
subjectivity by measuring the effect of malodour on the
individual concerned, for example what the problem of
malodour may cause them to change in their daily
activities. Clinical research and knowledge based on
experience (patient and professional) are used to dene
the outcome measures (Browne et al., 2004).
16. Treatments topical
A wide range of topical wound agents were recorded for
use on the wound and the low overall self-reported efcacy
of these agents is concerning. Charcoal was the most
frequent dressing reported and yet only 48.4% rated this as
being very effective. This may be due in part to the range of
products that are available, which raises inherent challenges when using them because the mode of action and
method of application vary between products. Some
products are applied directly to the wound bed and are
incorporated with silver, an antimicrobial agent; others are
merged with other dressings, which also manage exudate
and the charcoal is not direct to the wound bed. Other
dressings are applied as an outer layer away from the
wound, on the grounds that the charcoal layer needs to
remain dry to be effective in adsorbing volatile malodorous
substances. This requirement is coupled with the practical
challenge of maintaining a sealed dressing unit. This can be
very problematic in chronic wounds and in MFWs, in
which the contours of the wounds can be very eccentric,
the peri-wound skin is often very sensitive, sometimes
painful and in some cases, such as venous leg ulcers, which
may have concomitant varicose eczema.
The use of antimicrobials has raised an interesting
disparity between what is used and what is considered
effective. In our study, antimicrobials were not the most
frequently used dressings, but they were ranked highest in
terms of levels of efcacy for odour management.
Antimicrobial products play an important role in wound
management and are becoming increasingly clinically
relevant due to the emergence of antibiotic resistant
strains of bacteria. Although the use of antimicrobial

871

products should be underpinned by a clear understanding

of how these products work, including their relative
indications and contraindications, the current evidence
base to support them is weak (Gottrup et al., 2013).
Metronidazole remains the most widely cited topical
agent for odour management in the literature (da Costa
Santos et al., 2010) yet, it is the second least used product
in our survey with 43% (n = 496) not using this. This may be
due to lack of availability in some countries, cost issues and
additionally the requirements for a medical prescription
may limit the widespread availability. Of those who use it,
almost half report it as very effective. There remains a lack
of a standardised protocol for the mode, dose and
frequency of application of metronidazole. Applications
range from crushing tablets and mixing with a gel for
application to the wound site, to mixing with saline to use
as a rinsing agent. The amount of the drug used in these
practices is impossible to determine. Commercial preparations range in strength from 0 .075% to 0.8% (da Costa
Santos et al., 2010). However, clinically, it is unclear as to
how much of the preparation should be used in a wound to
achieve a minimum concentration of the drug to achieve a
therapeutic effect. Additionally and worryingly, the trials
on which current practice is based are over twelve years
old and of small sample sizes (da Costa Santos et al., 2010),
supporting the need for further research in this area.
Silver was the second most commonly cited agent, but
the reported level of efcacy was low. There is some
emerging research to support the use of silver in odour
management in MFWs with clinicians in one study
reporting 76.9% (n = 10) of patients showing signicant
reduction in odour compared to non-silver control group
30.8% (n = 4) (Kalemikerakis et al., 2012). However, the
small sample size and lack of patient evaluation limits the
generalizability of the ndings but the study does provide
data upon which future studies can be designed. A further
comparative uncontrolled study among 75 patients with
MFWs evaluated silver dressings versus honey dressings
for reduction of malodour (Lund-Nielsen et al., 2011).
While no statistically signicant differences were found
between groups, there was a signicant difference in
reduction of malodour after four weeks when both groups
were combined (p 0.007).
Although anecdotally there is much interest in aromatherapy for odour management this is not borne out in
our study where only 8% (n = 115) apply it to the wound bed.
A literature review of aromatherapy practice in nursing
identied one study of its use in open wounds (MaddocksJennings and Wilkinson, 2004). A further two studies were
identied in psoriasis and eczema but none for MFWs. The
main areas of potential benet of aromatherapy, as
identied in this review, were for anxiety and mental stress.
This may be of particular relevance in the management of
wound odour as this wound symptom is a signicant source
of stress and anxiety for patients.
It is argued that the lack of rigorous clinical trials
measuring patient outcomes remains a stumbling block for
widespread adoption of aromatherapy in nursing practice
(Maddocks-Jennings and Wilkinson, 2004). Studies are
required to investigate the effects of different dosage
regimes, compare blends of oils with single formulations

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G. Gethin et al. / International Journal of Nursing Studies 51 (2014) 865874

and study the volatile nature of the oils (Maddocks-Jennings

and Wilkinson, 2004). Mercier and Knevitt (2005) report
training of staff on the use of essential oils in their palliative
care setting underpinned by a protocol. They report using
aromatherapy oils, the choice of which is based on patient
preference, in 13 cases with positive effects on reduction of
odour. Additionally they report that the use of such oils is
more cost effective than other standard dressing regimes.
This work may provide future guidance for more widespread adoption. Undoubtedly further research is required
in the use of aromatherapy agents as clinicians risk using
unlicensed products in an unregulated manner with
potential adverse effects to their patients.
Research on interventions to manage wound odour
have predominantly been conned to topical agents on the
wound bed and to MFWs. It is notable that the current
evidence base at the level of randomised controlled trials
(RCT), as conrmed in two systematic reviews, for the
management of the most frequently cited wound related
problem (i.e. odour) is limited to two clinical trials, each of
over 18 years old and involving only 11 patients (Adderley
and Smith, 2007; da Costa Santos et al., 2010). Since
publication of these reviews, one RCT has been published
comparing silver with honey in which odour was one study
outcome (Lund-Nielsen et al., 2011). However, this study is
also limited to MFWs.
17. Treatments environmental
Our research shows that current practice in the
management of odour in the patient environment is
not well rened with people reporting using; essential
oils (usually in candles), cat litter in the room, shaving
foam and a range of commercial air fresheners. Many air
fresheners may offer temporary relief but risk simply
masking the odour by adding a new odour, with little
tangible benet to patients and carers. Research on the
impact of odour in patients homes has demonstrated
negative effects on sleep, appetite and mood (Avery
Hoton et al., 2009). This is further supported by a
systematic review of effects of sensory environment on
patient well-being and health related outcomes (Drahota
et al., 2012). The latter review identied two studies and
showed that non-fragrant environments were more
positive than when fragrant oils were used, and lavender
mist was better than placebo, (Drahota et al., 2012).
Although this review was not amongst patients with
wounds it provides some valuable insights to the effects
of smells on patient well-being and levels of stress and
anxiety.
There is potential and opportunity here to learn from
environmental agencies and to share expertise in order to
develop interventions which are safe, cheap and effective
in a room or ward setting. To date there are no clinical trials
in this area, with a focus on wounds.

and error, anecdotal evidence and locally developed

protocols to manage odour. The lack of odour assessment
is a cause for concern, which needs to be addressed.
Strategies on how to select dressings to manage odour
should be incorporated into wound management education programmes.
19. Implications for research
The lack of empirical research supporting the use of
many agents for odour management needs to be
addressed. Clinicians should be provided with the opportunity to contribute to trials to focus on odour in four
domains: identication of cause; assessment; topical
treatments and environmental strategies. LeBon et al.
(2009) recommended the use of N-of-10 trials to evaluate
the efcacy and clinical effectiveness of topical opioids in
painful wounds, because of the unique pathogenesis and
other descriptors of an individual wound (LeBon et al.,
2009). Similarly for malodour the N-of-1 study design can
combine individual level evaluation with the methodological rigour of controlled studies (MRC, 2008).
20. Limitations
The lack of data on the population size limits our
understanding of response rates to this on-line survey.
However, we believe that this limitation is off-set by the
large numbers who did respond from a range of health care
settings. Whilst every effort was made to strengthen the
validity of the study, we cannot be specic regarding the
level of professional qualication in wound management
as terms such as certicate/diploma hold different meaning in different countries. Nonetheless, respondents had a
high level of engagement with patients with wounds, thus
providing rst-hand experience of wound management.
Results are limited to a descriptive analysis. We had
planned to conduct correlations including those between
levels of education and the use of wound agents and the
country of origin, but the overwhelming representation
from nursing and the variations in levels of education
precluded any meaningful statistical analysis.
The use of an exclusively on-line survey means that
certain countries with weak information and communication technology infrastructure (access to email and
internet services) may not have been in a position to
participate and thus their current practice may be underrepresented. It is difcult to determine how much this
inuences the overall ndings as potentially effective
practices may be in place in such areas but are currently
unknown to us.
Patient concerns, which were reported second hand and
ltered through clinicians interpretation, should be
viewed with caution.
21. Conclusion

18. Implications for practice

The implications of these study ndings together with
the lack of evidence from the literature have enormous
practice implications for clinicians who currently use trial

Although there is widespread agreement among

patients and carers that odour is a distressing and
debilitating wound problem, the self-reported low efcacy
of many topical and environmental agents together with

G. Gethin et al. / International Journal of Nursing Studies 51 (2014) 865874

the limited evidence base to support current practice

warrants urgent research to investigate new treatment
approaches. Assessment and management practices are
unsupported by the scientic literature and could be
enhanced by the production of clinical practice guidelines.
We are in danger of not addressing this debilitating
problem but focusing on other areas of wound management which are of less concern to the quality of life of
individuals and in particular of those with MFW for whom
life expectancy may be reduced.
22. Conict of interest
The authors declare that they have no conict of
interest.
23. Ethical approval
We have made the statement that ethical approval was
granted in our paper. This was granted by the research
ethics committee of the Royal College of Surgeons in
Ireland (where I worked at the time the paper was
commenced).
24. Funding
This study was supported by an unrestricted research
grant from the Wound Management Association of Ireland.
Acknowledgements
The following organisations invited their members to
participate: Wound Management Association of Ireland;
European Wound Management Association; Swiss Association for Wound Care; Academy CWM Kammerlander;
American Academy of Wound Care; Leg Ulcer Forum;
Australian Wound Management Association; European
Oncology Nursing Society; All Ireland Institute for Hospice
and Palliative Care. Jose Verdu Soriano for help with
translation.
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