This section concludes the chapter on the findings from that part o t the study concerning the nature and management of fungating and ulcerating malignant lesions. It is hoped that the reader has gained insights into the nature of this condition, its management and the effects it has on the patients and their carers.
This study confirms many of the research findings and observations discussed in the literature on malignant lesions. For example, that the female breast is the most common site for fungating and ulcerating malignant lesions to develop, although they can develop on virtually any body site. Moreover, malignant lesions are more prevalent amongst women, particularly older women, although both sexes can be affected, with the
predominance of certain cancers in one sex rather than the other.
The incidence of fungating and ulcerating lesions amongst the population of cancer sufferers has not been systematically documented and thus remains relatively unknown. This study was not developed with the explicit aim of redressing this imbalance. Nevertheless, there is some evidence that their occurrence is perhaps more frequent than may be supposed, although there was little consensus amongst the doctors and nurses as to whether their incidence has increased or decreased in recent years.
The findings from this study confirm other research, indicating that a person1s perceptions and experiences determine what they see and the meanings they attach to their observations. The clinicians’ own life experiences - social and cultural - pre-dispose them to pay more attention to certain things in their occupational environment than others. Likewise, their occupational experience, in terms of the setting they work in, can shape in very significant ways how clinicians perceive things, as does the very nature of their actual work and its goals - macro as well as micro level factors. Institutional influences have been seen to influence not only the extent of clinicians' exposure to certain experiences, for example, their frequency of contact with certain types of wounds, but also the terminology they use, as an expression of the different conventions which exist in certain units. Thus the different definitions used by clinicians to describe the characteristics of fungating and ulcerating malignant lesions may be less of a reflection of these wounds’ complex clinical presentation and their non-uniformity and more an example of the above proposition. Indeed, the reported variability in the nature and extent of these lesions' associated symptoms and their perceived causes can also be attributed to the clinicians’ differential perceptions and experiences in clinical practice, and not merely argued in terras of the wounds' variable clinical presentation or multi-causal nature.
A person’s perceptions and experiences also shape, in very significant ways, his/her subjective responses. The extent to which respondents' comments varied regarding the tendency for malignant lesions to have a
malodour or be painful may not be too surprising, given the subjective nature of the sense of smell and the assessment of pain another person is thought to be experiencing. Thus what is revolting to one nurse, for whom her encounter with such lesions is a rare occurrence, is not for another, who deals with them on a regular basis and has become somewhat de-sensitised to them.
The different reactions observed amongst the clinicians, concerning the malodour of these lesions, may also be related to the settings in which they work. Thus, for example, a nurse from Unit C whose work practice takes place in the private sphere of a person's own home with all the variable smells that people's homes contain, may not find the malodour of these lesions distinctive or too distressing, mingling as it probably would with other household smells. In contrast, for a clinician working in a hospital environment the smell of a malignant lesion would be quickly noticed and probably regarded as offensive because of the contrast of its smell with that of the highly sanitised surrounding environment. Indeed, a G.P. at the turn of the century, although speaking on a different issue, made a cryptic observation about the association of environment and the attributes of certain nurses. He thought it impossible to keep up a supply of district nurses "because they wound have to be women absolutely without any sense of smell" (Loane, 1910).
The argument that clinicians bring to their occupational environment an accumulation of all kinds of influences, which in turn influence what they see in clinical practice and how they conceptualise their observations, is evident in the way clinicians define and order their observations and experiences using familiar categories, in order to make them meaningful. Such was the case with malignant lesions, where they were frequently described by way of reference to various food metaphors. The repeated use of food metaphors by the nurses, such as those of meat, fruit and vegetables, needs to perhaps be understood in terms of the gender divisions within nursing and the socialisation of women in our society more generally. Firstly, nursing is well recognised as being a predominantly female occupation (DHSS, 1986). The majority of nurses who took part in the study were female (34:2). Secondly, nurses as women are
frequently responsible for the purchase and preparation of food. Thus it is not altogether surprising to find the nurses in this study conceptualising and using language to describe certain realities in their occupational environment by way of reference to the social roles and domestic duties which they, as women, frequently have to perform outside the work setting.
There exists an illusion amongst the lay public, and even within the medical and nursing professions, that nursing (and for that matter medicine), is based on consensus, in that nurses possess 'shared* understandings and meanings with respect to their clinical practice. The findings from this study reveal that this belief is in fact more assumed than actual. The extent to which it is common for a malignant lesion to bleed or to exude discharge could be seen as a matter of clinical judgement on which nurses would agree, if only so as to be able to determine when a wound is deteriorating and when alternative action is called for. The fact that this is not the case does little to engender confidence in nurses' ability to assess the situation and to institute appropriate action. Moreover, if each nurse assesses the situation differently, s/he is likely to employ different treatment regimes, with resultant inconsistent patient care. However, this illusion of consensus is perpetuated through the heirarchical structure of nursing, where disagreement over, for example, choice of treatment, is resolved through senior nursing and medical staff exerting their authority and their definition of the situation. This effectively dissipates any challenge to traditional practices and disruption of the status-quo by "closing" any discordant views of the world.
The general uncertainty, level of clinical ignorance and lack of consensus over the causes of the various symptoms associated with malignant lesions may not appear to be a matter of paramount importance to some clinicians, as long as the particular treatment regime adopted has the desired effect. However, one could argue that without understanding the cause of a particular symptom such as malodour, bleeding or pain, the carers are unable to make an informed decision about which treatments to employ. Furthermore, without having a better understanding of the treatments used, informed by general principles and
theories, they will never understand why certain effects occur. This is particularly the case when harmful effects occur, either locally at the wound site or more systemically.
When discussing what influenced their choice of treatment for malignant lesions the nurses did not mention factors such as understanding the causes of the various symptoms associated with these lesions, or their knowledge of the general principles of wound healing. Nevertheless, taking the first issue first, it could be argued that nurses’ beliefs about the cause of certain symptoms determines their choice of treatments in very significant ways. Thus, if bleeding is thought to be caused by the extreme vascularity of the affected area or the very nature of the malignant condition itself, then the treatment or management regime adopted may differ to that employed if incorrect or inappropriate wound management procedures are thought to be to blame. Similarly, if the malodour is thought to be caused by the natural decomposition of body tissue or infection, then this may determine whether antibiotics are used or 'masking' agents such as perfumes and deodorisers. Do nurses need to know about the general principles of wound healing in order to treat' a malignant lesion effectively? Malignant lesions are frequently characterised by blood and discharge, so just how effective will the use of systemic or topical antibiotics be, given that some are totally inactivated in the presence of blood and discharge?
Another factor not explicitly mentioned by the respondents when discussing the influences on their management of these lesions was the need to establish goals and objectives before commencing treatment. In other words, what do they want to achieve by the employment of a given treatment? Depending on a nurse's goals the same action may produce contradictory effects. For example, if a nurse's aim is the short term alleviation of discharge then s/he may choose to dry the wound, but if his/her long term goal is healing (whatever definition is employed), then drying will in fact retard healing, according to the prevailing paradigm on wound healing that a moist and warm environment promotes healing better than a dry one does.
However, the researcher is fully aware that although it may seem reasonable to argue that clinicians1 choice of treatment ought to be informed by general principles and theories, empiricism is common-place in medicine and is vigorously defended. Indeed, the evidence from this and other chapters of the study demonstrate the primacy of empirical and informal types of knowledge over the theoretical and formal in informing clinicians' understanding of this condition, as well as of wound healing theory and practice more generally. However, these distinctions are not always so clearly discerned. There are instances where the complex inter-linking of both play an important role in informing clinical practice. The causes of malignant lesions and their associated symptoms are a case in point, where what is known theoretically, or at least postulated as generalisable theoretical knowledge, is presented alongside clinical observation and experience. Through their failure to explain adequately the development of malignant lesions in theoretical terms (whether because the clinicians, as individuals, lack such knowledge, or because there is a general lack of information about this condition, or because clinicians find such explanations inadequate), they turn to empiricism to furnish them with the necessary understanding.
Given the predominantly theoretical orientation of medical training it is perhaps not surprising to discover that doctors are more likely than nurses to locate the causes of the various symptoms associated with these lesions, such as bleeding and pain, in a theoretical framework, in terms of the disease process itself. However, their highly variable' and often conflicting understanding of this whole area demonstrates "the limited value of this type of knowledge. In contrast, nurses are more likely to blame dressing procedures and their own negligence for the existence of certain problems associated with malignant lesions. Their readiness to look to themselves as a contributory cause of certain problems is an example of the low self-image that nurses have. The literature on wound management does, however, indicate that the nurses are correct in their assumptions about the deleterious effects that certain dressing procedures have on wounds.
It is clear from the study that the clinicians hold various theories concerning the causes of malignant lesions and their associated symptoms, derived from scientific and non-scientific sources. However, the variability in the explanations given does not reflect, the researcher would argue, the lack of currently available scientific research on this condition, for even if this condition was an area of scientific inquiry, which it is not, the same argument would still hold true. For the production of scientifically validated theory does not guarantee its wholesale and immediate adoption, not least because the adopters will frequently adapt it to suit their observations and experiences, as will be demonstrated later in the section on the diffusion and adoption of the MWHT and associated dressings. Implicit in the attitudes of many of the practitioners is that scientific theory offers one version of reality, but one that is open to interpretation and is judged alongside other empirical evidence. This is in contrast to the orthodox view of the scientific paradigm, which posits it as the one most able to answer medical questions.
Although when discussing malignant lesions, we are referring to a malignant condition which is normally regarded as a medical matter over which doctors are seen as the experts, the external manifestation of an internal malignancy in the form of lesions seems to render it a nursing matter, over which nurses are regarded as the experts. This perhaps confirms some of the arguments put forward by certain sociologists and social anthropologists, that one of the distinctions between doctoring and nursing is that the former possesses knowledge of the 'invisible1 inner world of the body while the latter deals with the 'visible' elements (Foucalt, 1973).
A superficial reading of some of the data in this chapter would confirm the view that wound care is a nursing province free from too much control by the medical profession. In fact, there is evidence to suggest that doctors frequently rely on nurses for advice on wound care issues. Yet, a more careful reading of the data indicates that doctors still control, to a lesser or greater extent, nurses' actions and attitudes - sometimes covertly and informally and sometimes overtly. For example, a nurse from Unit C can only visit a patient if referred to by a doctor
and needs a doctor to prescribe many of the treatments required, even though there is some evidence in this chapter to suggest that the prescribing role of some doctors is merely a ’rubber-stamping1 exercise.
Moreover, doctors appear to have more rigid and stereotypical ideas about what ought to constitute nursing knowledge than the nurses do themselves. Of course the doctors' views, that practice and not theory is what nurses ought to be concerned with, should not be immediately taken as illustrative of their patronising attitudes towards nurses. For there is evidence in this chapter, as in the one which follows, which demonstrates that doctors perceive themselves in much the same way as they do nurses, essentially as pragmatists, for whom scientific and theoretical knowledge is virtually irrelevant as far as their everyday clinical practice is concerned. However, implicit in the comments made by some of the doctors is the idea that the predominantly practical nature of nursing, in the final analysis, makes a nurse more of a pragmatist than a doctor and so renders theoretical knowledge even more irrelevant to nurses than doctors.
It is clear that doctors have little idea of how nurses learn about wound care issues and what constitutes nursing knowledge. Nurses also tended to present a somewhat idealised view of how 'other' nurses acquire knowledge about the nature and management of malignant lesions. The reasons for the prevalence of these kinds of attitudes ought not to be sought simply in the ignorance of these two professions about one another or about colleagues in the same profession, notwithstanding the strength of this kind of argument, but in the different heirarchies of knowledge that exist and the status given to pure and applied knowledge - theory and practice.
The nurses and doctors in the study agreed that formal and structured channels of knowledge diffusion are the most appropriate for clinicians to learn about malignant lesions and their management. However, the clinicians are not merely attributing differential status to different channels of knowledge diffusion - the formal being of a higher order while the informal of a lower order, for implicit in their comments is the belief that a superior type of knowledge is disseminated via formal
and structured channels. Abstract theory has the image of a superior form of knowledge because of its association with science, whereas applied knowledge acquired through practice has tended to be regarded as lower in status because of its association with 'manual' forms of labour.
In various sections of this chapter the clinicians have spoken of their dissatisfaction with their current state of knowledge and demanded more theoretical understanding about the nature and management of malignant lesions. Such discussions one could take as indicative of the clinicians' poor opinion of pragmatic knowledge and the way it dominates their clinical practice. Yet elsewhere in this chapter the clinicians have demonstrated their dislike of theory. Thus what we appear to have here is, on the one hand, an abstract view of theory as irrelevant to clinical practice and, on the other, a view which recognises the value of theory when synchronised with practice. Or is all this merely an attempt by the clinicians to have themselves and their work regarded as professional, by saying what they think they ought to be saying?
The evidence clearly demonstrates that in reality clinicians gain most of their knowledge about malignant lesions by experience, 'on the job', rather than by formal training, and even when formal learning does occur, it is often inadequate as far as informing them about the nature and management of this condition. One of the reasons for this situation is the lack of both information and opportunity for formal structured learning. The result is that the only method available for learning is through experience. This being the case, it could be said that experience is the only option available rather than regarding it as the chosen learning method. This kind of learning is, however, a slow and often haphazard process of knowledge diffusion and one which produces an accumulation of a certain type of pragmatic task-orientated knowledge which is concerned more with what is done, and how, rather than why.
The evidence from this study indicates that both nursing and medical