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Aims and objectives. To understand the psychological aspects in patients undergoing post-operative wound care and to gain
insights for improving nursing practice.
Background. Very few studies have examined education on or practice of wound care with a view towards the patients
psychology.
Design. Descriptive exploratory qualitative study.
Methods. Four patients who had undergone open surgery of the upper gastrointestinal tract were interviewed using a semistructured format to gain an understanding of their feelings and opinions with regard to wound care. Interview transcripts
were analysed using an inductive coding approach.
Results. Fifteen categories of responses were finally identified from the data. Patients wanted nursing staff to observe their
wound more often so that patients could recognise improvement, to have better knowledge of the patients disease and
condition, to explain the patients situation more completely and to appropriately answer questions. Patients also said that
they felt more comfortable in posing questions or concerns regarding their condition to nursing staff than to their surgeons
and did so while the wounds were being taken care of by nurses.
Conclusions. These findings suggested the importance of nursing staff to fully understand and to be ready to share feelings
regarding a patients postoperative condition and to have skills in properly explaining the importance of each procedure or
steps in treatments that a patient must undergo. The present study also indicates that it is imperative for nursing staff to
learn methods to build relationships with patients so that they can express their feelings of fear or anxiety freely to nurses.
Relevance to clinical practice. It is not possible to develop nursing practice without understanding psychological aspects of
patients undergoing postoperative wound care.
Key words: postoperative care, practice nursing, psychology, wound care
Accepted for publication: 24 June 2012
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Introduction
The importance of basic nursing education to enable nurses
to provide advanced and diverse nursing care in the health
and medical sector has been pointed out from a variety of
fields. Wound care including observation of the postoperative wounds, in particular, by nurses is needed for patients
at all healthcare levels and nursing situations, such as from
acute to the chronic or terminal phase, from the newborn
to the elderly, in emergency medicine such as traffic accident trauma, perioperative nursing care and in-home medical assistance. Reflecting on this critical need, the Ministry
of Education, Culture, Sports, Science and TechnologyJapan (2004)s Committee on Nursing Education proposed
that decubitus ulcer care can be performed by student
nurses with guidance by teachers and nurses and that bandaging and wound care can be done with guidance by
teachers and instructors. Tanabe et al. (2006) stated that
practice in postoperative wound care before training in
adult nursing was effective for understanding the need for
wound care and learning wound care techniques and indicated that learning wound care was possible during basic
nursing education. However, in a survey conducted in 2005
by Murata (2006) on decubitus ulcer care, more than 60%
responded that knowledge learned in school on this subject
was useless and more than 70% responded that techniques
learned in school were useless. This suggested a gap
between basic nursing education and actual practice; filling
this gap is part of the agenda for nursing education of
rookies entering the work force. In addition, Watanabe
(2006) stated that information on wound care in basic
nursing education is primarily through lectures, with training in actual practice occurring in the workplace. Further,
it was stated that education on wound care, a field in which
advancements are constant, should begin with basic nursing
education, continue during clinical training and finally
become part of specialised education, such as certified nurse
programs.
Furthermore, the importance of psychological care related
to wound care for patients with acute trauma was addressed
(Magnan 1996, Devlin-Rooney & James 2005). For those
patients, nursing practice should not only involve technical
competence and attitudes that consider the patient psychologically both in providing wound care but also in other
nursing situations. However, the psychological needs of
patients undergoing wound care have been little studied, and
studies have been scant regarding education on or practice
of wound care with a view towards the patients psychology.
In this study, we aimed to understand the psychology of
patients undergoing postoperative wound care, such as
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Methods
This study used a descriptive exploratory qualitative
research approach, which is useful in summarising and
understanding an area of interest and was deemed appropriate for this study, which was intended to describe and
explore the psychology of patients undergoing postoperative wound care.
Survey period was six months from December 2007May
2008. Study participants had undergone abdominal surgery
of the gastrointestinal tract at a hospital to which the
investigator belongs. Participants were selected who could
understand the purpose of the study and consent to participate, had epidural anaesthesia with insertion of one or
more drains (open or closed) and could communicate verbally. The interview was conducted within three days after
suture removal, and study participation was approved by
the patients surgeon.
Semi-structured interviews were used to collect information relevant to the aims of the study, and questions were
consistent among all four patients. In these interviews,
participants were asked to describe thoughts and feelings
on their postoperative wound care. The interviewer listened
intently to the participants responses and, when appropriate, requested clarification of responses or further explored
issues raised by the participant. Where necessary, additional
open-ended questions were asked of the participant such as:
What do you think during receiving wound care, and also
before and after? and What do you feel during receiving
wound care, and also before and after?. A certified nurse
interviewed all of the patients.
Interviews ranged in length from 1530 minutes
(mean = 26 min) and were conducted two or three days
after removal of sutures. The interview was conducted
where privacy was ensured, such as in a private room. During the interview, consideration was given to minimise the
physical and mental burden on the patient. A digital voice
recorder was used to record each interview with the
patients consent, and this recording was transcribed verbatim. Moreover, patients non-verbal behaviours during the
interview were noted in transcripts. Transcripts were
repeatedly read and analysed using an inductive coding
approach. In addition, basic data from nursing and medical
records were used to understand the background of each
patient. Our goal was to devise a list of items that
expressed the patients feelings and that could be examined
for useful information on wound care. On each transcript,
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 939947
Results
Overview of the participants
Four adult patients (age 57 48 years) participated in this
research (Table 1). In one patient, the current hospital
admission was his first for surgery, while the other three
patients had had previous surgeries. Only four patients who
fit the conditions for participation in the study agreed to
participate. All patients had been provided wound care
from the first day after surgery and had a good postoperative recovery and wound healing.
Surgical experience
Number of
indwelling drains
Number of wound
care sessions
Hepatic
segmentectomy,
small bowel
fistula closure
3rd
2
15
D (male, 62 years)
Partial hepatectomy,
intra-abdominal tumor
resection
Radical cholecystectomy
lymph node dissection
Esophagectomy and
reconstruction
4th
2
2nd
2
1st
6
16
19
30
Until
postoperative
day 3 with the
patients request
for pain relief
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R Murakami et al.
Table 2 Psychology of patients undergoing post-operative wound
care
Psychological aspects of patients
I want to be looked at often rather than be left alone and want
someone check if my wound condition is good
I feel a lift in my mood and a sense that I am recovering each
time a drain is removed or gauze is replaced
I feel anxiety when I have strong pain, such as immediately after
surgery, and I want someone to come as soon as possible
I feel more at ease with quick and well-practiced procedures
from an experienced surgeon when I am calm and composed,
but I feel better with slow, careful handling when I am
uncomfortable and anxious
If I can leave the ward for a while, I want you to tell me
beforehand the time of wound care and let me know who
would perform it
I do not have any thoughts in particular about care of the
wound because the procedures were performed effectively by an
experienced caregiver
I do not have any complaints in particular because I get
disinfection procedures done when necessary and I get a
response to my concerns each time
The attending nurses change daily, which is unavoidable but
confusing
I feel more comfortable asking questions of nurses than surgeons
about my concerns when undergoing disinfection procedures.
Therefore, when a nurse disinfects, I tell her of my worries
I felt anxious when I thought a nurse was hesitant to tell me
something or when she did not reply to my question
I want a nurse to have all information and knowledge relevant
to my situation if possible and to be able to provide me with
answers to my questions
If a surgeon seldom speaks, I will be disappointed, but I am glad
when I am addressed by surgeons even if not the surgeon in
charge
I feel better when a surgeon gives me positive information in a
cheery voice, although this may be difficult for some surgeons if
it is not naturally part of their character
I feel nervous when I hear surgeons voices in the hallway after
the disinfection procedure since I am wondering what they are
discussing
I am happy to be seen since surgeons and nurses are kind and
I feel confidence in them
2 [I feel a lift in my mood and a sense that I am recovering each time a drain is removed or gauze is replaced.]
This expressed feelings of physical and mental recovery
when receiving wound care. This statement indicated a feeling that the wound was getting better and that anxiety was
decreasing when dressings were changed or the number of
drains was decreased.
3 [I feel anxiety when I have strong pain, such as immediately after surgery, and I want someone to come as soon
as possible.]
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Discussion
The 15 categories on the psychology of patients related to
wound care were divided into two viewpoints: psychology
regarding wound care conducted during the postoperative
recovery state and the attitude of the medical staff performing wound care. The characteristics of these categories
and the implications for improving nursing practice are
discussed.
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R Murakami et al.
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when the caregiver was very experienced in these techniques. Moreover, with the realisation that recovery was
taking place not only from the wound, but through regaining general physical and mental strength, wound care
became only part of hospital life and their focus on
wound care was reduced.
From these observations, variations are evident in how
patients adapt to wound care and that patients expect
wound care to contribute to their recovery status after surgery. Therefore, nurses should understand how patients perceive their recovery status. When patients are anxious about
their recovery, nurses should talk to them frequently, clearly
explain their status, and treat them gently. On the other
hand, for patients who believe that their recovery is progressing, nurses should make sure that they clearly understand their status and help them return to their normal life
as much as possible and with as few difficulties as possible.
Some categories showed that patients placed their confidence in the medical staff during wound care and it was
also shown that the medical staff helped the patients understand the need for wound care and the nature of the
wound. Therefore, these findings suggest that performing
wound care while appropriately explaining reasons for decisions made by the medical staff helps the patient to better
understand such decisions. In that way, patients can feel
comfortable placing their trust in the medical staff. Also,
communication with the medical staff is facilitated during
wound care and a relationship is fostered in which patients
can ask and get answers to questions instead of just leaving
everything to the medical staff.
On the other hand, as for effective and experienced
care in relation to the category [I do not have any thoughts
in particular about care of the wound because the procedures were performed effectively by an experienced caregiver.], providing safe and comfortable nursing techniques
is expected as a matter of course and the need to learn
techniques in this role has been described in the literature
(Murata 2006, Tanabe et al. 2006, Watanabe 2006,
Shimada & Niiyama 2008). However, a variety of issues
are involved in meeting patients needs for effective and
experienced care in the current state of nursing education
where it is difficult for not only new nurses, but also for
student nurses to get a chance to practice, as has been
described (Aso 2002). However, what the patients considered to be effective and experienced care was not
revealed in the present study. Specific procedures (nursing
techniques) that should be considered effective and experienced in wound care need to be clarified in the future.
What have been described so far are the perspectives
inherent in the statement: mastering nursing techniques is
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 939947
945
R Murakami et al.
Conclusion
These thoughts and feelings of patients undergoing wound
care were studied from two perspectives: psychology
regarding wound care in relation to the postoperative
recovery status and psychology regarding the attitudes of
medical staff that perform wound care. The study results
suggest that in nursing practice nurses should: (1) have
postoperative information on their patients and share this
information with team members, (2) fully understand the
postoperative recovery process to be able to answer
patients question, (3) have the communication skills
required to explain clearly the meaning of wound care and
the status of recovery and (4) have learned techniques to
build relationships with patients so that patients can easily
ask questions. Therefore, when newly licensed nurses or
expert nurses collaborate with medical staff of various disciplines to gain an understanding of a patients condition,
they can provide appropriate care leading to the patients
recovery as well as discuss wound care with the patient.
Acknowledgements
We thank the patients who cooperated in this study and
everyone in the cooperating facilities.
Contributions
Study design: RM, MS; data collection and analysis: RM,
MS, MN, YK, SY, MS, NT, HH, RY and manuscript
preparation: RM, MS.
Conflict of interest
The authors declare to have no conflict of interests.
References
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invasive nursing techniques. Nursing
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Kornhaber RM & Wilson A (2011) Building resilience in burns nurses: a
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Journal of Burn Care & Research 32,
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Magnan MA (1996) Psychological considerations for patients with acute
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