The aim of this section of the study was to investigate whether nurses and doctors involved in the management of various types of wounds are aware of recent developments in theories about wound healing, as this may have important implications for their wound care practice. To explore this issue a relatively new theory about wound healing - namely the moist wound healing theory (MWHT) - was used. Their knowledge and understanding of the MWHT and their usage of occlusive and semi-occlusive dressings (which represent the application of the MWHT in wound care practice) were explored. In addition to ascertaining what respondents knew about the MWHT and associated dressings, the sources of their knowledge were also investigated. How they acquire such knowledge gives important insights into the ways in which new knowledge and practices are disseminated within the health care system.
3.5.1 The Extent of Clinicians * Knowledge regarding Innovations in Wound Care
The findings indicate that both doctors and nurses are more up-to-date with developments in new treatments than they are with changes in wound healing theories. Less than half of the nurses (15) and doctors (7) interviewed had heard of the MWHT, as compared to over three quarters of the nurses and all of the doctors who said they had heard of and used certain dressings associated with this theory. Moreover, clinicians appear more likely to accept new products than new knowledge. In other words, it is easier to institute changes in wound care practice than to alter clinicians' understanding of the wound healing process. This may be because pure knowledge is an intangible thing and appears divorced from practice.
Three times the number of nurses from Unit C had heard of the MWHT (9 nurses) as those from the other two units. This suggests either that they are more up-to-date on such issues or are more aware of the association between the theory and the nursing practices deriving from it, such as the use of various occlusive and semi-occlusive dressings. What the above discussion does not do, however, is explain why these
nurses are so well informed. In the researcher's judgement the answer lies not in the psycho-social character of the particular nurses working in Unit C, nor indeed in the organisation or structure of this unit, but in its 'market potential' as perceived by the companies selling the new dressings associated with the MWHT (see section 4.7.2).
The importance of commercial influences in increasing clinicians' awareness and facilitating their adoption of innovations in the health care field will be discussed in more detail in the chapter which follows. Suffice it to say that the extent to which the companies marketing these new dressings consider any given setting to be a good market for their products (in terms of their potential for increased sales and thus increased profits) will determine the intensity with which they promote them, and by the same token, the level of awareness which clinicians working within these units have of developments in the health care field.
3.5.2 Should Clinicians' be Up-To-Date with Changes in Wound Healing Theories?
The assertion that nurses should be up-to-date on such matters was endorsed by the overwhelming majority of them (32). Most nurses supported the general principle of "moving with the times", equating change with advancement and progress - an obviously 'good thing'. Being up-to-date on such matters was regarded as important, not only for their own personal and professional advancement, but also for improving patient care. Most nurses considered it important for them to be up-to-date on such issues, whereas some doctors certainly did not, neither for themselves nor for nurses. The message seemed to be that clinical experience and the practical aspects of wound management are what matter rather than knowledge of the theories involved. According to two doctors, most doctors and nurses do not regard this area as "high priority" or of particular interest to them. As far as one of these doctors was concerned:
" I really have no great interest in what goes on under a microscope...and I am sure most nurses don't either."
The implication from this quote, and the comments made by other respondents, is that interest in, or knowledge of, the healing process is the domain of the academic or the research scientist and not the clinician. This view provides us, one could argue, with a concrete present day example of the historical division between the 'bench1 and the 'bedside' and the knowledge which clinicians think is appropriate for personnel in these two sections of the medical system to possess. However, implicit in the comments made by some of the doctors is that certain types of knowledge are even less appropriate for certain clinicians to possess than others, such as nurses' need of theoretical knowledge.
There were many contradictions in the comments made in this section and a tendency to shift responsibility for being up-to-date onto others, thereby deflecting criticism for their lack of knowledge in this field. Some nurses and doctors believed that, for example, 'other' doctors, from 'other' units which specialise in wound care or which deal with wounds regularly are, and indeed ought to be, more knowledgeable than themselves about innovations in this field. However, they often failed to recognise themselves in the descriptions they gave, a point which did not go unnoticed by some nurses. Five nurses from Unit C believed that for nurses such as themselves, for whom wound care represents the main part of their working day, and indeed for any nurse who influences the manner in which wounds are managed, then being up-to-date on advances in wound healing theory was important.
3.5.3 Constraints on Nurses and Doctors being Up-To-Date on Developments in Wound Healing Theories
A variety of constraints were cited as being responsible for nurses and doctors not being up-to-date on such issues. Criticisms were levelled at both the institutional and individual level. As far as some nurses were concerned, lack of resources - both financial and human - were to blame for such a situation. This together with increased work loads, left nurses little time to keep up-to-date. As far as some nurses were concerned, they were too busy "getting on with the job" to keep up-to-date on such matters. This was also the view of two doctors.
On another level, nurses complained of the lack of up-dating material and instruction, both in terms of its availability and accessibility. Insufficient encouragement or stimulation to keep up-to-date were also cited. On an individual level, some nurses believed that it was the responsibility of nurses to keep themselves up-to-date (4 nurses), and that if they were not, then it was their fault. They also attacked nurses in general for their conservative attitudes; of doing what they have always done; sticking to favourites and what they have been taught; being suspicious of new things and lacking the motivation to read or study once qualified, or to question their practice.
However, the argument that if nurses are not up-to-date on advances in wound healing theory, then they have only themselves and their conservative attitudes to blame, should, the researcher believes, be reappraised. The responsibility for nurses not being up-to-date on such issues lies not so much with the individual nurses themselves, but with the nursing profession and the attitudes it inculcates into its members. It is not so much that nurses as individuals are conservative, but the nursing profession itself is. It is the very nature of nursing which determines nurses' traditional, highly pragmatic and instrumental attitudes towards theory and practice, and transfers these attitudes to individual nurses through their socialisation.
A number of doctors and nurses implied that they did not think that there was a great deal to be up-to-date with. " Why, are there any new theories?" queried one nurse, while according to two doctors from Units S and C:
"I don't think there are any major advances in wound healing that I've heard of in the last five years."
and
"I don't know that there has been a great deal new found out about wound healing....I don't think anybody has proposed anything radical."
3.5.4 The Sources of Clinicians' Knowledge about Innovations in Wound Care
When asked how they thought nurses could be up-dated about innovations in wound healing theories and wound care practice, formal communication
channels such as lectures and meetings, in-service training, courses and study days were reported. Informal communication channels such as contact with "experienced others" were only cited by two nurses. A similar story was repeated when asked how they thought nurses are kept up-to-date on such matters, although reading was seen as particularly significant (27 nurses), especially of nursing journals (20 nurses). Only 6 nurses spoke of nurses learning about new treatments through informal channels.
However, despite the generally held view that nurses are and could be informed of changes in the wound care field via formal communication channels, the concrete example of the MWHT and associated dressings reveals that in reality nurses and doctors are more commonly up-dated through informal channels, including observations in clinical practice, personal experience and word of mouth from medical and nursing colleagues. Fourteen of the 15 nurses and 3 of the 7 doctors who had heard of the MWHT had done so indirectly through using certain of the associated dressings. Indeed, the nurses', knowledge of this theory derived almost exclusively from what they knew about one particular dressing - namely OpSite (13 nurses). Only one of the doctors cited OpSite. Another said he had come across the MWHT in connection with "plastic foams or...polythene things."
The most significant way by which the nurses and the doctors had learned about the dressings based on the MWHT was from the manufacturers of these dressings. Approximately half of the nurses and a third of the doctors had heard about them from lectures given by their sales representatives, particularly those promoting OpSite (13 nurses) and to a lesser extent from Granuflex representatives (4 nurses). The lectures given by these representatives, their leaflets (6 nurses), free samples (3 nurses) and information printed on and in the containers of these dressings (12 nurses) appeared to be the main ways by which nurses were introduced to these dressings. Equally significant for the doctors was learning about these dressings from journals (5 doctors).
Three times the number of nurses from Unit C reported sales representatives coming to talk to them, compared to those from the other
two units. The reasons for this are the same as those used in the earlier discussion to explain why more nurses from Unit C had heard of the MWHT than those from the other two units. OpSite representatives seem to have a higher profile in Unit C (9 nurses) than in Unit S (2 nurses), where Granuflex representatives seem to be more in evidence (7 nurses). The reasons for this difference may be two-fold. Firstly, the dressings' contracts negotiated between dressing manufacturers and the various Regional Health Authorities (RHA) determine which particular dressings are to be supplied to the various institutions under a particular RHA's jurisdiction. Thus it could be that the companies marketing OpSite and Granuflex are contracted with Unit C and Unit S respectively. Secondly, OpSite, as the first dressing to be associated with the MWHT and the first to be included on the Drug Tariff was available on prescription in the community at a much earlier date than any of the other related dressings, such as Granuflex. Thus it is not altogether surprising to find that OpSite is the more popular dressing amongst nurses from Unit C. (Issues concerning the contract system and the Drug Tariff as they pertain to the new family of dressings associated with the MWHT will be discussed in more detail in the chapter that follows).
Informal networks such as word of mouth from other nurses (12 nurses,5 doctors) and experience (15 nurses); from seeing them used (3 doctors) or using them themselves (2 doctors) on various wards were also reported as significant diffusion networks of the new dressings. These examples not only show the primacy of clinical experience in informing practitioners of changes in wound care practice, they also demonstrate the primacy of 'bedside' teaching, based on the wards, in the transmission of such esoteric knowledge.
However, several nurses complained of the inadequate nature of some of the explanations received through informal communication channels. They reported being instructed on how to use these new dressings but that no explanations were given as to how they work.
"She said you should leave it on till it healed. We only gave it the benefit of 2 days... didn't know how we would know when it had healed. I presumed when it looked clean underneath or you took it off, had a look at it and put it back on if it wasn't healed."
The role of observation in this regard is interesting, for being asked to observe a wound under one of these new dressings, such as OpSite, is all right, one could contend, if one knows what one is observing, but as with this nurse (who clearly did not), confusion and uncertainty lead to incorrect usage (in terms of the manufacturers' instructions). The manufacturers' advise clinicians not to remove the dressing (ie. "look at it and put it back on") for fear of bacterial contamination. The confusion and contradiction in some of the nurses' understanding of the MWHT and associated dressings led to them removing or seeing others remove these dressings because the wound looked dirty and nasty, or put perhaps more eloquently, looked "gungy". The reason for all this confusion, one nurse believed, was due to the conflicting ideas which exist about wound healing. To quote her:
"So many people have different ideas about wounds still. You can put something on a pressure sore one day that occludes it and makes it moist. Somebody comes along the next day and rips it off and says you've got to keep them dry."
It is perhaps significant that not one of the nurses cited doctors as key informants about these dressings, although two nurses from Unit T believed it to be a doctor's responsibility to keep nurses up-to-date on new treatments. After all, one of them said, doctors are the first to find out about new drugs and dressings from drug company representatives.
The overwhelming evidence suggests that as inadequate and incomplete as some of the nurses' knowledge about these dressings is, they are more knowledgeable about such matters than the doctors, a point readily conceded by many of the doctors (8 doctors). Moreover, nurses frequently keep doctors abreast of developments in the wound care field and not vice-versa. One doctor from Unit C described the first occasion he was introduced to OpSite by a district nurse:
" I said 'That sounds very interesting. Does it work?' She said ' It's magic,' so I said 'Here's a prescription'."
Yet despite all this, and the fact that it is nurses and not doctors who are the target audience for company representatives selling dressings, the kind of attitude displayed by the respondents from Unit T cited
above is indicative of the heirarchical and paternalistic basis on which the doctor-nurse relationship continues to be perceived by some