STATEMENT OF THE PROBLEM
In this discussion we prepare a report and perform an analysis of a clinical topic to show how theoretical frameworks may be useful in the explanation of practical problems and how theories, or research evidence can be used to solve a clinical problem case. For our purposes we analyse and examine the efficacy of aseptic technique in wound care versus clean technique in wound care in an outpatient clinic treating fractured patients. Considering cases of delayed healing, we discuss the implications in nursing practice. The theoretical framework used here is Eraut's (1990) theory on three types of knowledge and we use this theory and knowledge divisions in clinical care to help caring for patients in a fracture clinic.
In the course of our study and analysis we would be able to evaluate how and whether a research or formal theory or a philosophical knowledge resource make any important contribution towards resolution of a practical clinical problem to help improve care services provided.
THE CLINICAL CONTEXT
In this study we deal with the treatment of fracture and wound care and discuss possible complications that are associated with such cases. A bone breaks or cracks and shows a fracture when too much force beyond its elastic limit causes it to break into pieces or in a spiral, transverse or oblique manner. In a simple fracture, the skin and soft tissue being intact, the conditions are less complicated, whereas in a compound fracture, the fractured bone is exposed and may involve infection of bone and bone marrow that may progress to a chronic infection (known as osteomyelitis) and requires treatment with antibiotics and careful management in hospital (Edlich et al, 1977).
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A fracture may become considerably complicated if the bones do not join up again or if this attaching of one bone to another is unduly delayed. With considerable delay, the bone may lose its blood supply and may die, a condition known as avascular necrosis. Fractures near or in the joints may lead to stiffness of the joint and may hinder bending or proper movement.
Fractured or broken bines may lead to immobilization for a few weeks or months depending on the bone involved and the nature of injury. In case of compound fracture or infection in wound area, or lack of blood supply complete cessation of movement is recommended (Mollitt, 2002).
According to the NHS, the various methods used to ensure immobilisation of fractured bones are:
. Plaster, plastic or resin casts
. Sustained traction with weights and pulleys
. Steel plates and screws
. Internal steel rods (intramedullary nails) for long bones
. Cast bracing with a joint to allow joint movement
. External fixing devices consisting of a steel beam to which are attached at least four steel pins (fixators) that pass into the bone above and below the fracture site.(NHS, 2005)
Bree-Williams and Waterman (1996) discussed nursing practices while performing wound care dressings to highlight the care principles that should be followed for injured patients showing fractures or deep wounds. The study aimed to establish whether nurses' actions when carrying out aseptic technique for wound care or the gloves technique are simple and based on updated knowledge. The sample selected for the study involved 21 trained nurses and observation and formal interviews were used to collect the quantitative and qualitative data. The results indicated that all the nurses within the sample did not use the simple aseptic technique and the rationale for using aseptic techniques of wound management has been found to be not always based on research or theoretical framework. However many other aspects of wound management seem to be grounded in research findings and the authors emphasise that even aseptic techniques should have adequate support of research findings
In this study, however we compare the aseptic /sterile technique of wound management with that of the clean dressing change method. A sample of 20 patients was selected for the study and all of them were outpatients being treated for fractures and wounds in general facture clinic. All the patients age between 35-55 years were randomly assigned to two groups, a group of 10 patients were given aseptic treatment in wound care and the other group of 10 patients were treated with the clean technique of wound management. Of the 20 patients selected, 10 were men and 10 women and each group comprised of 5 men and 5 women. Most of the patients showed some complications and had compound or complicated fractures and required regular dressing and almost all had the same level of complications or wound problems. The mean age was 42.3 years for all the 20 patients and they were randomly assigned to get either the clean or the sterile method of dressing. This manner of intervention continued for four weeks and the rate of healing was evaluated quantitatively and qualitatively.
In a similar study, Stotts et al (1997) determined whether there were differences between the sterile aseptic and clean dressing change technique for open surgical wounds in patients being treated at the postoperative period within the clinical setting. The differences between the two techniques of dressing and treatment were studied with regard to the rate of healing and the cost of the medical supplies. Stotts and associates also used the two group design for the pilot study in which a sample of 30 patients who underwent elective gastrointestinal operations with wound healing were selected and among these 30 inpatients, 15 were men and 15 women with mean age of 40.6 years. Patients were randomly assigned to the two groups either to receive clean dressings or sterile dressings with the intervention beginning on the first postoperative day and repeated three times a day until the day of discharge from hospital. The authors performed an analysis of the rate of healing using the Mann-Whitney U test whereas the cost comparison was done using a t test. The study indicated that the subjects were examined for 3 to 9 days and both the groups were homogeneous at the beginning of treatment with respect to age, length of operation, wound volume, nutritional status and perfusion. Findings indicated that there was no difference in the rate of wound healing between the clean and the sterile groups. However mean cost of supplies was found to be significantly less for the clean technique group than for the sterile group. The pilot study indicates that there is no difference in the rate of wound healing between the clean and sterile groups although the clean dressing method is much less expensive. The authors emphasise that since this study has been done with only a sample of 30 patients it cannot be generalised, may contain errors and need to be reconfirmed using a larger and more representative sample.
In our study we attempted to examine a similar parameter, that is, the differences in aseptic and clean techniques of wound dressing for patients treated in a general fracture clinic. The patients were chosen to form two homogeneous groups in terms of wound level and complexity, nutrition, medical care and period of fracture. The only difference that was deliberately maintained was the manner of dressing changes that was done one every week for the patients and the level or extent of healing for both the groups was tabulated and compared. The nature of this clinical problem is thus finding out the efficacy of a particular nursing technique and how it compares to a closely related method. A comparison of two popular techniques of wound care can help understand which technique is more effective and helps in faster healing and also which technique is more expensive and time consuming than the other.
However the study findings indicated that there have been several cases of delayed healing of fracture as the methods used for dressing may not have been appropriate and highlights the need for nursing practices to be more individual or circumstance oriented rather than general methods oriented. At least 3 of the patients in both the groups reported increased infection, delayed healing, pain and stiffness problems, situations that could not be explained by standard procedural nursing methods or principles. Considering this problem of care we discuss the underlying principles of care and a theoretical framework that may be necessary in evaluating the kind of knowledge used in providing standard treatment.
Focusing on these aspects we turn to the discussion of the implications and usefulness of research resources in handling a clinical problem and suggest that a redefinition of the framework of care using a theoretical basis may be the best method of approaching specific cases of treatment. In this case we have used examples of similar case studies by Stotts et al (1997) and Schrader (2002) and several other researchers. Similar studies have been done by Gray and Doughty (2001) and Perelman et al (2004). Vega and Tellado (1999) have emphasised on evidence based practice in controlling and treatment of infections.
Lund and Caruso (1993) emphasise that 'the significance of nurses' attention to the principles of aseptic technique need to be re-established in nursing practice'(p.215).
Attention to the principles of wound care is as important as attention to the practice as although apparently unnoticed all nursing practice and solution of practical problems should be and are based on theoretical principles. However, apart from basing our knowledge on research findings, nursing approaches can also be based on theoretical frameworks and nursing philosophy. Most nursing professionals however base their judgement on experience and treat patients as in this case of wound care according to standard symptoms and corresponding care according to process or procedural knowledge from experience. Using research findings as a systematic base for understanding the methods of treatment that should be used is also a part of procedural knowledge although it has a major element of conceptual knowledge. We will discuss these forms of knowledge as given by Eraut (1990). However improved new ways of understanding knowledge may help in improving methods of treatment and quality of care.
One of the examples of new knowledge that can help in improving patient care by providing a theoretical basis to solve practical problems has been given below.
NEW KNOWLEDGE AVAILABLE
Eraut (1990) provided an influential theoretical framework that can be successfully translated into nursing care and practical approach to wound healing and management as well. A brief description of the theory is given below:
Three Types of knowledge (Eraut 1990, 1994) - Eraut identified three types of knowledge, namely
Conceptual Knowledge -
This kind of knowledge is made up of the concepts, theories and ideas that a person has absorbed. For example the concept of grief helps us understand what is happening when a bereaved woman loses her appetite and seem distant and lacking in energy. Conceptual knowledge within a profession will be different from a knowledge of that of a lay person.i.e:- what a nurse thinks of pyrexia for instance is known by people without healthcare background as having a temperature. Extrapolating this conceptual knowledge in the treatment of wound care helps a nursing professional to understand the usefulness of a clean versus aseptic technique in wound management. Nursing professionals have a better concept of a wound or a fracture and knows which type of wound should be treated with which specific technique. Thus a simple fracture may be treated with a clean dressing technique whereas a compound or complicated infected fracture will have to be treated with aseptic sterile methods.
This refers to how things happen, how care is delivered, and how nurses and others get things done. For instance there is a process knowledge associated with making referrals to physio or arranging the discharge of a patient or client into community. This knowledge may also be complex involving not only the standard formula for how things should happen but also practical insights into how things are really achieved. So there is a mixture of the knowledge about the procedure and knowledge that comes form experience of what usually happens or the kind of things that can go wrong. Example of process knowledge would be if you wanted to introduce a change to an aspect of practice in response to a research study. The process knowledge you would need to use would involve knowing who to approach and when, the evidence you would need to bring and how to present it to have the most impact on the person. Process knowledge is thus practical and situational knowledge in which a nursing professional is expected to know the fundamentals of the nursing practice in general to tackle specific problems in particular areas of nursing. For instance in caring of patients with deep wounds or fractures, nursing professionals are expected to know the process of care, the standard method of treatment, the use of clean and aseptic techniques in specific cases as necessary and such knowledge is generally largely learnt from experience and is practical and procedural.
This is the knowledge that is important for controlling ones own behaviour, and excludes that concerned with the control of others. Control knowledge for example - to keep ourselves calm when dealing with aggressive behaviour or to keep fully present when confronting grieving relatives. It is also the knowledge we use after difficult events or a stressful day to work through our feelings so that we can let go of what has happened and move on. This may be an important aspect of reflective practice as this sort of knowledge helps a nursing professional to evaluate the situation calmly and without apprehension. This knowledge is essential when dealing with difficult situations or with aggressive non-cooperative patients and is based more on a personal reflection and growth rather than conceptual knowledge or knowledge through experience. In case of wound management, knowledge based on personal reflection and understanding may be important to implement the right approach to treatment and differentiate between patients who need different techniques of care. Unlike conceptual knowledge which depends on the knowledge of the concept of wound or wound care for instance, or procedural knowledge that springs from experience, control knowledge being reflection based and rooted in entirely personal judgement may just be the ultimate tool that helps to distinguish a successful and effective nursing professional from an unsuccessful nursing professional.
Keeping Eraut's perspectives in mind, we can use the theoretical framework of the three kinds of knowledge that can be used within nursing practice and examine or evaluate the understanding of a specific aspect of nursing care, in this case wound management on the basis of this theory. Eraut's theory highlights several issues in nursing and care management.
The theory emphasises on the situational and practical usefulness of three types of knowledge. The conceptual knowledge is mainly based on the qualifications of a nursing professional and the concepts she is familiar with and the concepts of nursing she is expected to know by virtue of being in the profession. For instance, knowledge if wound care is largely based on the concept of what a wound is , the different kinds of wounds, fractures, the treatment and underlying physiology and biology of fractures and which kind of fracture requires which method of change dressing is also known to a trained nurse.
However Briggs et al (1996) voices out the ambivalence in nursing owing to controversial or scarce research evidence which sometimes forms the basis of conceptual knowledge. The authors write, 'Research evidence on asepsis is patchy, ambivalent and cannot always be generalised. There is no substitute for assessment of the individual circumstances before each procedure. Hand washing is vital, well researched and uncontroversial'(p.805). As seen in this argument there is a growing need recognised by professionals to judge each case on the basis of unique or individual circumstances and to be specific rather than general in using knowledge of care principles.
Understanding care in terms of individual circumstances is largely knowledge on the basis of experience rather than concepts or research findings. Experiential knowledge is what is known as process or procedural knowledge as discussed by Eraut(1990) and within nursing experiential knowledge is largely used to improve clinical understanding of individual cases. Although process knowledge is largely general and includes knowledge of fundamentals or how a particular case should be treated based on previous similar cases, there is much space for change in this correspondence method in which the symptoms and problems are treated against corresponding standard established solutions. For example in case of wound management and the technique of dressing used, it is generally known by nurses as to which techniques of dressing would be most appropriate for which kind of wound. Although there have been some findings as discussed that suggest that dressing techniques make no difference to wound healing or time taken to recover, it is generally accepted that sterile or aseptic methods are safer and required for complicated, infected and compound wounds and fractures (Raahave, 1974).
However this method as we see may not be effective as several cases of severe infection and complications have been reported despite using conceptual and procedural knowledge in wound care. All the precautions were taken depending on the circumstances and the right kind of treatment was given to the outpatients under consideration. Yet our study reported several cases of delayed recovery or healing. This suggests the limitations in using standard methods of care without using a conceptual or philosophical base or recent research findings or even personal reflective judgement to increase effectiveness of treatment.
The custom in present nursing practice, that is using procedural standard knowledge to treat patients whose symptoms fall within known categories, may be fallacious as is seen from the study. Standard knowledge application and general treatment methods without a philosophical approach to care may be inadequate and not suitable in case of individual complications and subsequent treatment.
In this study we selected 20 outpatients suffering from fractures and were being treated in a general fracture clinic. All these patients had the same level of wound and needed considerable wound care and regular dressing. The sample subjects wee randomly assigned to two different groups in which members of one group were given treatment with clean dressing technique and the members of another group received treatment with aseptic or sterile dressing technique. We discussed various implications and principles of both the methods of treatment and wound care and tried to understand which is a more suitable and effective method. Our results indicated that in both the groups there have been some unexpected delays in wound healing as 3 of the patients in both the groups showed prolonged infection, pain, stiffness and delays in recovery. This brings us to the challenges within medical profession of explaining delays in recovery despite providing the standard known treatment. The study forces us to reconsider and revaluate the efficacy of using standard methods and procedures or even standard principles in nursing care.
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We subsequently highlight the role and necessity of a new kind of knowledge or theoretical framework against which we place our case study and evaluate nursing care in terms of three types of knowledge suggesting that an integration of all types of knowledge is essential to improving the quality of care and method of treatment. In this context we discussed Eraut's three types of knowledge emphasising on concepts, procedures and experiences and personal reflection and judgement. We suggested that although at present nursing practice is largely based on standard procedural and experiential methods in which all diseases including wound care are treated according to fixed or standard methods of treatment, using personal reflective judgement and underlying philosophical knowledge and framework may be necessary to treat individual cases from unique perspectives.
In this study, we showed the importance of an underlying theoretical framework and research findings that can form the philosophical basis of a nursing practice that tends to highlight the importance of an integrated system of knowledge in improvement of nursing care. This is a step forward from a general nursing practice that seems to follow treatment according to standard methods of treatment without considering individual needs of the patient or reflective judgement of the nurse. Our study highlights the necessity of considering a theoretical framework rather than practical and experiential knowledge only to improve quality of care.
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NHS -2005 www.nhsdirect.nhs.uk
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