© Rowene Brooker 1997
This article will describe how a project of action research was set up and implemented by nurses, in order to improve and maintain the standard of wound care in a paediatric surgical ward. It outlines how the project was established; describes the issues the project addressed from junior nurses up to the surgeons; discusses the problems encountered in carrying out such a project; and what strategies were used to overcome some of these problems. This action research project ended up being a smaller study within a larger one, and was focussed on issues relevant to nurses as regarding their knowledge and practice in wound care. The project leader and author of this article was the Clinical Nurse Educator in the ward, who was embarking on a staff development programme and wanted to use a research method more relevant to nurses.
Wound care management is becoming more complex for nurses due to new insights into wound healing (Hayward & Morrison, 1996, p.11) and because of the wide variety of wound dressings that are available (Wikblad & Anderson, 1995, p.312 and Miller, 1994, p.62). Erwin-Toth and Hocevar (1995, p.46) stated that there were approximately 400 brands of wound care dressings on the market to choose from and that wound care is made even more difficult because no one dressing method suits all wounds and the choice is dependent on the cause of the wound, infection, favourability and cost (Findlay, 1994, p.836). Because of these many different wound care techniques and dressings, nurses are becoming confused and nonplussed regarding wound care practice. Unfortunately, Millers (1994, p.62) research showed that in 85% of cases nurses were using inappropriate dressings, and OConnor (1993, p.64) found in her study on wound care that nurses were having difficulty in applying their theory and knowledge to their practice.
Action Research was the strategy used for this study because it is very appropriate for nursing research. Traditional nursing research is failing nurses because so often they do not see its relevance to their practice (Greenwood, 1984, cited in Hart, 1995, p.9). Action Research is more suited to nursing, not only because of its problem solving and evaluating features, but also for its similarity to the stages of the nursing process of planning, acting, observing, reflecting and often replanning (Bellman 1996, p.130) . Action Research is also appropriate for nurses because, it does not require expert researchers; the participants define the problem themselves; both researchers and practitioners participate together in the process (Kemmis & McTaggart, 1988, pp.22-23, Hart & Bond, 1995, p.55 and Birkett, 1995, p.191); it is less structured and leaves room for possible changes; it is empowering for the participants; and reflective of their practice (Kemmis & McTaffart, pp.11-12, 50 and Titchen & Binnie, 1993, cited in Hart, 1995, p.8). Titchen and Binnie (1993, cited in Hart, 1995, p.8) also highlighted the empowering effect, and reflective practice, action research gave nurses so that they can hopefully free themselves from the medical hierarchy.
The setting of this project was a 16 bed surgical ward of a major paediatric teaching hospital. It was classified as a clean surgical ward and the casemix of patients were cardiac, ear, nose and throat (ENT), ophthalmic and the occasional others. Most of these patients were under the age of five years which made their participation in the project impossible. Because of the range of surgery performed there were many different wounds and many surgeons using different techniques in wound management even for the same procedure. This was confusing to the nursing staff and created an attitude that they did not have any say in their patients wound care.
Two issues of concern were raised by different members of the nursing staff . Firstly, the Unit Manager and Clinical Educator were concerned about the nursing staffs lack of observation and reflection on their patients wound care and the second was from the nurses regarding the many types of dressings and treatment used by different surgeons for as many different wounds--was one better than the others and for what wound? This was exacerbated even more by the introduction of yet another new dressing by one of the surgeons. From discussion on these two concerns it was decided to perform a ward audit using action research on how the nurses could improve their wound care practices and devise it so that quantitative outcomes could be compiled in the long term regarding the many types of wound management and dressings that were being used. The long term project would also be used to monitor infection rate which is required by the Health Department.
As the project was implemented as a ward audit, which did not involve patients or parents, neither financial assistance nor approval from the Hospital Ethics Committee were required.
During the planning stage when discussions were held with senior nursing staff, the following strategies were proposed and developed:
(i) A wound survey chart (See Appendix A) was devised that documented the process of observations to assess the effectiveness of wound care procedures and dressings for all the different wounds. This was formulated by two members of staff and shown to other staff for comments and suggestions for changes. For a long term project this survey chart was also shown to a member of the Hospital Research Department who made suggestions on how to improve it so data could be processed for quantitative research outcomes.
(ii) A research proposal was written in order to be able to inform, not only the nurses, but also the other disciplines that will be involved in the goals and objectives of the project.
(iii) The Head of the Surgical Department was also informed of the project and on his own reflection decided to collect data and take photos himself in his office when he saw the patients post-operatively. This information would also be made available for our project. The new dressing he was using, which he felt would promote better scarring outcomes in the future, was not removed until two weeks post-operatively so we needed his cooperation in obtaining the final outcome of the wound healing. The other surgeons and community liaison nurse were informed of the project by letter and discussion at a senior staff meeting. Out of the discussion at this meeting it was suggested that the data collected should be processed with the data they already had on the patients in their department. The same problem was raised when the Infection Control Department was informed of the project. This was our first major problem but was only relevant to the larger project in collecting data for quantitative outcomes. The facillitator would meet again with these departments to resolve this issue.
(iv) To provide us with a knowledge base for our decision making it was decided that the members of staff who were on relevant hospital committees, such as, infection control, product review, wound care, quality assurance, research and professional practice, would carry out literature reviews pertaining to their specific committee subject and our research project. This information they would present to the rest of the staff at following meetings or inservices. This would equip the nurses with evidence-based knowledge to obtain consensual agreement on decisions made for better practice strategies.
(v) The Nurse Educator, who was reasonably familiar with the process of action research, became the facillitator and in this capacity held inservices to educate all the nurses regarding action research. This also helped to solicit more participation and inform the nurses of their role in the process.
As it was difficult to hold meetings that all senior staff could attend, the facillitator kept those that were not present informed by mail.
A two week trial of using the wound survey chart was implemented in order to iron out any teething problems with the chart, and so the nurses could get use to using the chart and reflecting on their practice. Even though the nurses were fairly busy and inundated with hospital paper work already, the wound survey chart was accepted and well utilised.
After the trial implementation, discussion was held regarding the survey chart during a ward meeting to obtain feedback from the nurses. Obtaining feedback from all the nurses was difficult because of their shift work making it impossible for some to attend. Another problem was getting the nurses to reflect on what effect using the chart had on their thinking about their own wound care. To overcome these two problems it was decided to produce a fairly simple questionnaire for all nurses to answer (See Appendix B). Twelve of these questionnaires were returned out of the 16 that were distributed. The results were:
This questionnaire was very successful as it showed that the survey chart was useful in making nearly all nurses more observant of their patients wounds, but unfortunately only half showed any interest in wanting to learn more about wound care.
Comments from this questionnaire also made us aware that some nurses, because of shift work and annual or study leave, were not adequately informed of the project. To overcome this problem it was suggested that the facillitator put a copy of the project proposal and an article on action research in the ward memo folder for all to read. The wound survey chart proved successful and was not changed in any way.
A week after the first cycle the second cycle was implemented for another four weeks. During this cycle the senior members of staff reviewed relevant articles on appropriate topics, such as, wound healing, infection control and treatments, and comparison of wound dressings.. These reviews were presented to the rest of the staff by a series of in services and the notes made up as a folder for all staff to read and for future reference.
Also during this cycle the facillitator was able to present the project and explain Action Research to the rest of the hospital staff at the Hospitals Clinical Presentation which is held each month. Though this presentation was not that well attended, it did give the opportunity to inform other ward staff about how useful Action Research was for nursing research.
At the end of the four week cycle, discussion was again held at a ward meeting. The nurses felt that they had learnt more about wound care because of the literature reviews and inservices given by senior staff. These literature reviews revealed that there was a lot of new theory and knowledge regarding wound healing and management and this challenged one of our current habitual wound practices which we would look into changing. These literature reviews also enthused the senior staff and encouraged more staff into wanting to know more about wound care and change our practices where we felt necessary. These inservices would continue and involve other staff members who wished to contribute.
As the ward did not have a policy on wound care it was suggested that we develop one out of our readings and research. One of the senior staff members volunteered to take on this task.
As the previous questionnaire proved to be a very efficient, fast and confidential method of obtaining information and comments, future questionnaires would be used to help obtain information from nurses that could not attend meetings.
The facillitator proposed that during the next cycle that the nurses might try and do more reflecting on their nursing practice, and that they could do this by writing their thoughts and feelings in a journal which would be confidential. As Schon (1987, cited in McCaugherty, 1991, p.539) stated, a lot of professional practice in medicine creates unique issues and problems to which answers cannot be found in textbooks. Bellman (1995, p.129) found in her action research study that the participants reflections were essential in obtaining feedback regarding the implementation and the changes made. The facillitator agreed to do a literature review on the reflective practitioner and hold inservices on her findings during the next cycle to help the nurses in this process of reflecting.
Nurses play a crucial role in the management of wounds so they need to have good current knowledge and be more aware of their own wound care practices so to bring about more effective wound management (Professional Development in Nursing Times, 1994, p.1).
This article only describes the first two cycles of this project but already it has had results. It has helped the nurses to be more observant of their patients wounds; increased their knowledge and skills on wound care; assisted them in acquiring more experience and skills in nursing research; and set up an on-going framework for improvements in wound management.
In the long term by using this action research process, hopefully the nurses will acquire evidence-based knowledge and skills in wound management so that they will be able to challenge the heirachical structures and participate in the decisions made in their patients wound care. It should also help the junior nurses put their theory into practice, and to challenge senior nurses habitual practices. Overall, the project should foster better team work among the many disciplines; improve the nurses reflection on their clinical practice; and ultimately produce better nurse practitioners.
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Date of transfer from PICU: __________
Post-op day number: ________________
Please begin on transfer and fill in once every day:
Date Wound Dressing Condition Comments/treatment
Dry and Intact S
Drain Sites HS
Serous Ooze PD
Peritoneal Drain O
Others, eg. burn, cutdown S
D Dry and Intact
DS Drain Sites
SO Serous Ooze
PD Peritoneal Drain
O Others, eg. burn, cutdown