International Wound Journal ISSN 1742-4801
ORIGINAL ARTICLE
The lived experience of the wound care nurse in caring for patients with pressure ulcers Marlene A Varga1 & Samantha L Holloway2 1 Covenant Health, Edmonton, Alberta Canada 2 Wound Healing Research Unit, Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
Key words Life world; Lived experience; Phenomenology; Pressure ulcers; Wound care nurse
Varga MA, Holloway SL. The lived experience of the wound care nurse in caring for patients with pressure ulcers. Int Wound J 2016; 13:243–251
Correspondence to Marlene Varga, MSc, BScN, IIWCC Wound Care Nurse Covenant Health Edmonton Alberta Canada E-mail: [email protected]
The aim of the study was to report the lived experience of the wound care nurse (WCN) in caring for patients with pressure ulcers (PU). WCN play an important role in caring for patients with PU, but the effect on caring for individuals with such wounds is poorly understood. A descriptive and interpretative study on the life worlds of spatiality, temporality, relationality and corporeality was carried out. Utilising the hermeneutic Heideggerian phenomenology, data were collected over a 3-month period in 2012 using in-depth interviews with five WCN. The interviews revealed eight themes: ‘challenge’, ‘making sense of it all’, ‘coping and self-care’, ‘advocate of mine/making a difference’, ‘knowledge and technology’, ‘we have seen what can happen’, ‘holistic caring’ and ‘frustration’. Twenty-five sub-themes were also identified. WCN experienced a demanding and rewarding role of caring, influenced by the environment and the challenges with individuals living with PU. This study demonstrated an enriching yet challenging role. Recommendations for WCN, health care authorities and education providers include raising awareness of the importance of self-care, greater recognition of the effect of this role on patients with PU and changing education to include reflective practice and resilience strategies.
doi: 10.1111/iwj.12279
Abstract
Introduction
Pressure ulcers (PU) are one form of skin breakdown that has been observed in Egyptian mummies (1) and still exist today despite the advances in science and industry (2). PU are considered a nurse-sensitive outcome measure (3) as it is nurses who are primarily responsible for preventing skin breakdown and subsequently caring for the person who may develop PU. In Canada, wound care nurses (WCN) provide a variety of functions and supports in the area of skin care and prevention along with assessment and management of non-healing or chronic wounds such as PU (4,5). Enterostomal therapy (ET) nurse is the term for Registered Nurses who have completed a postgraduate program in ET from a recognised provider with or without certification (6,7). A WCN is educated in the area of wound care through specialised courses such as the International Inter-professional Wound Care Course (8) or Master’s level programs. For the purpose of this study, the term WCN is operationalised to reflect the varied roles in practice including ET and WCN within the health care system in one
province in western Canada. This study explores the lived experience of WCN who care for individuals with PU. A PU is defined as a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear (9). Within Canada, the quality outcome indicator of PU prevalence is estimated to be 25% across all sectors (10) and a global estimate of
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Key Messages
• the majority of research in the area of pressure ulcers (PU) has focused on the individual living with these wounds. Wound care nurses (WCN) play an important role in caring for patients with PU; however, the effect of this experience is poorly understood. The aim of this study was to develop insight into the effect on nurses caring for patients with PU
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• interviews revealed eight themes: ‘challenge’, ‘making sense of it all’, ‘coping and self-care’, ‘advocate of mine/making a difference’, ‘knowledge and technology’, ‘we have seen what can happen’, ‘holistic caring’ and ‘frustration’. WCN experienced a demanding and rewarding role of caring, influenced by the environment and the challenges with individuals living with PU. These shared stories offer glimpses into the challenges, successes and limitations of this role serving to create and seek opportunities for an improved experience for patients with PU and those who care for them
the problem remains unknown (11). It has been reported that recurrence rates of PU can be as high as 70% (12) depending on various factors such as the clinical area and the individual risk levels. To date, the concern of individuals with PU has not received attention from funding agencies, government policy makers (13) and the media (14) and remains unrecognised (15). Although the management of wounds is increasingly being acknowledged as a priority for Canadian health care organisations (16–18), a worldwide gap remains because there is no sustainable method for preventing PU (2). PU increase the personal and financial burden to individuals and society (11), threatening public health and the economy (19). It has been estimated that PU cost individual Canadian hospitals more than one million dollars each year (20). Furthermore, PU are costly to individuals in terms of suffering and pain (21,22), disfigurement and loss of productive time (23). There have been a number of studies that have examined the effect of living with a wound as well as exploring the effects of individuals caring for people living with chronic wounds (21,23–50). For the purposes of the current study, it is the latter aspect that was of particular interest. It is acknowledged that there is a lack of research directly related to the lived experience of the WCN in caring for patients with PU. An early phenomenological study by Walshe (26) included 13 individuals with venous leg ulcers (VLU) that were present for between 4 months and 10 years. Themes elicited included symptoms, treatments, restrictions and coping. Walshe (26) identified that a holistic approach to assessment and care was required to assist patients in coping with their illness. Chase et al. (28) also employed a phenomenological approach to examine the lived experience of 37 patients with VLU that attended an ambulatory surgical clinic setting. Chase et al. identified themes related to forever healing, limits and accommodations, powerlessness and difficulty in caring. More recently, Walsh and Gethin (44) sampled seven nurses who cared for patients with chronic leg ulcers for a minimum of 3 years. Within this phenomenological approach, it was determined that nurses place a great emphasis on therapeutic relationships with their patients. These studies collectively demonstrate challenges to both the patient and health care professional but do not provide a clear picture of how the individual caring may be affected. A study, which focuses on the health care professionals’ perspective on looking after patients with PU, was carried out by Krasner (27). The author invited generalist and specialist nurses 244
(n = 42) to write their experiences with patients who experienced pain. Employing a hermeneutic analysis approach, three patterns and eight common themes emerged, including ‘nursing expertly’, ‘denying the pain’, and ‘confronting the challenge of pain’. Nurses described anger, hopelessness, helplessness and emotional pain. Using a Heideggerian phenomenological approach for a pilot study, Hopkins et al. (21) examined the lived experience of eight informants over the age of 65 years with grade III or IV PU incorporating the EPUAP 1998 guidelines (51). Through interpretative phenomenological analysis (IPA), it was determined that PU caused endless pain, produced a restricted lifestyle and revealed coping as a constant issue. This was one of the first studies that highlighted the burden for the researchers who were surprised at the findings that the cycle of pain was endless. In a phenomenological study of ten patients with non-healing wounds, Neil and Munjas (30) identified patterns of contending with the wound and staying home related to feeling isolated. The fact that classification and duration of wounds were not provided is a limitation. Three major categories of non-healing cutaneous wounds, leg ulcers, PU and diabetic foot ulcers, have different standards of care, aetiologies and responses to therapy (52). Understanding the varied experiences of each aetiology is an essential part of providing the person-centred care. In a later phenomenological study, Beitz and Goldberg (37) identified similarities with the study by Neil and Munjas (30). A larger sample of 16 patients living with non-healing wounds, more than 8 weeks in duration, were interviewed by two researchers. Themes identified included the effects on the physiological, psychological and social aspects of the patients including pain, changing eating patterns, losing mobility, adapting, dealing with treatment, altered sleep, living and ageing, receiving care, contending with chronic illness, explaining causes of wounds and healing and recuperating. Goldberg and Beitz (46) extended their study to examine the perspective of elders from diverse ethnic backgrounds living with chronic wounds. Eleven patients, with a mean age of 68 years, were purposively sampled from elder care programs, nursing homes and assisted living. Based on Colaizzi’s (53) approach to phenomenology, their analysis revealed that chronic illness was a strong influential factor as wound issues occurred frequently in this context. Although these studies involved VLU and ulcers of unknown aetiology, the findings add to our knowledge that non-healing wounds require patients to adapt to challenging situations. It is relevant to inquire about the effect on those who care for such individuals. Kohr and Gibson (39) used a hermeneutic phenomenological method to examine the management of wound pain. A convenience sample of 18 generalist nurses reported the need to protect the patient from dressing change discomfort and identified a lack of knowledge as a barrier to caring. This study further supports the concern of the WCN for patients with pain and highlights the barriers of time and knowledge in the health care environment. A more recent study by Alexander (45) using a hermeneutic phenomenological method included a sample of 14 purposively sampled nurses from the hospital and community setting. Through unstructured interviews, the nurses described their account of caring for individuals with malignant wounds as confronting, emotionally draining and
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extraordinarily impactful. The nurses described these wounds as rotting flesh and in caring for these individuals felt hopeless, helpless, inadequate, frustrated, guilty, angry and sad. The nurses developed strategies to cope with the enduring memories; however, these were not elaborated up on. Although this study involved malignant wounds, there may be similarities in caring for such individuals with PU that require exploration. In the same year, Eskilsson and Carlsson (47) examined the experience of seven homecare nurses with 3–32 years of caring for patients with hard-to-heal wounds. A reflective life world approach was used involving phenomenology and semi-structured face-to-face interviews. Life world was defined as experiences including suffering, well-being and health and which is considered an epistemological foundation for caring science (54). Nurses described how caring was enriching and burdensome and this was handled through coping strategies including reflection, acceptance and distance. Nurses felt that their care affected their confidence while others struggled with limited time to spend with their patients. Nurses also described wanting control of the wound and frustration when there was a lack of continuity of care. The relationship established with the patient was balanced with closeness and distance. Social defences were also important when the health care professional felt drained of emotions during care. A more recent international survey of health care professionals involved in regular chronic wound care globally identified that approximately a quarter of the respondents (n = 1249) stated that caring for patients with hard-to-heal wounds was frustrating (50). These pieces of evidence are important as the implementation of PU prevention strategies into practice has been previously identified as limited (55). An ageing population accompanied by an escalating incidence of diabetes suggests that the number of chronic wounds and PU will increase (56) potentially further contributing to frustration for the WCN. The current study reported here stems principally from the recent pertinent phenomenological study by Sylvia and Jones (48), which explored the role of WCN in caring for patients with wounds. The informants had three or more years of experience and were all Master’s prepared. Eight themes emerged from thematic analysis including ‘essence of practice’, ‘holistic approach’, ‘the dichotomy’, ‘art of wound care’, ‘growth in practice’, ‘allure of the challenge’, ‘acknowledging limits’ and ‘teaching, mentoring and being a role model’. The essence of practice and the bond of caring was at the centre of the WCN practice. The holistic approach accounted for the emotional, spiritual and physical aspects of caring in contrast to the traditional medical model. The results of this study resonated with the researcher in terms of caring for patients with wounds but did not answer the question of what is the experience of the WCN caring for patients with PU. The current evidence suggests that chronic non-healing wounds have a profound effect on the person living with them in terms of physical, social and psychological effect. In terms of those who care for persons with chronic wounds, it is evident that this experience can be challenging in terms of a negative emotional effect brought on by situations involving human suffering such as pain. This can also be an enriching experience of caring. What remains unclear is the effect on WCN specifically caring for patients with
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PU. It is therefore relevant that WCN examine their own rewards and limitations in caring for such individuals living with PU. The study Aim
The aim of the study was to illuminate the lived experience of WCN in caring for patients with PU. Primary objective
(1) To articulate the essence and meaning of this role. Secondary objective (s)
(1) Describe, interpret, understand and give meaning to this experience. (2) Identify practical solutions for the WCN to apply locally in clinical practice. Methods
A framework of qualitative inquiry using Heideggerian hermeneutic phenomenology was chosen because the aim of the study was to describe and interpret the lived experience of the WCN in caring for patients with PU. Martin Heidegger (57) focused on what it means to be a human being or the problem of ontology relating to the theory of existence. Hermeneutic phenomenology is consistent with the interpretive paradigm that includes full engagement of the researcher’s experience in data collection and interpretation process (58). Existing evidence suggests that the value of this knowledge within the practice of wound care can lead to thoughtful practice to improve outcomes as new knowledge may reform our current understanding and influence decisions and actions. (59). Informants
A pool of 30 WCN within the local urban area of Alberta was established through the working knowledge of the researcher and by review of an informal regional listing of WCN in the region. Two WCN and three industry representatives validated the pool. Specific criteria determined the eligibility for inclusion. Inclusion criteria
• An individual who defined themselves as a WCN. • WCN working in any setting whose role involves managing patients with PU on a regular basis for at least 3 years. • Can communicate and understand English. Data collection
A purposive sampling strategy was used to select informants. This is considered to be the best method to gather examples of experience with balance of breadth, depth and diversity
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(60,61). An email was sent to 30 potential informants to invite them to participate. Semi-structured interviews were used to collect the data and a conversation guide was included to help the researcher obtain the relevant information. All the interviews were conducted by the primary researcher between March and June 2012. Ethical considerations
Ethical and operational approval was obtained from the Human Research Ethics Board, consistent with the 1975 Declaration of Helsinki, prior to any data collection. Informed written consent was obtained and the informants were advised in writing that participation was completely voluntary and their confidentiality and anonymity would be preserved. Informants were not offered any incentive to participate. Data analysis
IPA was selected to aid in the analysis (62). This approach is suited to the exploration, description and interpretation of detailed experiences that are significant to individuals and acknowledges the researcher as an active contributor to the deeper understanding in the analysis (63). The data were examined initially by describing the informant’s world then interpreting this experience relative to a cultural, social and theoretical context (63) balancing a representation of interpretation and contextualization. After reading the transcripts several times, and at least once while listening to the audio recording, information of interest was noted in the margin of each transcript and specific themes were assigned to reflect the essence of the text. For each informant, the data were organised and clustered combining similar themes to create a revised theoretical table of superordinate and sub-themes that were linked together to generate a meaningful picture of this experience. The researcher remained open at this point to allow re-naming of themes and superordinate themes to emerge instinctively, which led to the reconfiguring of themes and the development of a master superordinate theme table (63). Rigour
A reflective journal was kept throughout the research process to maintain awareness of the researcher’s personal biases (64,65). The researcher incorporated reflexivity as an active conscious process to move within and outside the phenomenon as it unfolded in the construction of knowledge. A methodological decision trail captured decisions made during the research process. The researcher captured contextual documentation through field notes that described the setting in which the conversations took place including non-verbal behaviour of the informants to aid in analysis to establish trustworthiness (66). Validity was assured through purposive sampling from varied environments and data were collected, transcribed and analysed by the primary investigator. Another expression of rigour involved balanced integration (67) that included ample articulation of the philosophical underpinnings and consistency with the topic and researcher (68). The researcher 246
also selected openness as an expression in this process consistent with being oriented and attuned to the phenomenon (69). Expressions of rigour addressing the outcome include concreteness provided in examples that situate the readers in the context of the phenomenon (69). The ultimate criterion for evaluating this account is the degree to which it resolves the breakdown and opens up new possibilities to engage in the problem (70). Member checking has been accepted as the gold standard in qualitative research, but there is debate surrounding whether the textual interpretation seeks meaning on the informant or the meaning of the text (66). The process involves returning the interpretations to the informants to see if they regard the findings as a credible account of their experience. The question is how the researcher is going to know when the correct interpretation is apparent, which suggests an external, valid, independent reality of truth consistent with the positivist paradigm, which is not consistent with the researcher’s method of inquiry. In some instances, member checking is regarded as a potential threat to rigour because if informants are invited to revisit these concepts, an informant may overemphasise a concept interpreted by the researcher contributing to the ‘halo effect’ (71). Member checking was not conducted in this study; however, to ensure the credibility and comprehensiveness of the data, typed transcripts were returned to each informant to validate the conversation (64,72). The researcher chose to immerse herself within the inter-subjective dynamics between the researcher and the data and recognised herself as the primary analytic tool while reading and reflecting on the experiences of the researcher and informants as the primary analytic activity. An independent auditor therefore was not used to corroborate that the interpretations were warranted against the data. Results
A total of five individuals participated in the study, all of which were Caucasian. Four of these individuals had an undergraduate degree in nursing, one had a graduate degree in nursing and one was enrolled in a Master’s program in wound healing. A total of four participants were practicing as an ET nurse (education in ET course) and one as a WCN currently enrolled in a wound care course (8). Three were aged >50 and their years of experience as a WCN ranged from 3 to more than 20 years. The analysis of the five transcripts produced eight main themes with 25 associated sub-themes. The ordering of the list does not imply that the first theme is the priority; however, the themes of challenge and frustration were dominant throughout all conversations (Tables 1 and 2). The challenge of the role encompassed a dichotomy of satisfaction in the midst of PU complications. Danielle: ‘Has everyone lost their mind, that’s basic nursing. It irritates me because we have all the tools available to prevent them, oh it really upsets me.’ A second superordinate theme was given the title ‘making sense of it all’. The informants struggled to put together some sense related to PU development and the lack of prevention.
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Sarah: ‘I feel like it’s my fault, I have to remember that these people have a lot of co-morbidities.’
Table 1 Demographic information and pseudonyms Pseudonym and conversation length
WCN experience
Area of work
1. Sarah, 61 minutes
3 years
Oncology
2. Danielle, 69 minutes
12 years
Acute care
3. Nina, 59 minutes
14 years
Nursing homes
4. Heather, 70 minutes
12 years
Rehabilitation
>20 years
Health Canada
5. Nicky, 70 minutes
Table 2 Superordinate themes and sub-themes Superordinate theme
Sub-theme (s)
1. Challenge
Role of the WCN The health care environment Cascading co-morbid events Senseless wounds What keeps you up at night Coping defences Reality check Here to make a difference Symptom management Well-being Helping all over the place Speaking out Learning more to make a difference Searching for answers Expertise of specialty Mentor I know what’s going to happen
2. Making sense of it all 3. Coping and Self Care
4. Advocate of mine/Making a difference
5. Knowledge and technology
6. We have seen what can happen 7. Holistic caring
8. Frustration
Pulling people together Patient-centred care Cure and care Attitudes in wound care Following the plan Autonomy Competing priorities Is this enough?
Sarah: ‘I know that some PU are unavoidable but I really do think they are senseless wounds, that to me is the most distressing part of PU.’ The third superordinate theme related to the coping and self care. Caring for patients with PU appeared to have a lingering effect on the informants long after the caring experience. Danielle: ‘I wake up in the night and I’ll think oh I should I should try that tomorrow.’ Coping defences were developed by some informants to manage this experience. Although reminders of the big picture provided this reality check for the informants, some still continued the endless search for answers and even questioned their competency.
A clear theme of caring and advocating for patients while striving to make a difference was identified through all the conversations. Sarah: ‘It just makes me feel I have made a difference; I felt more fulfilled treating that PU than anything that I had ever done in nursing up to this point, I’m not kidding.’ This role was described as situational; searching for those in need and responding to various situations at various times which described the transient role. The identification of specific needs helped to establish a strong bond between the patient and the informant. Heather: ‘I’m all over the place really.’ Danielle: ‘You kind of flit in and you flit out right? The patient is so glad to see you, oh my God, she knows what she’s doing and she cares.’ Knowledge was a strong theme with all informants. The patients with a PU brought forward challenges related to treatment and the situation was viewed as a puzzle that was difficult to figure out. Nicky: ‘I remember amniotic sacs, it held the moisture but did anybody ever explain it to me? These are all kind of complicated situations and you are trying to put the pieces of the puzzle together.’ The reference to amniotic sacs by Nicky suggests that although these interventions were implemented into practice, there was a lack of knowledge related to the rationale for this intervention on the part of the WCN who was trying to understand and find meaning within the puzzle of wound healing. Theme 6 characterised the experience and memories that were triggered in response to current impending situations. The informants stored memories of those that they had cared for and this influenced the urgent preventative care they provided because they learned from the past and anticipated the suffering. Sarah: ‘We have seen what can happen; we don’t want that to happen again.’ Theme 7 was identified in the transcripts as the informants referred to their focus on multidisciplinary, patient-centred care with references made to cure and care. This theme related to the theme of challenge, as the informants were aware of the need for additional services while acknowledging the limits of cure in these situations. Nicky: ‘You feel like Inspector Gadget.’ Danielle: ‘It’s not about the wound, find something out about them and don’t forget that.’
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The quote by Danielle suggests that health care professionals may focus primarily on the wound and forget that there is an individual attached to the area of interest on the body (73). As we continue to expand the science of wound care, we must also continue the art of caring for individuals holistically with person-centred care. Frustration was the final theme identified including attitudes in wound care, consistency, autonomy, competing priorities and the wonder of ‘is this enough?’ Danielle: ‘There are nurses that couldn’t give a flying you know what about wound care. You watch them clean a wound and you want to say, GIVE ME THAT THING!’ Sarah: ‘There is always something more important that comes along, another roll out. I know that skin assessments aren’t done.’ Discussion
The existential dimensions of spatiality, temporality, relationality and corporeality aided in the processing of the phenomenological material to provide a deeper perspective (74). Spatiality refers to our environment or in this study as the experience of WCN connected to this space. The informants in this study were challenged to improve the environment and to elevate prevention of PU to a priority. Caring for patients with PU was described more specifically in the context of chronic illness and psychosocial aspects of care similar to previous research (21,37,46). Collectively, this evidence suggests that a holistic model of care is needed to care for the patient with a PU. The informants appeared to struggle to meet the physical, emotional, spiritual and social needs of their patients and this affected their well-being. One of the striking features of all the conversations was the diverse and numerous uses of metaphorical expressions. Sarah referred to patients with PU who do not have everything ‘lined up’ and Nicky referred to her ‘hands being tied.’ Shinebourne and Smith (75) suggested that use of metaphors might be a strategy to avoid painful feelings. The use of the metaphor, ‘hands being tied’ suggests that limitations contribute to the challenge and frustration within this role emotionally affecting the WCN. Temporality refers to a time in which we are living in subjectively as opposed to clock time (69,74). Temporality is formed and specific from what has happened in the past and by what is anticipated (76). For the participants in this study, the burden of not having the time to care for those in need was troubling; therefore, it is suggested that stress and coping of the informants was shaped by temporality. Temporality allows the present, past and future to be experienced as a continuity or unity because WCN was influenced by past experiences and future possibilities reflective of Sarah’s comment, ‘We don’t want it to happen again.’ Heidegger (57) would suggest that the past and future dimensions contributed to the present experience. Responses from the informants demonstrated that they were aware of the challenges patients faced in coping with chronic disease. However, what was also apparent was that taking the time to involve patients in their care facilitated coping strategies and improved their experience of care. This 248
finding is something that Sylvia and Jones (48) identified. In this current study, prioritising time to involve patients was also a way of coping for the informant as the time to care was rewarding in this mutually positive interaction. Relationality refers to the world in which we find ourselves in meaningful relation to others (69,77). As relationships were established with patients, personal and professional growth appeared to be nurtured similar to the study by Sylvia and Jones (48). This was supported by the statement by Danielle who referred to ‘getting here first (pointing to her heart) and then everything falls into place’. The current study captured the essence of caring which is specific and relational. These relationships were personally and professionally valued, similar to the study by Walsh and Gethin (44). It is through these caring relationships that this role was characterised as one of care and concern, frustration and challenge similar to the dichotomy identified by Eskilsson and Carlsson (47). It is suggested that the WCN was struggling to come to terms with the relationship between healing and holistic care in the environment of the medical model. Embodiment (corporeality) refers to body intelligence that experiences phenomena through our mind and body and is central to inquiry-based practice for access of taken-for-granted situations (70,77). This role is interpreted from this current study as one of reward, challenge, satisfaction, advocacy and caring which is consistent with previous studies (47,48). The role also involved emotions such as concern and worry for the WCN. Examples from the clinical practice of the WCN provided exemplars in caring humanistic terms that serve to deepen the grasp of this role (78). Caring for patients with PU was also described within the framework of chronic disease and psychosocial aspects of care. These factors did not seem to be viewed in isolation. Through these meaningful experiences, care was not overshadowed by systems and technology (79). Rather prevention and care of patients with PU was overshadowed by complex co-morbid conditions and limitations within the health care environment that caused challenge and frustration to the WCN. Embodiment can help us to understand the ethical stance that the WCN may make in their choice to be fully engaged, present and intentional about attending to the patient with a PU as a whole while contending with the bodily emotions that may be a challenge to cope with. Study limitations
It is argued that the informants are rarely able to give complete explanations of their intentions or actions rather they offer accounts about what they did and why (80). Although a reflective journal was kept throughout the research process, to document preconceived ideas and to reflect on the researchers’ own values, interests, experiences and beliefs within this role, the researcher recognised that the interpretive process might be inherently subjected to some bias based on the limitations of the researcher’s lived experience (81). The researcher was aware that her socio-cultural background could potentially contribute to bias in the final analysis and interpretations (82). It is also acknowledged that the researcher did not work with any of the informants but did have a pre-existing professional awareness of two of the informants. It is acknowledged that informants
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may have therefore provided answers that they considered the researcher may want to hear (83). Findings from hermeneutic phenomenological studies are open to alternative interpretations. Meaning is never fully exhausted as a glimpse or approximation was gleaned in this study to stimulate more wonder (84). Recommendations
Health authorities must understand that caring for patients with complex social, psychological and physical issues can only occur in contexts where the WCN–patient contact has been provided opportunity for the occurrence of genuine caring encounters (85). Health authorities are encouraged to plan for the increase in patients with PU to incorporate specialty wound care and service improvements that focus on organisational conditions that support this pivotal role in relational caring, while understanding the challenges in the role that were raised in this study. It is suggested that clinical supervision (CS), which focuses on the provision of empathetic support to improve therapeutic skills, facilitation of reflective practice and transmission of knowledge, be actively incorporated into health care environments (86). CS provides the time and opportunity, within the context of professional relationships, to engage in reflection on current practice to enhance and develop future practice. This can be facilitated by ensuring that structures are in place to support employee self-care. Knowledge about building resilience and effective coping skills is suggested to be incorporated into wound care education programs to raise awareness and to provide support for WCN who may be affected by the challenging environment in which they work. Understanding the lived experience of this role has the possibility to transform nursing education to advance knowledge by re-thinking epistemology of practice and pedagogical assumptions to involve reflection in practice and knowledge at the level of motivational ontology connecting theory, evidence and practice (77,87). It is recommended that WCN acknowledge and share with other WCN the challenges, frustrations and emotional responses that this role may evoke. Debriefing and discussing the challenges of this role is therefore essential to maintain efficiency and compassion to prioritise well-being for patients with PU. WCN must acknowledge that self-care begins with one self. It is therefore crucial that WCN consider investing in the renewal of their own internal resources that may provide them with the capacity to offer compassion and to be present emotionally with families and patients with PU (88). Suggested future research involves further qualitative inquiry including focus group discussions and reflective narratives to generate experiential stories to enhance opportunities for reflecting on and evoking meaningful caring practice related to caring for patients with PU. This study can be expanded upon to explore how WCN respond in action and in the moment by remaining involved in or creating distance within these complex situations of caring for patients with PU. Conclusion
Within this phenomenological method of inquiry, meaning was found within these everyday situations providing living
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knowledge for this specialty practice of caring for patients with PU. The results suggest that WCN find ways to act on these narratives that provide direction and implications for change towards being open to the wonder of these experiences and enhancing quality experiences (74,89). This is significant because a positive caring relationship can influence the healing process and contribute to higher quality care (90,91). It is through phenomenology that this practice has been grasped and it is argued here that this method has contributed to the ontology of this specialty to gain an understanding of why WCN feel and behave the way they do (69). Acknowledgements
The authors did not receive any funding or benefits from industry or elsewhere to conduct this study. The research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Adapted from a submission in partial fulfilment of a Masters in Wound Healing and Tissue Repair at Cardiff University. The authors have no conflict of interest to declare. References 1. Rowling J. Pathological changes in mummies. Proc R Soc Med 1961;54:409. 2. Phillips L, Clark M. Can meaningful quality benchmarks be derived from pressure ulcer prevalence data? J Tissue Viability 2010;19:28–32. 3. Bolger, G. Nurse sensitive outcome indicators for NHS commissioned care. High impact action: your skin matters – technical sheet, 2010: 9–11. URL http://tinyurl.com/3ob67m5 [accessed on 14 July 2012] 4. White R. Tissue viability in tomorrow’s NHS. J Wound Care 2008;17:97–9. 5. Collier M. Tissue viability: time for a change? Time for a coalition? Wounds UK 2010;6:10–1. 6. CAET. Canadian Association for Enterostomal Therapy. 2012. URL www.caet.ca [accessed on 10 July 2012]. 7. Parslow N, Kuhnke J, Kozell K. Canadian enterostomal therapy nurses advancing wound, ostomy and continence nursing. J Wound Ostomy Continence Nurs 2012;39:240–2. 8. Sibbald R, Ayello E, Smart H, Goodman L, Ostrow B. A global perspective of wound care. Adv Skin Wound Care 2012;25:77–86. 9. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (EPUAP/NPUAP). Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel, 2009. 10. Woodbury G, Houghton P. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy Wound Manage 2004;50:22–38. 11. Harding K, Queen D. A 25-year wound care journey within the evolution of wound care. Adv Skin Wound Care 2012;25:66–70. 12. Bauer J, Phillips L. MOC-PS CME article: pressure sores. Plast Reconstr Surg 2008;121(Suppl 1):1–10. 13. Organization for Economic Co-operation and Development. Countries spend only 3% of healthcare budgets on prevention, public awareness. 2003. URL http://www.oecd.org/document/0/0,2340,en_ 2649_33929_35625856_1_1_1_1,00.ht ml [accessed on 8 June 2012] 14. Harding K, Queen D. Chronic wounds and their management and prevention is a significant public health issue. Int Wound J 2010;7:125–6. 15. Queen D, Sibbald R. Primary care reform project: concluding discussion and recommendations. Wound Care Canada 2007;5(Suppl 1):S57–60. 16. Botros M, Woodbury G, Kuhnke J, Despatis M. Saving diabetic limbs in Canada: partnership between the Public Health Agency of Canada and the Canadian Association of Wound Care. Int Wound J 2012;9:231–3.
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ORIGINAL ARTICLE
The lived experience of the wound care nurse in caring for patients with pressure ulcers Marlene A Varga1 & Samantha L Holloway2 1 Covenant Health, Edmonton, Alberta Canada 2 Wound Healing Research Unit, Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
Key words Life world; Lived experience; Phenomenology; Pressure ulcers; Wound care nurse
Varga MA, Holloway SL. The lived experience of the wound care nurse in caring for patients with pressure ulcers. Int Wound J 2016; 13:243–251
Correspondence to Marlene Varga, MSc, BScN, IIWCC Wound Care Nurse Covenant Health Edmonton Alberta Canada E-mail: [email protected]
The aim of the study was to report the lived experience of the wound care nurse (WCN) in caring for patients with pressure ulcers (PU). WCN play an important role in caring for patients with PU, but the effect on caring for individuals with such wounds is poorly understood. A descriptive and interpretative study on the life worlds of spatiality, temporality, relationality and corporeality was carried out. Utilising the hermeneutic Heideggerian phenomenology, data were collected over a 3-month period in 2012 using in-depth interviews with five WCN. The interviews revealed eight themes: ‘challenge’, ‘making sense of it all’, ‘coping and self-care’, ‘advocate of mine/making a difference’, ‘knowledge and technology’, ‘we have seen what can happen’, ‘holistic caring’ and ‘frustration’. Twenty-five sub-themes were also identified. WCN experienced a demanding and rewarding role of caring, influenced by the environment and the challenges with individuals living with PU. This study demonstrated an enriching yet challenging role. Recommendations for WCN, health care authorities and education providers include raising awareness of the importance of self-care, greater recognition of the effect of this role on patients with PU and changing education to include reflective practice and resilience strategies.
doi: 10.1111/iwj.12279
Abstract
Introduction
Pressure ulcers (PU) are one form of skin breakdown that has been observed in Egyptian mummies (1) and still exist today despite the advances in science and industry (2). PU are considered a nurse-sensitive outcome measure (3) as it is nurses who are primarily responsible for preventing skin breakdown and subsequently caring for the person who may develop PU. In Canada, wound care nurses (WCN) provide a variety of functions and supports in the area of skin care and prevention along with assessment and management of non-healing or chronic wounds such as PU (4,5). Enterostomal therapy (ET) nurse is the term for Registered Nurses who have completed a postgraduate program in ET from a recognised provider with or without certification (6,7). A WCN is educated in the area of wound care through specialised courses such as the International Inter-professional Wound Care Course (8) or Master’s level programs. For the purpose of this study, the term WCN is operationalised to reflect the varied roles in practice including ET and WCN within the health care system in one
province in western Canada. This study explores the lived experience of WCN who care for individuals with PU. A PU is defined as a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear (9). Within Canada, the quality outcome indicator of PU prevalence is estimated to be 25% across all sectors (10) and a global estimate of
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Key Messages
• the majority of research in the area of pressure ulcers (PU) has focused on the individual living with these wounds. Wound care nurses (WCN) play an important role in caring for patients with PU; however, the effect of this experience is poorly understood. The aim of this study was to develop insight into the effect on nurses caring for patients with PU
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• interviews revealed eight themes: ‘challenge’, ‘making sense of it all’, ‘coping and self-care’, ‘advocate of mine/making a difference’, ‘knowledge and technology’, ‘we have seen what can happen’, ‘holistic caring’ and ‘frustration’. WCN experienced a demanding and rewarding role of caring, influenced by the environment and the challenges with individuals living with PU. These shared stories offer glimpses into the challenges, successes and limitations of this role serving to create and seek opportunities for an improved experience for patients with PU and those who care for them
the problem remains unknown (11). It has been reported that recurrence rates of PU can be as high as 70% (12) depending on various factors such as the clinical area and the individual risk levels. To date, the concern of individuals with PU has not received attention from funding agencies, government policy makers (13) and the media (14) and remains unrecognised (15). Although the management of wounds is increasingly being acknowledged as a priority for Canadian health care organisations (16–18), a worldwide gap remains because there is no sustainable method for preventing PU (2). PU increase the personal and financial burden to individuals and society (11), threatening public health and the economy (19). It has been estimated that PU cost individual Canadian hospitals more than one million dollars each year (20). Furthermore, PU are costly to individuals in terms of suffering and pain (21,22), disfigurement and loss of productive time (23). There have been a number of studies that have examined the effect of living with a wound as well as exploring the effects of individuals caring for people living with chronic wounds (21,23–50). For the purposes of the current study, it is the latter aspect that was of particular interest. It is acknowledged that there is a lack of research directly related to the lived experience of the WCN in caring for patients with PU. An early phenomenological study by Walshe (26) included 13 individuals with venous leg ulcers (VLU) that were present for between 4 months and 10 years. Themes elicited included symptoms, treatments, restrictions and coping. Walshe (26) identified that a holistic approach to assessment and care was required to assist patients in coping with their illness. Chase et al. (28) also employed a phenomenological approach to examine the lived experience of 37 patients with VLU that attended an ambulatory surgical clinic setting. Chase et al. identified themes related to forever healing, limits and accommodations, powerlessness and difficulty in caring. More recently, Walsh and Gethin (44) sampled seven nurses who cared for patients with chronic leg ulcers for a minimum of 3 years. Within this phenomenological approach, it was determined that nurses place a great emphasis on therapeutic relationships with their patients. These studies collectively demonstrate challenges to both the patient and health care professional but do not provide a clear picture of how the individual caring may be affected. A study, which focuses on the health care professionals’ perspective on looking after patients with PU, was carried out by Krasner (27). The author invited generalist and specialist nurses 244
(n = 42) to write their experiences with patients who experienced pain. Employing a hermeneutic analysis approach, three patterns and eight common themes emerged, including ‘nursing expertly’, ‘denying the pain’, and ‘confronting the challenge of pain’. Nurses described anger, hopelessness, helplessness and emotional pain. Using a Heideggerian phenomenological approach for a pilot study, Hopkins et al. (21) examined the lived experience of eight informants over the age of 65 years with grade III or IV PU incorporating the EPUAP 1998 guidelines (51). Through interpretative phenomenological analysis (IPA), it was determined that PU caused endless pain, produced a restricted lifestyle and revealed coping as a constant issue. This was one of the first studies that highlighted the burden for the researchers who were surprised at the findings that the cycle of pain was endless. In a phenomenological study of ten patients with non-healing wounds, Neil and Munjas (30) identified patterns of contending with the wound and staying home related to feeling isolated. The fact that classification and duration of wounds were not provided is a limitation. Three major categories of non-healing cutaneous wounds, leg ulcers, PU and diabetic foot ulcers, have different standards of care, aetiologies and responses to therapy (52). Understanding the varied experiences of each aetiology is an essential part of providing the person-centred care. In a later phenomenological study, Beitz and Goldberg (37) identified similarities with the study by Neil and Munjas (30). A larger sample of 16 patients living with non-healing wounds, more than 8 weeks in duration, were interviewed by two researchers. Themes identified included the effects on the physiological, psychological and social aspects of the patients including pain, changing eating patterns, losing mobility, adapting, dealing with treatment, altered sleep, living and ageing, receiving care, contending with chronic illness, explaining causes of wounds and healing and recuperating. Goldberg and Beitz (46) extended their study to examine the perspective of elders from diverse ethnic backgrounds living with chronic wounds. Eleven patients, with a mean age of 68 years, were purposively sampled from elder care programs, nursing homes and assisted living. Based on Colaizzi’s (53) approach to phenomenology, their analysis revealed that chronic illness was a strong influential factor as wound issues occurred frequently in this context. Although these studies involved VLU and ulcers of unknown aetiology, the findings add to our knowledge that non-healing wounds require patients to adapt to challenging situations. It is relevant to inquire about the effect on those who care for such individuals. Kohr and Gibson (39) used a hermeneutic phenomenological method to examine the management of wound pain. A convenience sample of 18 generalist nurses reported the need to protect the patient from dressing change discomfort and identified a lack of knowledge as a barrier to caring. This study further supports the concern of the WCN for patients with pain and highlights the barriers of time and knowledge in the health care environment. A more recent study by Alexander (45) using a hermeneutic phenomenological method included a sample of 14 purposively sampled nurses from the hospital and community setting. Through unstructured interviews, the nurses described their account of caring for individuals with malignant wounds as confronting, emotionally draining and
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extraordinarily impactful. The nurses described these wounds as rotting flesh and in caring for these individuals felt hopeless, helpless, inadequate, frustrated, guilty, angry and sad. The nurses developed strategies to cope with the enduring memories; however, these were not elaborated up on. Although this study involved malignant wounds, there may be similarities in caring for such individuals with PU that require exploration. In the same year, Eskilsson and Carlsson (47) examined the experience of seven homecare nurses with 3–32 years of caring for patients with hard-to-heal wounds. A reflective life world approach was used involving phenomenology and semi-structured face-to-face interviews. Life world was defined as experiences including suffering, well-being and health and which is considered an epistemological foundation for caring science (54). Nurses described how caring was enriching and burdensome and this was handled through coping strategies including reflection, acceptance and distance. Nurses felt that their care affected their confidence while others struggled with limited time to spend with their patients. Nurses also described wanting control of the wound and frustration when there was a lack of continuity of care. The relationship established with the patient was balanced with closeness and distance. Social defences were also important when the health care professional felt drained of emotions during care. A more recent international survey of health care professionals involved in regular chronic wound care globally identified that approximately a quarter of the respondents (n = 1249) stated that caring for patients with hard-to-heal wounds was frustrating (50). These pieces of evidence are important as the implementation of PU prevention strategies into practice has been previously identified as limited (55). An ageing population accompanied by an escalating incidence of diabetes suggests that the number of chronic wounds and PU will increase (56) potentially further contributing to frustration for the WCN. The current study reported here stems principally from the recent pertinent phenomenological study by Sylvia and Jones (48), which explored the role of WCN in caring for patients with wounds. The informants had three or more years of experience and were all Master’s prepared. Eight themes emerged from thematic analysis including ‘essence of practice’, ‘holistic approach’, ‘the dichotomy’, ‘art of wound care’, ‘growth in practice’, ‘allure of the challenge’, ‘acknowledging limits’ and ‘teaching, mentoring and being a role model’. The essence of practice and the bond of caring was at the centre of the WCN practice. The holistic approach accounted for the emotional, spiritual and physical aspects of caring in contrast to the traditional medical model. The results of this study resonated with the researcher in terms of caring for patients with wounds but did not answer the question of what is the experience of the WCN caring for patients with PU. The current evidence suggests that chronic non-healing wounds have a profound effect on the person living with them in terms of physical, social and psychological effect. In terms of those who care for persons with chronic wounds, it is evident that this experience can be challenging in terms of a negative emotional effect brought on by situations involving human suffering such as pain. This can also be an enriching experience of caring. What remains unclear is the effect on WCN specifically caring for patients with
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PU. It is therefore relevant that WCN examine their own rewards and limitations in caring for such individuals living with PU. The study Aim
The aim of the study was to illuminate the lived experience of WCN in caring for patients with PU. Primary objective
(1) To articulate the essence and meaning of this role. Secondary objective (s)
(1) Describe, interpret, understand and give meaning to this experience. (2) Identify practical solutions for the WCN to apply locally in clinical practice. Methods
A framework of qualitative inquiry using Heideggerian hermeneutic phenomenology was chosen because the aim of the study was to describe and interpret the lived experience of the WCN in caring for patients with PU. Martin Heidegger (57) focused on what it means to be a human being or the problem of ontology relating to the theory of existence. Hermeneutic phenomenology is consistent with the interpretive paradigm that includes full engagement of the researcher’s experience in data collection and interpretation process (58). Existing evidence suggests that the value of this knowledge within the practice of wound care can lead to thoughtful practice to improve outcomes as new knowledge may reform our current understanding and influence decisions and actions. (59). Informants
A pool of 30 WCN within the local urban area of Alberta was established through the working knowledge of the researcher and by review of an informal regional listing of WCN in the region. Two WCN and three industry representatives validated the pool. Specific criteria determined the eligibility for inclusion. Inclusion criteria
• An individual who defined themselves as a WCN. • WCN working in any setting whose role involves managing patients with PU on a regular basis for at least 3 years. • Can communicate and understand English. Data collection
A purposive sampling strategy was used to select informants. This is considered to be the best method to gather examples of experience with balance of breadth, depth and diversity
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(60,61). An email was sent to 30 potential informants to invite them to participate. Semi-structured interviews were used to collect the data and a conversation guide was included to help the researcher obtain the relevant information. All the interviews were conducted by the primary researcher between March and June 2012. Ethical considerations
Ethical and operational approval was obtained from the Human Research Ethics Board, consistent with the 1975 Declaration of Helsinki, prior to any data collection. Informed written consent was obtained and the informants were advised in writing that participation was completely voluntary and their confidentiality and anonymity would be preserved. Informants were not offered any incentive to participate. Data analysis
IPA was selected to aid in the analysis (62). This approach is suited to the exploration, description and interpretation of detailed experiences that are significant to individuals and acknowledges the researcher as an active contributor to the deeper understanding in the analysis (63). The data were examined initially by describing the informant’s world then interpreting this experience relative to a cultural, social and theoretical context (63) balancing a representation of interpretation and contextualization. After reading the transcripts several times, and at least once while listening to the audio recording, information of interest was noted in the margin of each transcript and specific themes were assigned to reflect the essence of the text. For each informant, the data were organised and clustered combining similar themes to create a revised theoretical table of superordinate and sub-themes that were linked together to generate a meaningful picture of this experience. The researcher remained open at this point to allow re-naming of themes and superordinate themes to emerge instinctively, which led to the reconfiguring of themes and the development of a master superordinate theme table (63). Rigour
A reflective journal was kept throughout the research process to maintain awareness of the researcher’s personal biases (64,65). The researcher incorporated reflexivity as an active conscious process to move within and outside the phenomenon as it unfolded in the construction of knowledge. A methodological decision trail captured decisions made during the research process. The researcher captured contextual documentation through field notes that described the setting in which the conversations took place including non-verbal behaviour of the informants to aid in analysis to establish trustworthiness (66). Validity was assured through purposive sampling from varied environments and data were collected, transcribed and analysed by the primary investigator. Another expression of rigour involved balanced integration (67) that included ample articulation of the philosophical underpinnings and consistency with the topic and researcher (68). The researcher 246
also selected openness as an expression in this process consistent with being oriented and attuned to the phenomenon (69). Expressions of rigour addressing the outcome include concreteness provided in examples that situate the readers in the context of the phenomenon (69). The ultimate criterion for evaluating this account is the degree to which it resolves the breakdown and opens up new possibilities to engage in the problem (70). Member checking has been accepted as the gold standard in qualitative research, but there is debate surrounding whether the textual interpretation seeks meaning on the informant or the meaning of the text (66). The process involves returning the interpretations to the informants to see if they regard the findings as a credible account of their experience. The question is how the researcher is going to know when the correct interpretation is apparent, which suggests an external, valid, independent reality of truth consistent with the positivist paradigm, which is not consistent with the researcher’s method of inquiry. In some instances, member checking is regarded as a potential threat to rigour because if informants are invited to revisit these concepts, an informant may overemphasise a concept interpreted by the researcher contributing to the ‘halo effect’ (71). Member checking was not conducted in this study; however, to ensure the credibility and comprehensiveness of the data, typed transcripts were returned to each informant to validate the conversation (64,72). The researcher chose to immerse herself within the inter-subjective dynamics between the researcher and the data and recognised herself as the primary analytic tool while reading and reflecting on the experiences of the researcher and informants as the primary analytic activity. An independent auditor therefore was not used to corroborate that the interpretations were warranted against the data. Results
A total of five individuals participated in the study, all of which were Caucasian. Four of these individuals had an undergraduate degree in nursing, one had a graduate degree in nursing and one was enrolled in a Master’s program in wound healing. A total of four participants were practicing as an ET nurse (education in ET course) and one as a WCN currently enrolled in a wound care course (8). Three were aged >50 and their years of experience as a WCN ranged from 3 to more than 20 years. The analysis of the five transcripts produced eight main themes with 25 associated sub-themes. The ordering of the list does not imply that the first theme is the priority; however, the themes of challenge and frustration were dominant throughout all conversations (Tables 1 and 2). The challenge of the role encompassed a dichotomy of satisfaction in the midst of PU complications. Danielle: ‘Has everyone lost their mind, that’s basic nursing. It irritates me because we have all the tools available to prevent them, oh it really upsets me.’ A second superordinate theme was given the title ‘making sense of it all’. The informants struggled to put together some sense related to PU development and the lack of prevention.
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Sarah: ‘I feel like it’s my fault, I have to remember that these people have a lot of co-morbidities.’
Table 1 Demographic information and pseudonyms Pseudonym and conversation length
WCN experience
Area of work
1. Sarah, 61 minutes
3 years
Oncology
2. Danielle, 69 minutes
12 years
Acute care
3. Nina, 59 minutes
14 years
Nursing homes
4. Heather, 70 minutes
12 years
Rehabilitation
>20 years
Health Canada
5. Nicky, 70 minutes
Table 2 Superordinate themes and sub-themes Superordinate theme
Sub-theme (s)
1. Challenge
Role of the WCN The health care environment Cascading co-morbid events Senseless wounds What keeps you up at night Coping defences Reality check Here to make a difference Symptom management Well-being Helping all over the place Speaking out Learning more to make a difference Searching for answers Expertise of specialty Mentor I know what’s going to happen
2. Making sense of it all 3. Coping and Self Care
4. Advocate of mine/Making a difference
5. Knowledge and technology
6. We have seen what can happen 7. Holistic caring
8. Frustration
Pulling people together Patient-centred care Cure and care Attitudes in wound care Following the plan Autonomy Competing priorities Is this enough?
Sarah: ‘I know that some PU are unavoidable but I really do think they are senseless wounds, that to me is the most distressing part of PU.’ The third superordinate theme related to the coping and self care. Caring for patients with PU appeared to have a lingering effect on the informants long after the caring experience. Danielle: ‘I wake up in the night and I’ll think oh I should I should try that tomorrow.’ Coping defences were developed by some informants to manage this experience. Although reminders of the big picture provided this reality check for the informants, some still continued the endless search for answers and even questioned their competency.
A clear theme of caring and advocating for patients while striving to make a difference was identified through all the conversations. Sarah: ‘It just makes me feel I have made a difference; I felt more fulfilled treating that PU than anything that I had ever done in nursing up to this point, I’m not kidding.’ This role was described as situational; searching for those in need and responding to various situations at various times which described the transient role. The identification of specific needs helped to establish a strong bond between the patient and the informant. Heather: ‘I’m all over the place really.’ Danielle: ‘You kind of flit in and you flit out right? The patient is so glad to see you, oh my God, she knows what she’s doing and she cares.’ Knowledge was a strong theme with all informants. The patients with a PU brought forward challenges related to treatment and the situation was viewed as a puzzle that was difficult to figure out. Nicky: ‘I remember amniotic sacs, it held the moisture but did anybody ever explain it to me? These are all kind of complicated situations and you are trying to put the pieces of the puzzle together.’ The reference to amniotic sacs by Nicky suggests that although these interventions were implemented into practice, there was a lack of knowledge related to the rationale for this intervention on the part of the WCN who was trying to understand and find meaning within the puzzle of wound healing. Theme 6 characterised the experience and memories that were triggered in response to current impending situations. The informants stored memories of those that they had cared for and this influenced the urgent preventative care they provided because they learned from the past and anticipated the suffering. Sarah: ‘We have seen what can happen; we don’t want that to happen again.’ Theme 7 was identified in the transcripts as the informants referred to their focus on multidisciplinary, patient-centred care with references made to cure and care. This theme related to the theme of challenge, as the informants were aware of the need for additional services while acknowledging the limits of cure in these situations. Nicky: ‘You feel like Inspector Gadget.’ Danielle: ‘It’s not about the wound, find something out about them and don’t forget that.’
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The quote by Danielle suggests that health care professionals may focus primarily on the wound and forget that there is an individual attached to the area of interest on the body (73). As we continue to expand the science of wound care, we must also continue the art of caring for individuals holistically with person-centred care. Frustration was the final theme identified including attitudes in wound care, consistency, autonomy, competing priorities and the wonder of ‘is this enough?’ Danielle: ‘There are nurses that couldn’t give a flying you know what about wound care. You watch them clean a wound and you want to say, GIVE ME THAT THING!’ Sarah: ‘There is always something more important that comes along, another roll out. I know that skin assessments aren’t done.’ Discussion
The existential dimensions of spatiality, temporality, relationality and corporeality aided in the processing of the phenomenological material to provide a deeper perspective (74). Spatiality refers to our environment or in this study as the experience of WCN connected to this space. The informants in this study were challenged to improve the environment and to elevate prevention of PU to a priority. Caring for patients with PU was described more specifically in the context of chronic illness and psychosocial aspects of care similar to previous research (21,37,46). Collectively, this evidence suggests that a holistic model of care is needed to care for the patient with a PU. The informants appeared to struggle to meet the physical, emotional, spiritual and social needs of their patients and this affected their well-being. One of the striking features of all the conversations was the diverse and numerous uses of metaphorical expressions. Sarah referred to patients with PU who do not have everything ‘lined up’ and Nicky referred to her ‘hands being tied.’ Shinebourne and Smith (75) suggested that use of metaphors might be a strategy to avoid painful feelings. The use of the metaphor, ‘hands being tied’ suggests that limitations contribute to the challenge and frustration within this role emotionally affecting the WCN. Temporality refers to a time in which we are living in subjectively as opposed to clock time (69,74). Temporality is formed and specific from what has happened in the past and by what is anticipated (76). For the participants in this study, the burden of not having the time to care for those in need was troubling; therefore, it is suggested that stress and coping of the informants was shaped by temporality. Temporality allows the present, past and future to be experienced as a continuity or unity because WCN was influenced by past experiences and future possibilities reflective of Sarah’s comment, ‘We don’t want it to happen again.’ Heidegger (57) would suggest that the past and future dimensions contributed to the present experience. Responses from the informants demonstrated that they were aware of the challenges patients faced in coping with chronic disease. However, what was also apparent was that taking the time to involve patients in their care facilitated coping strategies and improved their experience of care. This 248
finding is something that Sylvia and Jones (48) identified. In this current study, prioritising time to involve patients was also a way of coping for the informant as the time to care was rewarding in this mutually positive interaction. Relationality refers to the world in which we find ourselves in meaningful relation to others (69,77). As relationships were established with patients, personal and professional growth appeared to be nurtured similar to the study by Sylvia and Jones (48). This was supported by the statement by Danielle who referred to ‘getting here first (pointing to her heart) and then everything falls into place’. The current study captured the essence of caring which is specific and relational. These relationships were personally and professionally valued, similar to the study by Walsh and Gethin (44). It is through these caring relationships that this role was characterised as one of care and concern, frustration and challenge similar to the dichotomy identified by Eskilsson and Carlsson (47). It is suggested that the WCN was struggling to come to terms with the relationship between healing and holistic care in the environment of the medical model. Embodiment (corporeality) refers to body intelligence that experiences phenomena through our mind and body and is central to inquiry-based practice for access of taken-for-granted situations (70,77). This role is interpreted from this current study as one of reward, challenge, satisfaction, advocacy and caring which is consistent with previous studies (47,48). The role also involved emotions such as concern and worry for the WCN. Examples from the clinical practice of the WCN provided exemplars in caring humanistic terms that serve to deepen the grasp of this role (78). Caring for patients with PU was also described within the framework of chronic disease and psychosocial aspects of care. These factors did not seem to be viewed in isolation. Through these meaningful experiences, care was not overshadowed by systems and technology (79). Rather prevention and care of patients with PU was overshadowed by complex co-morbid conditions and limitations within the health care environment that caused challenge and frustration to the WCN. Embodiment can help us to understand the ethical stance that the WCN may make in their choice to be fully engaged, present and intentional about attending to the patient with a PU as a whole while contending with the bodily emotions that may be a challenge to cope with. Study limitations
It is argued that the informants are rarely able to give complete explanations of their intentions or actions rather they offer accounts about what they did and why (80). Although a reflective journal was kept throughout the research process, to document preconceived ideas and to reflect on the researchers’ own values, interests, experiences and beliefs within this role, the researcher recognised that the interpretive process might be inherently subjected to some bias based on the limitations of the researcher’s lived experience (81). The researcher was aware that her socio-cultural background could potentially contribute to bias in the final analysis and interpretations (82). It is also acknowledged that the researcher did not work with any of the informants but did have a pre-existing professional awareness of two of the informants. It is acknowledged that informants
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may have therefore provided answers that they considered the researcher may want to hear (83). Findings from hermeneutic phenomenological studies are open to alternative interpretations. Meaning is never fully exhausted as a glimpse or approximation was gleaned in this study to stimulate more wonder (84). Recommendations
Health authorities must understand that caring for patients with complex social, psychological and physical issues can only occur in contexts where the WCN–patient contact has been provided opportunity for the occurrence of genuine caring encounters (85). Health authorities are encouraged to plan for the increase in patients with PU to incorporate specialty wound care and service improvements that focus on organisational conditions that support this pivotal role in relational caring, while understanding the challenges in the role that were raised in this study. It is suggested that clinical supervision (CS), which focuses on the provision of empathetic support to improve therapeutic skills, facilitation of reflective practice and transmission of knowledge, be actively incorporated into health care environments (86). CS provides the time and opportunity, within the context of professional relationships, to engage in reflection on current practice to enhance and develop future practice. This can be facilitated by ensuring that structures are in place to support employee self-care. Knowledge about building resilience and effective coping skills is suggested to be incorporated into wound care education programs to raise awareness and to provide support for WCN who may be affected by the challenging environment in which they work. Understanding the lived experience of this role has the possibility to transform nursing education to advance knowledge by re-thinking epistemology of practice and pedagogical assumptions to involve reflection in practice and knowledge at the level of motivational ontology connecting theory, evidence and practice (77,87). It is recommended that WCN acknowledge and share with other WCN the challenges, frustrations and emotional responses that this role may evoke. Debriefing and discussing the challenges of this role is therefore essential to maintain efficiency and compassion to prioritise well-being for patients with PU. WCN must acknowledge that self-care begins with one self. It is therefore crucial that WCN consider investing in the renewal of their own internal resources that may provide them with the capacity to offer compassion and to be present emotionally with families and patients with PU (88). Suggested future research involves further qualitative inquiry including focus group discussions and reflective narratives to generate experiential stories to enhance opportunities for reflecting on and evoking meaningful caring practice related to caring for patients with PU. This study can be expanded upon to explore how WCN respond in action and in the moment by remaining involved in or creating distance within these complex situations of caring for patients with PU. Conclusion
Within this phenomenological method of inquiry, meaning was found within these everyday situations providing living
Pressure ulcers
knowledge for this specialty practice of caring for patients with PU. The results suggest that WCN find ways to act on these narratives that provide direction and implications for change towards being open to the wonder of these experiences and enhancing quality experiences (74,89). This is significant because a positive caring relationship can influence the healing process and contribute to higher quality care (90,91). It is through phenomenology that this practice has been grasped and it is argued here that this method has contributed to the ontology of this specialty to gain an understanding of why WCN feel and behave the way they do (69). Acknowledgements
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