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The relationship between nurses’ values and care delivery that has emerged from the data in this study does not appear to be unique to pressure ulcer prevention and may also be relevant to other aspects of nursing. This is because the participants’ accounts of the relative importance of pressure ulcer prevention and other aspects of nursing suggest the value that a nurse places on different aspects of nursing influences the manner in which they deliver care to their patients.

Preventing a heart attack

The participants said that taking regular patient observations and initiating the appropriate treatment measures for patients whose observations suggested that they were at risk of a heart attack was more important than preventing a pressure ulcer. The participants stated that delivering care to prevent a heart attack was more important than care to maintain skin integrity because a heart attack was more acute and more likely to result in a death than a pressure ulcer. The participants said that the higher value that they placed on preventing a heart attack compared to pressure ulcer prevention, meant that they undertook measures to prevent a heart attack with greater urgency than those for preventing a pressure ulcer:

Michelle (Ward Manager): “A pressure ulcer is not viewed as being the same as a

heart attack because it doesn’t have such an impact on the patient’s life. If the patients have heart attacks, they could die. I know that the patients could die if they had a pressure sore but death from a heart attack is more immediate as it could lead to a cardiac arrest and that is an emergency situation. So, obviously nurses link the heart attack with a cardiac arrest and see it as an emergency situation where action is required. Pressure sore prevention isn’t recognised as an immediate or emergency situation, even though it is a necessity.”

Leah (2nd year student): “People don’t really know that you can die from a pressure

ulcer. They think that a pressure ulcer is just a wound that can be healed. If you look at somebody that’s having a heart attack, then you can see that they could

potentially die in front of you if you do nothing. But pressure ulcers can have a slow formation, they can be dealt with at different stages, and they can be healed. So people don’t see a pressure ulcer as needing urgent attention because we can be kind and put a dressing on it, but when someone has a heart attack, people automatically think of the possibility of death if no action is taken.”

These responses indicate that the participants and their peers think that preventing a heart attack is more important than preventing a pressure ulcer. The relative importance that the participants placed on preventing a heart attack and preventing a pressure ulcer was a novel

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finding of this study. The participants’ statements also suggest that the higher value that a nurse places on a specific intervention, the more likely it that particular intervention will be a high priority and the nurse will deliver that intervention.

The findings with regards to the relative importance of preventing pressure ulcers and heart attack are novel, but the implied relationship between values and actions in the

participants’ accounts is congruent with what is known about values. A number of values studies report that if a person values something then they are more likely to have an active interest in it (Hall 1997; Hebel 1998; Baker 1999). These studies have largely focused on people’s world values, which is different from the value placed on a specific issue. Most of these value studies are surveys that sit in the middle tiers of their hierarchy of evidence, which suggests that their results are worth noting. Therefore, the basic premise of the participants’ views about the impact that the relative value placed on different aspects of nursing has on the prioritisation and delivery of care is supported by the evidence from values research.

Preventing MRSA infection

The participants had a wide range of views on the relative importance of preventing pressure ulcers and preventing MRSA infection, which has a more insidious onset than a heart attack. The majority of participants felt that their colleagues viewed MRSA prevention as being more important than preventing pressure ulcers. Different reasons were put forward as to why this might be the case namely, the amount of attention that nosocomial MRSA infections generate in the media, the risk of the nurses picking up MRSA themselves and the monitoring of MRSA prevention practices by the Infection Control Team:

Cerys (Deputy Ward Manager): “Nurses are more concerned about preventing MRSA

and infection control than preventing pressure sores. We’re all so aware of the implications of MRSA with cross infection, ‘cause if nothing else, you wouldn’t want to take MRSA home to your family. Nurses look at preventing MRSA as THE problem, ‘cause it can even infect pressure sores.”

Joanne (3rd year student): “Nurses are more careful about spreading MRSA

infection, whereas they aren’t so careful about things to do with pressure ulcers. The follow up of things pertaining to MRSA on the ward by the infection control people helps to raise the profile of MRSA, but we don’t see the tissue viability nurse on the ward except when we refer patients to them.”

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The participants felt that their colleagues’ views on the relative importance of pressure ulcer prevention and MRSA prevention were largely consistent with the views held by patients and the general public. There was a unanimous view that patients and their families viewed MRSA prevention as being more important than pressure sore prevention due to the high profile of MRSA in the media and the risk of litigation:

Catherine (2nd year student): “MRSA is immediately on people’s minds because the

patients and their families know somebody who has gotten it or they know of people who’ve got it because of the media and newspapers. Even patients with diarrhoea say to us: do you think I have MRSA?”

Leah (2nd year student): “MRSA is at the top of the scale (of importance) but the

patients and their families don’t even think about pressure ulcers unless they get one because of the media coverage they get. MRSA is a huge subject because there’s a lot of litigation about it now. Look at Leslie Ash (a famous British actor); she got five million pounds compensation for a hospital acquired infection.”

The participants’ personal views on the relative importance of pressure ulcer prevention and MRSA prevention were largely at odds with the contemporary perspective. The majority of participants felt that pressure ulcer prevention was more important than MRSA

prevention because pressure ulcers can be seen with the naked eye unlike MRSA:

Cordelia (Senior Staff Nurse): “Pressure sores are more in the forefront than MRSA

because MRSA is an unseen element. But a pressure sore is something that you can see, you can visualise it and if somebody starts to get red areas you can see that happening.”

Leah (2nd year student): “Pressure ulcer prevention is more important than MRSA

(prevention). A pressure ulcer is in your face, it’s there, it can be treated, it can be dealt with, and it can be looked after, whereas MRSA is an invisible problem. You can’t see MRSA unless it’s actually in a wound as an infection.”

At first glance, the participants appear to be confusing pressure ulcer prevention and

treatment in their comparisons with MRSA infection because by the time that most pressure ulcers are visible, the skin has already started to disintegrate. Nonetheless, there seems to be a subtle underlying point about the relative importance of pressure ulcer and MRSA prevention that can be drawn from the participants’ statements. The increased visibility of pressure ulcers in comparison to MRSA infection makes it easier to tell when measures to prevent pressure ulcers have failed than when measures to prevent MRSA infection have failed. So, a detailed examination of the participants’ statements suggests that they place a higher value on pressure ulcer prevention than MRSA prevention because it is easier to tell

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when measures to maintain skin integrity have failed than it is to tell when a patient gets a nosocomial MRSA infection.

There appears to be a difference in the relative value that is placed on pressure ulcer prevention compared to preventing MRSA infection by the participants, their peers and the general public. The participants’ maintained that pressure ulcer prevention should be a greater priority than preventing MRSA infection, but they felt that their peers and other members of society held the opposite view. It is possible for a person to place the same value on preventing pressure ulcers and preventing MRSA infection as they are both key aspects of patient care, but the participants’ statements imply that most people place a higher value on one aspect of patient care than the other. The participants stated that their colleagues and the general public placed a higher value on preventing MRSA infection than pressure ulcer prevention because MRSA infection had a high media profile and MRSA infection rates and the adherence to infection control policies were closely monitored by the Infection Control Team in clinical practice.

The participants put forward a different explanation for why they felt pressure ulcer

prevention was more important than preventing MRSA infection. The participants said that the main reason why they placed a higher value on preventing pressure ulcers than

preventing MRSA infection was due to the relative visibility of pressure ulcers compared with MRSA infection. To put it succinctly, the participants said that they placed a higher value on pressure ulcer prevention because a pressure ulcer could be seen by the naked eye unlike MRSA infection.

A number of reasons have been put forward to account for the differences in the relative value that the participants, their peers and the public place on preventing MRSA infection and pressure ulcer prevention. Therefore, the relative value that is placed on different aspects of nursing by nurses and the public is a topic that merits further investigation. This research would help to establish the extent to which the findings of this study apply to nurses working in other settings. If this topic were to be subjected to further research, it would also shed further light on the factors that affect the relative value that people place on different aspects of nursing.

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The evidence from this study also suggests that understanding the relative value that is placed on different aspects of patient care and understanding the reasons for these

differences is more important than establishing whether or not these reasons are valid. This is because the best available evidence indicates that the value that is placed on a nursing intervention influences the manner in which that aspect of patient care is prioritised and delivered. Therefore, understanding the value placed on a nursing intervention and the rationale underpinning this value offers the greatest prospect of influencing the care that patients receive. This is perhaps the most compelling reason why the findings of this study must be subjected to scientific scrutiny in other settings if patients are to receive the highest standard of nursing care.

The participants’ statements about the value that is placed on MRSA prevention also

highlight the differences between their values and those of their colleagues and the general public. The participants state that their colleagues and the public feel that preventing a heart attack and preventing MRSA infection are more important than preventing a pressure ulcer. All of the participants maintained that preventing a pressure ulcer is less important than preventing a heart attack but is more important than preventing MRSA infection. This indicates that there is a disparity in the relative value placed on different nursing

interventions by the participants, other nurses and the public.

The disparity in the values of the participants, their peers and the public is a novel finding in terms of pressure ulcer, values and nursing research. This difference in values that is evident in participants’ accounts can be accounted for by the results of empirical value studies. A person’s values have been shown to be susceptible to socio-cultural influences, but they are primarily formed through personal experiences (Hebel 1998; Goodwin 2001; Pakizeh 2005). This raises the possibility that the differences in the relative value placed on different nursing interventions by the participants, their colleagues and the public are due to variations in their experiences of looking after patients.

The participants’ accounts also indicate that the relative value placed on different aspects of patient care by some nurses is consistent with the values of the general public. This is also consistent with the relationship between socio-cultural factors and a person’s values that has been identified in empirical studies. The participants’ accounts about the relative value

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of delivering care to prevent a heart attack, MRSA infection and pressure ulcer formation also serve to reinforce one of the hypotheses that emerged from this grounded theory. That is the statements made by the participants show that higher the value that a nurse places on a specific aspect of nursing care, the greater the priority it becomes and the more likely it is that the nurse will deliver that aspect of care.

Fundamental nursing care

The participants argued that their nursing colleagues also placed a low value on pressure ulcer prevention and all the other aspects of basic, essential or fundamental nursing care. They stated that even though basic nursing care was at the core of what nursing is about, this was not reflected in its position on the contemporary nursing agenda:

Joanne (3rd year student): “Basic nursing care should be at the top of the nursing

agenda! But it’s probably somewhere in the middle of the nursing agenda because of the government’s decision to tighten their grip on funds as the NHS is run like a business now. The managers are even counting the number of plasters we use now and they say we shouldn’t use too many disposable flannels and all that sort of rubbish!”

Millie (Principal Lecturer): “Essential, basic or fundamental care, whatever you want

to call it, is undervalued ‘cause it is hard work, repetitive, unglamorous and unsexy. For example, pressure ulcer prevention is essential care but you don’t see it in the media and patients do not appreciate it because pressure ulcers affect mainly elderly patients and anything to do with the elderly is seen as unsexy by society. But the way nursing has organised itself has contributed to the devaluing of essential care,

because there are less qualified nurses and there is a huge emphasis on other things in nursing because of economic demand.”

The participants said that fundamental nursing care could be defined as care that made a difference to the patient’s wellbeing and outcomes. They also maintained that not all nurses were proficient at the delivery of basic care, even though all nurses are expected to be able to deliver it:

Millie (Principal Lecturer): “Essential or fundamental care is the things that make a

difference to patients. Essential care is physical comfort, emotional wellbeing, being kept clean, being comfortable and free from pain. Essential care also includes making sure that a patient is clean, their hair is washed and styled, they’ve got their teeth in, they have their make up or cologne on and the patient’s bed space is tidy.

Fundamental care is also about the patient’s ability to ask questions and challenge things as well as implementing the appropriate high tech interventions to ensure that patients recover, ‘cause that’s as essential as somebody cleaning your teeth.”

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Michelle (Ward Manager): “Not everyone can deliver good basic nursing care. Not

everyone can feed a patient, not everyone realises that the patients need to be turned and not everyone realises that you need to know when a patient has had their bowels open. That is nursing to me.”

The participants’ accounts indicate that the low value placed on basic nursing care and pressure ulcer prevention by some nurses may result in these aspects of patient care being a lower priority than other aspects of nursing in clinical practice. This suggests that the relationship that between value and care delivery that has emerged from this grounded theory with regards to pressure ulcer prevention may be applicable to other aspects of nursing.

The terms basic care, essential care and fundamental care are used to refer to the same aspects of patient care that are viewed as comprising the essence of nursing. In recent times, the term basic care has fallen out of favour and the terms essential or fundamental care are more widely used. This is largely due to the fact that the term basic conjures up images of something that is simple and easy to do, which has led to basic care being misconstrued as something that is so easy to do that it can be done by anyone. The term basic care actually refers to aspects of patient care that are at the heart of nursing and should be performed by all nurses irrespective of the setting that they work in. Therefore, the terms essential or fundamental care are now more widely used to refer to the key aspects of patient care that all nurses are expected to deliver. This is because the terms essential care and fundamental care are felt to better highlight the integral nature of these aspects of patient care to nursing practice than the term basic.

The semantic distinction between the terms basic care and essential or fundamental care may appear to be a bit pedantic, but it may also be important for other reasons. Words are merely containers of meaning, which means that the same word can have a wide range of meanings for different people (Bernstein 1971; 1975; 2000). This characteristic of words has been highlighted in a number of linguistic and educational studies, which suggests that in everyday life what a person construes to be the meaning of a word is of greater significance than the actual the definition of that word. A person’s understanding of the meaning of a word is also important because the meaning of words often changes in everyday usage