NURSES’ AND DOCTORS’ UNDERSTANDING OF THE GENERAL PRINCIPLES OF WOUND HEALING

This section of the study deals with a number of issues: firstly, nurses' understanding of the general principles of wound healing and the sources of their knowledge; and secondly, doctors' perceptions of nurses' knowledge of this area and the extent of their own knowledge and understanding. One of the aims of this section is to establish the extent of clinicians' knowledge and understanding of an important area of their practice. Another aim is to ascertain the extent to which clinicians' knowledge and understanding about wound care issues are consistent with or conflict with current scientific theories of the healing process, and changes in wound care practice.

3.2.1 The Extent of Nurses' Understanding of the General Principles of Wound Healing

Only a quarter of the thirty six nurses, from specialist and non-specialist units, felt that nurses in general do possess an understanding of the wound healing process. Three quarters of them were less certain, and the nursing auxiliaries in the sample said that untrained nurses like themselves certainly do not.

Nurses were said to "generally" (2 nurses) or "basically" (4 nurses) know how wounds heal but not to understand the whole process (1 nurse), particularly not on any detailed technical level (1 nurse) in the way that doctors were thought to (1 nurse). The kind of attitude underlying the latter two comments has its roots in the stereotypical view of doctors as being more knowledgeable about theoretical matters than nurses. However, as various parts of this study demonstrate, it is an illusion to suppose that doctors are more knowledgeable about wound healing theory or wound care practice than nurses. Their medical education may cover the healing process in a more theoretical and detailed way than nurse training; nevertheless, doctors, like nurses, do not appear to use this knowledge to inform their clinical practice.

Various reasons were given by the nurses to explain their lack of knowledge of the healing process. The limited availability and accessability of information on this subject was blamed, as was the insufficient time or emphasis given to teaching nurses about wound healing during their basic training or in their work situations once qualified. Some thought that nurses understand such things at the time they are taught them, but soon forget them once they enter practice (5 nurses). The implication of this is that issues relating to wound healing are academic and theoretical in nature and as such are irrelevant to the day-to-day nursing management of wounds, as the following quote illustrates:

"... you forget, you know - it’s awful - when you're not using it every day. You’ve got to sit and read it and think 'oh yes, that's right.'"

The motivation to learn, and indeed to continue learning about such matters, was not generally regarded as the sole responsibility of individual nurses. 'Others', such as institutions (through, for example, in-service training) and colleagues were thought to have an equal responsibility to stimulate nurses' interest in this direction. As far as one nurse was concerned:

" (nurses) need stimulus to be able to go home and look things up ... I think too often that stimulation is not there for you to go home and read a textbook and to keep revising things like that and keep afresh..."

3.2.2 Should Nurses Understand the General Principles of Wound Healing?

The majority of nurses answered in the affirmative, giving a range of responses to explain why the possession of such knowledge was considered important. The responses varied from the belief that understanding the general principles of wound healing would allow nurses to make more sense of their observations (4 nurses) and to make more informed decisions regarding what treatments to use (4 nurses), to it being "handy" and "interesting" to know such things (3 nurses).

The important role which nurses play with respect to wound management

was highlighted by a number of nurses, further underlining the importance of their understanding the healing process. As far as one nurse was concerned:

"because in terms of wounds, district nurses ... are very influential in what happens to a wound... most GPs, if we say we want something will just give us it. They won’t argue with us ’’ However, there were nurses who took the view that nurses "can get by without it" or that such knowledge is only relevant for certain nurses (4 nurses), such as those dealing with wounds on a regular basis (1 nurses). What was clear from the comments made by some of the nurses, illustrated by this last one, was that they frequently failed to recognise themselves in the descriptions they gave. What this kind of attitude reflects is the tendency to shift responsibility for being knowledgeable about such matters onto 'others’ thereby avoiding any implied criticism.

3.2.3 Sources of Nurses’ Knowledge about the General Principles of Wound Healing

Three quarters of the nurses interviewed said that they had learned about wound healing in their basic training, taught by a variety of staff such as nurse tutors (14 nurses), clinical tutors (4 nurses) and surgeons (5 nurses), in formal classroom situations. Others felt that they had learnt "little" this way, citing practical experience in ward situations as the most significant method by which they had acquired such knowledge. This was particularly true for both pupil nurses,. who receive less formal tuition than student nurses on such matters, and nursing auxiliaries, who receive no formal training, despite the fact that in certain units some of them are frequently as involved in the day-to-day wound management of patients as qualified staff.

Over three quarters of the nurses spoke of having learned about wound healing in informal clinical situations through observation (5 nurses) and contact with nursing colleagues, such as ward sisters (6 nurses) and clinical tutors (2 nurses). The following quote is typical of the comments made by these nurses.

"...I did a little in my initial nurse training... but mostly I've just learned little bits as I've gone along in my career. . . by experience, by doing and by asking questions..."

3.3 NURSES’ KNOWLEDGE OF THE PHYSIOLOGICAL ASPECTS OF THE WOUND HEALING