One of the great frustrations of clinical practice as a Tissue Viability Nurse is to be asked to assess a patient in hospital only to find that the nurse who requested advice is not there. Indeed, there may be a good opportunity for someone to do some systematic research to test the following hypothesis: 'Patients in hospital are usually self-caring, therefore the number of clinical staff can be reduced to one person operating through a telephone link'.
Though I have not devised a detailed methodology for testing this, I suspect that the null hypothesis will be disproved. Here is some evidence: almost every nurse I encounter on a ward was either on holiday, or on night duty (wounds don't get dressed at night!!), or on their days off, or on their coffee break, or had not seen the wound at all, or had only seen the wound three or four weeks ago, or didn't know that patient had a wound. Further, the nurse was not the person looking after that patient, the patient is 'in the other nurse's team', or all the above but applying to the 'appropriate' colleague. No doubt readers can think of some more evidence of the absence of clinical staff?
Seriously, though (as if I wasn't!) there may be real reasons why nurses do not admit to having any knowledge of the patient's wound. Amongst these is likely to be the fact that wound care takes less priority in a pressurised environment than other things which demand immediate attention. Also, I have no doubt that some staff are frightened of dealing with wounds. Perhaps they don't know what they are looking at, and therefore are uncertain as to what to do about it? On one occasion, I saw a look of apprehension on a nurse's face when she realised I was going to leave her to do a particular dressing, using a product with which she was not familiar. Indeed, she made an excuse and pre-empted me by leaving the room so that I had to get on with it myself.
Further evidence of lack of knowledge is found in wound assessment forms (on the rare occasions that these are used). It is not uncommon to see no change in any of the categories over several assessments. Perhaps each nurse presumes that the previous one knew better? More than once I have had reason to dispute the assertion that 'the wound has deteriorated' when this has been written in the hospital notes. It only serves to illustrate that a large number of practitioners of differing disciplines do not know a great deal about the phases of wound healing, or the advantages of moisture etc. Nevertheless, some, particularly medical staff, are enculturated to interfere and to change the treatment despite the fact that the wound is actually improving.
No wonder the patients are anxious and do not know who to believe. In fact, this can be damaging to their progress and leaves the Tissue Viability Specialists with the difficult job of establishing trust and their own credibility (without destroying the relationship to the original staff, who may still need to be involved in the treatment).
Perhaps readers of this journal will recognise what I have been rambling on about. There may be a core of indicators which could be properly developed into systematic research in order to improve care?
Yours faithfully,
Miles Maylor
(Not "Disgusted, Tunbridge Wells"!)
Published 28 July 1997. Please respond to a.heenan@smtl.co.uk