Monday, April 18, 2011

Improving Wound Care in a Pediatric Surgical Ward

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Wound care management is becoming more complex for nurses due to new insights into wound healing (Hayward & Morrison, 1996, p.11) and because of the wide variety of wound dressings that are available (Wikblad & Anderson, 1995, p.312 and Miller, 1994, p.62). Erwin-Toth and Hocevar (1995, p.46) stated that there were approximately 400 brands of wound care dressings on the market to choose from and that wound care is made even more difficult because no one dressing method suits all wounds and the choice is dependent on the cause of the wound, infection, favorability and cost (Findlay, 1994, p.836). Because of these many different wound care techniques and dressings, nurses are becoming confused and nonplussed regarding wound care practice. Unfortunately, Millers (1994, p.62) research showed that in 85% of cases nurses were using inappropriate dressings, and O’Connor (1993, p.64) found in her study on wound care that nurses were having difficulty in applying their theory and knowledge to their practice.
Action Research was the strategy used for this study because it is very appropriate for nursing research. Traditional nursing research is failing nurses because so often they do not see its relevance to their practice (Greenwood, 1984, cited in Hart, 1995, p.9). Action Research is more suited to nursing, not only because of its problem solving and evaluating features, but also for its similarity to the stages of the nursing process of planning, acting, observing, reflecting and often replanting (Bellman 1996, p.130) . Action Research is also appropriate for nurses because, it does not require expert researchers; the participants define the problem themselves; both researchers and practitioners participate together in the process (Kemmis & McTaggart, 1988, pp.22-23, Hart & Bond, 1995, p.55 and Birkett, 1995, p.191); it is less structured and leaves room for possible changes; it is empowering for the participants; and reflective of their practice (Kemmis & McTaffart, pp.11-12, 50 and Titchen & Binnie, 1993, cited in Hart, 1995, p.8). Titchen and Binnie (1993, cited in Hart, 1995, p.8) also highlighted the empowering effect, and reflective practice, action research gave nurses so that they can hopefully free themselves from the medical hierarchy

The Setting and Problem
The setting of this project was a 16 bed surgical ward of a major pediatric teaching hospital. It was classified as a clean surgical ward and the case mix of patients were cardiac, ear, nose and throat (ENT), ophthalmic and the occasional others. Most of these patients were under the age of five years which made their participation in the project impossible. Because of the range of surgery performed there were many different wounds and many surgeons using different techniques in wound management even for the same procedure. This was confusing to the nursing staff and created an attitude that they did not have any say in their patients wound care.

Two issues of concern were raised by different members of the nursing staff. Firstly, the Unit Manager and Clinical Educator were concerned about the nursing staffs lack of observation and reflection on their patients wound care and the second was from the nurses regarding the many types of dressings and treatment used by different surgeons for as many different wounds--was one better than the others and for what wound? This was exacerbated even more by the introduction of yet another new dressing by one of the surgeons. From discussion on these two concerns it was decided to perform a ward audit using action research on how the nurses could improve their wound care practices and devise it so that quantitative outcomes could be compiled in the long term regarding the many types of wound management and dressings that were being used. The long term project would also be used to monitor infection rate which is required by the Health Department.
As the project was implemented as a ward audit, which did not involve patients or parents, neither financial assistance nor approval from the Hospital Ethics Committee was required.

The Planning
During the planning stage when discussions were held with senior nursing staff, the following strategies were proposed and developed:

  1. A wound survey chart (See Appendix A) was devised that documented the process of observations to assess the effectiveness of wound care procedures and dressings for all the different wounds. This was formulated by two members of staff and shown to other staff for comments and suggestions for changes. For a long term project this survey chart was also shown to a member of the Hospital Research Department who made suggestions on how to improve it so data could be processed for quantitative research outcomes.
  2. A research proposal was written in order to be able to inform, not only the nurses, but also the other disciplines that will be involved in the goals and objectives of the project.
  3. The Head of the Surgical Department was also informed of the project and on his own reflection decided to collect data and take photos himself in his office when he saw the patients post-operatively. This information would also be made available for our project. The new dressing he was using, which he felt would promote better scarring outcomes in the future, was not removed until two weeks post-operatively so we needed his cooperation in obtaining the final outcome of the wound healing. The other surgeons and community liaison nurse were informed of the project by letter and discussion at a senior staff meeting. Out of the discussion at this meeting it was suggested that the data collected should be processed with the data they already had on the patients in their department. The same problem was raised when the Infection Control Department was informed of the project. This was our first major problem but was only relevant to the larger project in collecting data for quantitative outcomes. The facilitator would meet again with these departments to resolve this issue.
  4. To provide us with a knowledge base for our decision making it was decided that the members of staff who were on relevant hospital committees, such as, infection control, product review, wound care, quality assurance, research and professional practice, would carry out literature reviews pertaining to their specific committee subject and our research project. This information they would present to the rest of the staff at following meetings or in-services. This would equip the nurses with evidence-based knowledge to obtain consensual agreement on decisions made for better practice strategies.
  5. The Nurse Educator, who was reasonably familiar with the process of action research, became the facilitator and in this capacity held in-services to educate all the nurses regarding action research. This also helped to solicit more participation and inform the nurses of their role in the process.



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