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The patient’s experience in a plaster cast
International Journal of Orthopaedic and Trauma Nursing (2010) 14, 132–141
www.elsevier.com/locate/ijotn
The patient’s experience in a plaster cast Marion Williams RGN, MSc, Cert Ed, Ortho Tech Cert (Clinical Practitioner) * Royal Gwent Hospital, Cardiff Road, Newport, Gwent NP20 2UB, United Kingdom
KEYWORDS
Summary Plaster casts have been used to treat fractures for over 150 years. This qualitative research describes this experience from the patient’s point of view. The aims of the study were to describe patients’ experiences in a below knee cast, establishing common themes and determining how the themes identified could inform nursing practice. A purposive sampling strategy was used; selecting participants who had been in a lower limb cast for at least 4 weeks, were over 18 years of age, treated as an outpatient and previously mobile. Data were collected using unstructured interviews which were recorded and transcribed. Individual manuscripts were analysed using interpretive phenomenological analysis. Common themes were identified and related to the literature. Seven main themes were identified: ‘hard work’ illustrated how difficult everyday tasks became; ‘it gets you down’ described how the participants began to feel frustrated and sorry for them selves; ‘different circumstances’ showed how participants put their situation in context in order to cope. Other themes were: ‘making it better’, ‘back to normal’, ‘pain’ and ‘getting through it’. The data were further explored in relation to the Roper, Logan and Tierney’s (1996) model for nursing and Davis’ (1997) adaptation, illustrating how the five main elements of the model inter-related so that difficulties in one dimension affected the others. c 2010 Elsevier Ltd. All rights reserved.
Plaster; Experience; Phenomenology; Roper
Editor’s comments The sheer volume of casts applied in any orthopaedic department can lead us to forget the impact a cast can have on the daily lives of those who have to live with them – often for several months. This patient-orientated study acts as a timely reminder that patients with casts need information and support in coping with the often sudden and significant impact the cast and its implications can have on their ability to carry out activities they do not normally have to think about. JS
Introduction * Tel.: +1 633 234408. E-mail address: [email protected]
Research related to limb immobilisation using plaster casts has strong and weak points. Research
1878-1241/$ - see front matter c 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2010.03.007
The patient’s experience in a plaster cast relating to the effectiveness of new products and methods in terms of fracture stability or wound healing are fairly easy to find. However, references to the patient’s experience of this process beyond comfort and length of treatment are limited. Anecdotal evidence has suggested that being in a plaster cast is, at best, frustrating and, at worst, a disabling and life-changing experience. In an attempt to hear the patient’s story, a smallscale phenomenological study was undertaken because, as McKenna (2004) explains: in order to care for patients in particular circumstances, it is essential to understand what life is like for them; what is their lived experience?
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Plaster of Paris has been used to immobilise fractures and treat orthopaedic conditions since 1850 when it was first used in the Dutch army (Large, 2001). Nowadays, there are a variety of alternative materials such as resin impregnated bandages, ready-made orthoses and external fixators. An essential element of fracture healing is to maintain the bony alignment of the fracture in order to promote healing and enable maximum function of the limb once the fracture has healed. In many fractures bony alignment can be effectively maintained using a plaster cast (McRae and Kinninmonth, 2002).
using an air-stirrup brace rather than a cast. The long-term results were no different in the two groups but an earlier return to activity and the ability to remove and reapply a brace may be appealing during the treatment period. Wykes et al. (2003) demonstrated that the benefits for the patient and health providers in terms of an earlier return to work and normal function off-set the initially high cost of a pneumatic brace. Petty and Wardman (1998) compared a focused rigidity casting technique (FRC) with traditional plaster of Paris or synthetic casting. This trial compared clinical and functional outcomes for patients in a variety of casts and considered overall costs. An emphasis was placed on performing activities of living (ALs) during treatment which were measured using the Bradford Criteria (Petty and Wardman, 1998), indicating that the patient’s journey is important as well as the final outcome of treatment. From reviewing these studies, it appears that the benefits of new casting techniques and functional stabilisation, whether by cast or splint, lie in the patient’s experience during treatment and early recovery rather than long-term clinical results. A growing picture emerged of a need to adapt treatment to suit individual patient needs as well as providing good clinical results. In order to address these needs, a deeper understanding of the patient’s experience in these situations is important.
Literature
Qualitative research
Quantitative research
Qualitative research is widely recognised as being able to provide in-depth accounts of the patient’s experience in a variety of circumstances. It can be used to evaluate effectiveness, appropriateness and quality in healthcare and as such is an important component of evidence-based practice within clinical governance (Gray, 2001). This type of research in nursing is interested in the patient journey; their experience of illness in all dimensions and therefore providing theoretical and practical knowledge to facilitate making decisions regarding care provision (Holloway and Freshwater, 2007). Qualitative research directly related to the patient in a plaster cast is not common but there are a few studies that may have transferability to this phenomenon. Griffiths and Jordan (1998) used patient diaries and semi-structured interviews to explore the experience of patients admitted to hospital for surgery following lower limb trauma. The use of patient diaries provided a longitudinal record
Background
Quantitative research has been used with good effect to compare different treatment methods and outcomes related to treatment of fractures or other trauma using plaster casts. Quantitative methods are well suited for comparing different treatments and producing numerical data (Parahoo, 2006). In a randomised controlled trial (RCT) comparing weight-bearing orthosis with non-weight-bearing plaster cast treatment for ruptured Achilles tendon, Costa et al. (2006) advocated careful patient allocation to either treatment with a weight-bearing orthosis or with a non-weight-bearing plaster cast. Using an orthosis requires the strict following of a treatment protocol and may encourage some patients to return to strenuous exercise too quickly. Enabling patient choice where possible is suggested by Beynnon et al. (2006) who showed an improvement in short-come outcomes when
134 which enabled exploration of the patient’s journey to recovery. As the data were analysed, the three main themes arising (stress and uncertainty, seeking control and returning to normal) were found to concur with the cognitive appraisal model of stress and coping (Lazarus and Folkman, 1984): this model was then used by Griffiths and Jordan (1998) as a theoretical framework for further analysis and discussion.
The patient’s story In addition to information obtained from formal research methods, including the broad spectrum of qualitative approaches, nurses can listen to the human experience described through various methods of story-telling. The emergence of the internet as a source of information has meant that access to certain patient’s stories is easily possible by looking at sites such as www.bbc.co.uk/health and www.patient.co.uk. Headland (2006) suggests that these stories are in the public domain, have been freely given and represent an unbiased account of illness and healthcare experiences. Exploration of these web-sites to seek patient stories relating to plaster casts or fractures revealed a substantial discussion area related to Achilles tendon rupture. One recurring theme from exploring these messages is a level of confusion, or dissatisfaction, with information given by doctors and, in particular, a lack of complete information to enable informed decision making. It can be seen, therefore, that while a number of researchers (Bone et al., 1997; Vioreanu et al., 2007; Oakley et al., 2008) advocate informed patient choice, this is not consistently available in practice. Another emerging theme was the consolation taken by patients that their injury could be ‘more serious or permanent’, they ‘feel lucky really’ (when compared to a colleague with a broken back) and ‘never forget it could be worse’ (Patient UK, 2008). Dewar and Lee (2000) have described this way of coping as ‘boosting’ where patients boost their self-esteem by comparing their situation with others. It has been suggested previously that many factors combine to determine the eventual effect of disease or injury on the individual such as social, environmental and personal factors (Dekkers and Søballe, 2004). The patient’s story and illness narratives, therefore, add to the depth and breadth of available knowledge both for individual patients and for nursing as a profession that is concerned with holistic care.
M. Williams
Methods Since nurses holistically care for patients, nursing research requires an approach which encompasses the whole human experience (Polit and Hungler, 1995). Qualitative methods, and particularly phenomenology which explores the ‘integrated whole’, are well suited to this approach (Speziale and Carpenter, 2007). Interpretive phenomenological analysis (IPA) was chosen as a guide for analysis of the data in this study. IPA combines elements of descriptive and interpretive phenomenology. Although the aim is to describe the participant’s experiences, this is done through the interpretive work of the researcher in creating themes from the data collected (Quinn and Clare, 2008). Although IPA is not intended to be prescriptive and is enriched by the individual researcher’s interpretive process (Smith et al., 1999), the stages described in Fig. 1 were used as a guide to enable the analytical process to take shape. The quality of the analysis will be improved by repeatedly returning to the text to check emerging themes (Quinn and Clare, 2008). This iterative process results in ‘layers of analysis’ and involves reflexivity as the researcher acknowledges their own influence on the data (Carter, 2004). The process of analysis is cyclical and moves from contextualised original data to data reduced to a form where conceptualisation and theory building can occur (Carter, 2004). Smith et al. (1999) describe an idiographic process where the researcher starts by analysing one transcript and then works up to include the other transcripts and culminates in the development of over-arching themes. The concept analyses and theory generation that can result from this process add to the transferability of the study. A purposive sampling strategy was used (Speziale and Carpenter, 2007). This study sample comprised the first four subjects who fulfilled the inclusion criteria and were willing to be interviewed who presented to the researcher in the Stages of IPA Analysis (from Quinn and Clare 2008 pp 378-380) 1 Reading the transcript 2 Making margin notes 3 Summary list of margin notes 4 Grouping of margin notes into thematic areas 5 Left margin codes 6 Full listing of theme summaries 7 Grouping of theme summaries 8 Recoding transcripts with overall themes 9 Final list of themes with extracts 10 Writing up the findings
Fig. 1 Stages of IPA analysis (from Quinn and Clare (2008, pp. 378–380)).
The patient’s experience in a plaster cast plaster room of a Welsh district general hospital in June and July of 2008. The inclusion criteria were that the participant should have received plaster cast treatment of a lower limb injury for at least 4 weeks, be over 18 years of age, treated as an out-patient with no surgical intervention and previously fully mobile. The exclusion criteria were: being admitted to hospital for surgery, a pre-existing wound under the plaster, previous use of walking aids or wheelchair and mental incapacity. Permission for the study was gained from the University Research Review and Ethics Screening Committee, the Trust Research Scrutiny Committee and the Independent Research Ethics Committee. Participants were recruited who had finished their plaster treatment in order to reduce bias as participants who require further treatment might withhold pertinent information in a ‘desire to please’ the researcher (Polit and Beck, 2006). Although it is important to the researcher to find common patterns in the data, this must not be achieved at the expense of acquiring each individual’s unique story (Holloway and Wheeler, 2002). To this end, participants were encouraged to talk about what was important to them while in a plaster cast by asking a general question ‘What was your experience of living with a plaster cast?’ Interviews were tape-recorded and transcribed verbatim as soon as practicable, including indications of pauses, emotion and any particular emphasis given to specific subjects by the participants. These are all included so that the transcript reflects the interview as accurately as possible (Morse and Field, 1996).
Results During data analysis seven main themes emerged which are shown with their associated sub-themes in Table 1. The sub-themes reflect the progression within IPA analysis from listing to grouping of theme summaries (Fig. 1). These themes reflect the participants’ own words in order to keep the analysis as close to their original stories as possible; different participants are indicated with the pseudonyms Frank, Alan, Kate and June. Underlined words reflect particular emphasis given by the participants. ‘Making it better’ describes circumstances that helped participants cope with life in a plaster cast. Alan, who lived with his wife, describes the support he had from his wife, despite her own health problems: She’s absolutely brilliant, you know, because she’s not the strongest of girls, she only
135 Table 1
Main themes and sub-themes.
Theme
Sub-themes
Theme 1: making it better
I just came home It made a difference They held my hand Same attitude? How do they cope? Better than I am You find it difficult It was a mission Hard going Just the little things Why me? Sitting round all day Sorry for myself Asking for help On my feet Relieved when the plaster came off Didn’t know where to put my leg Still swollen Painful In all my years Do the job I managed I had no choice Got through it
Theme 2: different circumstances Theme 3: hard work
Theme 4: it gets you down
Theme 5: back to normal Theme 6: pain
Theme 7: getting through it
weighs about seven stone. But, no complaints, she did wonders. While discussing things which had made a difference to their individual experience, participants were also keen to describe situations where they may not have coped so well. This is shown in theme 2, ‘different circumstances’. Here the participants made social comparisons, mainly with people who they would consider to be ‘worse off’ than themselves. Kate reflected on those people who need to be in a plaster cast for a long period of time: I think if it had been any longer than 6 weeks, like I know some people do, I don’t know how they cope. I think if it had been any longer than 6 weeks, I would have lost the will to live, I would have gone insane. Despite various favourable circumstances and, as Kate says ‘I know, and everyone knows that’s not the worst thing in the world’, all four participants described some times when the experience was simply ‘hard work’ (theme 3). Frank vividly describes the complexities of trying to have a cup of coffee and a sandwich:
136 you can make a cup of coffee by standing on your crutches or whatever in the kitchen, but you can’t get your coffee somewhere where you can drink it! I found that I was walking round with a sandwich stuck between my teeth, trying to get back to the lounge. All the participants had times when they felt ‘down’ (theme 4). Alan, who lives in a first floor maisonette, was unable to get out of his home once the ambulance men had taken him there: very fed up . . . because all I could really do, all the time I had the plaster on, was to get up from the chair, very gingerly, and look out the window . . .. And you’d see the youngsters running around, people laying out there sunbathing . . ., and I’m stuck in here. He goes on to say that it was not a big problem but that (I) felt more sorry for myself than probably should’ve done. And ‘why me?’ type of thing. These times which ‘got them down’ were tempered by the fact that there would be an end to the experience and this is expressed in theme 5, ‘back to normal’. Since interviews were conducted a few days after removal of the plaster casts, the participants could describe how they felt once the cast came off: I was just so relieved, so very relieved when the plaster came off. just the fact that I could put my foot down and walk properly . . . just to be able to walk, to get back to work. (Kate) The theme of pain was common to the three older participants. None of them had been in a plaster cast before and they considered it to be very different from previous illness experiences: then they put me in plaster, and I wouldn’t wish that on my worst enemy, it is the most uncomfortable thing that I think I have ever experienced. (Alan) I’d never had a plaster in my life, never experienced anything like that. (June) These topics of pain, discomfort and swelling were frequently discussed along with the various coping mechanisms discussed in themes 1 and 2 and the suggestion that it was something that had to be put up with in order to achieve the desired result: this is explored in theme 7. Three of the participants talked about resigning themselves to a period of time in plaster:
M. Williams if that’s what you got to do, that’s what you got to do. (Alan)
Discussion A number of themes and issues raised by the participants could be identified in the existing literature. Participants expressed frustration and embarrassment at having to ask others to help them. The extent to which this is necessary in different injuries and treatments could be quantified in future work by using the Enforced Social Dependency Scale, as described by Morris (2000). In their seminal work, Lazarus and Folkman (1984) suggest that an individual’s ability to cope in various situations may well be far greater than they expect. All the participants, in quite varied circumstances, found ways of coping with their immobility by using strategies such as ‘boosting’ (Dewar and Lee, 2000) and accepting help from others. The theme ‘hard work’ describes similar issues to those identified by Helm and Dickerson (1995) in their theme ‘just the everyday things’. Here, their participant described her frustration at being unable to do what she considered to be the simple things in life such as brushing her children’s hair. She also found it difficult to allow others to do those things that she considered to be her role as a mother and wife. Two participants spoke of their need for more information to improve the experience in a plaster cast. This was also a common theme in the online material from Patient UK (2008); these patients frequently recounted conflicting information from different health professionals which resulted in possibly unnecessary confusion and stress. As the data analysis progressed, the relationship of the emerging themes to the Roper, Logan and Tierney model of living became apparent (Roper et al., 1996).
The Roper, Logan and Tierney model This model consists of five inter-related concepts: activities of living, life span, the dependence/independence continuum, factors influencing the ALs and individuality in living (Roper et al., 1996). The ALs will be familiar to many since they have been widely adopted for use in patient care plans. The other four concepts which complete the model may not be so widely known. It would be difficult to write about each part of the model in isolation as a problem which affects
The patient’s experience in a plaster cast one aspect of living will often affect others; a view which Roper et al. (1996) anticipated. Therefore, as the various aspects of the model were considered in relation to the study’s findings, other interlinked concepts were highlighted. The first AL is ‘maintaining a safe environment’, which is reflected in the theme ‘hard work’. Using crutches or a walking frame to keep body weight off the injured limb can mean that what would normally constitute a safe environment for an individual becomes unsafe (such as rugs on the floor). Kate described having to ‘crawl up (the stairs) on my knees and my hands like a kid’ in order to be safe. It can be seen immediately that this one issue that also impacts on the AL of ‘elimination’ as it will take longer than usual to reach the toilet. Kate’s reference to ‘like a kid’, one that she repeats again in the interview, points us to the lifespan element of the model because her injury has made her more child-like. ‘Communicating’ as an AL was not directly affected for these participants but problems could potentially arise for patients with a cast on their arm who might use their arms and hands to communicate. For example, users of sign language or those who communicate regularly via electronic media. ‘Breathing’ was affected for Alan who has asthma. He described how using the walking frame ‘was taking up all my breathing’. This problem was addressed by him and his wife when they rented a wheelchair, expressed in the theme ‘making it better’. This highlights that assessment of mobility needs cannot be limited to assessing the injury. ‘Eating and drinking’ featured in the theme ‘hard work’. Activities, such as having a cup of coffee, required forward planning and ingenuity. For Frank, his usual position on the independence/ dependence continuum of the Roper–Logan–Tierney model was altered because he was unable to sit at the dining table to eat his meals: I didn’t get up to the main meal table. I had one of those little tables that you slide in, you know? ‘Elimination’ was potentially affected by at least two factors; increased time and physical effort to get to the toilet and the effects of reduced exercise on the elimination functions of the body, such as constipation (Rutishauser, 1994). In the theme ‘hard work’, participants described the forward-planning required to get to the toilet. The AL of ‘personal cleansing and dressing’ was affected in a number of ways for these participants. Obviously, they were unable to wash or
137 attend to the skin underneath their casts and this was evident in Kate’s account where she describes her leg as ‘minging’ when the cast came off (indicated in theme 5 ‘back to normal’). Showering and bathing is also a problem even if a waterproof cover is available because of problems trying to balance on one leg or if the shower is too small for a seat or a plastic chair. Alan’s account of changing his usual routine of showering every other day to showering every fourth day gives an indication of the extra effort, help and forward-planning required to perform this activity. This contributed to the theme ‘getting through it’. None of these participants related problems with actually dressing. This may be because their casts were on their legs and dressing becomes more of an issue with an arm in plaster. Beaule ´ et al. (2000) and MacDermid et al. (2003) both show difficulties in dressing activities such as doing up buttons and tying shoe laces for patients with distal radius fractures. Problems with ‘controlling body temperature’ were not obvious in the transcripts from this research. The potential for loosing heat due to lack of movement or rapidly increasing body temperature during moving with crutches or a walking frame are both possible. The AL of ‘mobilising’ is probably the one most frequently associated with a fracture, particularly of the lower limb, as the individual will have problems moving from one place to another; this in turn impacts on other aspects within the Roper, Logan and Tierney model: ‘eating and drinking’, ‘elimination’, ‘breathing’, the ‘independence/dependence continuum’, ‘lifespan’ and ‘maintaining a safe environment’ (Roper et al., 1996). The accounts gathered from these participants all give indications of how problems with mobility have affected many other areas of their lives, as suggested in the themes ‘hard work’, ‘it gets you down’ and ‘getting through it’. In the themes ‘different circumstances’, ‘back to normal’ and ‘getting through it’ there is an indication of how important being able to continue with ‘normal’ work and social activities was for the participants. The AL ‘work and play’ reflects this in the Roper, Logan and Tierney (1996) model. The effects are manifested in different ways for different individuals. For example, Frank was glad to be able to go to work: where I could do my, I won’t say my job, but, part of my job, and be worthwhile. June, also was determined to continue to do what she considered to be her work:
138 I could do my own washing, my cooking, my cleaning, I could manage everything with the plaster on, but I was that much slower. Expressing sexuality has many facets and aspects can be affected by illness or injury (Roper et al., 2000). Personal dressing and grooming are related to this AL as how we dress reflects our sexual identity (Roper et al., 2000). Relationships between couples can also be affected by reduced mobility as the usual patterns of dependence on one- another may be altered. Problems with sleeping were mentioned by June and Alan – getting in a comfortable position to sleep was one issue, along with pain or discomfort preventing sleep. Alterations in daily routine and depression can also affect sleep patterns (Roper et al., 2000). June displayed a classic symptom of depression when she describes, in the theme ‘it gets you down’, waking early in the morning (Douglas, 2002). Although none of the participants in this study displayed problems that related to the AL of dying, it is important for nurses to be aware of this important aspect of living. Occasionally, patients receiving treatment for fractures will have been involved in major trauma where they or others have been critically ill or even died. Similarly, the feeling of isolation for someone recently bereaved could be exacerbated by the enforced immobility that life in a plaster cast can bring. ‘Lifespan’ is the second concept of the Roper, Logan and Tierney model used to reflect the inevitable progress of an individual from birth to death (Roper et al., 2000). Kate and Frank would be seen to be in the adulthood stage where work and family are the important focus. Both these participants were affected by being unable to work as normal and having to rely on others to help them in activities where they were used to independence. This contributed to the theme ‘it gets you down’. June and Alan would probably be perceived as being in the ‘old age’ stage, where increasing illhealth often affects ALs. In Alan’s case we see his chronic asthma making the use of walking aids more difficult than for a healthy adult. For June, her husband’s ill-health gave her increased concerns as she needed to be available to assist with his needs as well as her own. The ‘dependence/independence continuum’ is closely linked to lifespan. In infancy, the baby is totally dependent on others. As the child grows, independence increases and is encouraged through to adulthood where most people will be completely independent in addressing ALs (Roper et al., 2000). It can be distressing for an adult to accept
M. Williams help with ALs following illness or injury, particularly those of a personal nature (Dekkers and Søballe, 2004). As the individual moves into the ‘old age’ end of the continuum, dependence in various ALs will increase. An appreciation of those factors which can affect the ALs helps nurses to asses for, plan, implement and evaluate individualised nursing care. These factors are described under five headings by Roper et al. (1996). These headings are: biological, psychosocial, sociocultural, environmental and politico-economic factors. An awareness of biological factors would have been useful in Alan’s case. His chronic asthma meant that the usual provision of crutches or walking frame was not adequate. Alan rented a wheelchair so that he could move around without becoming breathless. Psychosocial factors which may influence the individual’s ability to perform the ALs include forms of depression, which was alluded to by some participants. There are also potential problems with individuals who are emotionally immature, poorly educated or unable to express themselves adequately (Roper et al., 2000). Children and vulnerable adults were excluded from this particular study but the importance of accurate assessment of these individuals when being placed in a plaster cast should not be underestimated. Sociocultural influences include religious and societal factors. Kate experienced the effects of society’s expectations of a 25 year old woman when she wanted to use an electric wheelchair in the supermarket. Firstly, the shop assistant was reluctant because Kate was not ‘old’ and secondly, Kate noticed how people treated a ‘disabled person’: You know you feel quite strange because people do look at you, they look at you so much differently. The main environmental factor relevant for these participants was the built environment, in particular their homes. The presence of stairs, the location of the bathroom and toilet all played a major part in these individuals’ experiences. Environment has an important part to play in the individual’s experience of the out-patient department. The noise from the oscillating cast saw can be distressing (Prior, 1997; Harness, 2006) and patients should be prepared for this in advance. The use of a cast saw can also be avoided by the use of new materials and progressive techniques (Wierzimok, 1996). The accessibility of the clinic is also crucial along with suitable seating.
The patient’s experience in a plaster cast Politico-economic factors affecting the ALs were discussed at length by one participant, Frank, who is concerned that aids which made his life tolerable in a cast may be out of reach of some patients. In particular, he discusses the use of waterproof covers for showering, which have to be purchased by the individual, and the fact that he had a stair-lift and plenty of space in his house. Another participant was able to make use of a hired wheelchair. Individuality in living results from a combination of all the elements previously discussed: ALs, lifespan, independence/dependence continuum and influencing factors. For example, religious beliefs can influence ALs such as personal cleansing and dressing or eating and drinking; these then contribute to the individuality in living for that person.
A model for orthopaedic nursing Davis (1997) describes a model for orthopaedic nursing which is based on the problem-solving approach of Roper et al. (1996) but also incorporates Parse’s view of health and illness (Sarter, 1992) and an ‘ethos of self-empowerment’ (Davis, 1997, p. 46). These concepts are combined in a model with mobilising as its central concept. Mobilising in this context refers broadly to physical mobility including upper limb, rather than the restrictive use of mobility to refer solely to walking. The effects of reduced physical mobility on social or psychological aspects of an individual’s life can then be assessed alongside the effects of reduced mobility on other aspects of the original model such as the ALs. Davis (1997) adds to this a self-empowerment framework. This framework relies as much on the attitudes and beliefs of the nurse and the nursing profession as on the individual. Davis (1997), therefore, includes a list of beliefs that will lead to selfempowerment. This list includes ‘every individual is unique, valuable and worthy of respect’ through to ‘everyone has something to teach and something to learn’ (Davis, 1997, p. 45). Petty and Wardman (1998) discovered how empowerment was important for their clients during their RCT. They realised that a change of attitude among the staff was required to move from a traditional role of knowing what was best for the patients to a new role which involved patients in the decision-making process so that ultimately the patient took responsibility for using removable casts appropriately.
139
Conclusions This study sought to describe the patient’s experience in a plaster cast. The participants’ journeys from injury to removal of the plaster cast can be seen in terms of a balancing act; on the one side are factors which could potentially be seen as stressors (Lazarus and Folkman, 1984); identified in themes of ‘pain’, ‘hard work’ and ‘it gets you down’. On the other side are the various coping mechanisms that the participants used; seen in ‘making it better’, ‘different circumstances’, ‘back to normal’ and ‘getting through it’. All the participants managed to balance the negative factors with positive actions or thoughts. There may be circumstances where this delicate balance is altered and these occasions need to be recognised in practice. Being in a plaster cast can be seen as a frustrating, often painful experience. The experience is made bearable by seeing it as a means to an end with a time limit; making social comparisons to other groups and support received from others. The ability to see the role of the nurse in this process is vital. Nurses and orthopaedic practitioners have essential roles to play as trained specialists in casting techniques alongside holistic patient assessment. Since we may only have a very short time to interact with these patients in the out-patient setting, the quality and usefulness of that interaction is paramount. An awareness of potential problems for the patient will aid accurate patient assessment. As Davis (1997) suggests, compromised physical mobility will affect other aspects of the Roper, Logan and Tierney (1996) model. Addressing the issues from a self-empowerment perspective enables us to promote the beliefs in ourselves and others which will lead to self-empowerment and its eventual benefits (Davis, 1997). This study has identified some of the problems that this group of patients faces. Now that the problems have begun to be identified, there is scope for quantitative research to attempt to measure the extent of the problems among a larger population (Closs and Cheater, 1999). The Enforced Social Dependency Scale used by Morris (2000) is just one example of a measurement tool that could be considered for further research in this population. Embracing the concepts of individualised assessment and care, self-empowerment and evidencebased practice are just some of the challenges faced by nurses in all settings and specifically, as indicated in this study, nurses in the fracture clinic.
140 The provision of detailed information for patients in a cast could address some of the issues raised by these participants. Information related to how they may feel when they return home, how being in a cast may affect various aspects of their life and how to access additional help and advice would be a useful addition to the usual cast care and emergency contact details provided. As a result of this research, a clearer picture has emerged of what information may be of use to patients in coping with life in a plaster cast. Systems of individualised holistic assessment, grounded in theory and reflecting a departmental philosophy need to be developed locally in order to reach these objectives. Models such as the Roper, Logan and Tierney model (1996) or the Davis (1997) model provide bases from which to develop a model suitable for the situation. During this research, the focus has been on the patients’ priorities in this particular situation. It has been interesting to consider their thoughts in relation to the common perceptions of staff within the fracture clinic. These results can now be used alongside other forms of evidence by the multidisciplinary team to ensure that we provide the best available care for our patients.
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The patient’s experience in a plaster cast Marion Williams RGN, MSc, Cert Ed, Ortho Tech Cert (Clinical Practitioner) * Royal Gwent Hospital, Cardiff Road, Newport, Gwent NP20 2UB, United Kingdom
KEYWORDS
Summary Plaster casts have been used to treat fractures for over 150 years. This qualitative research describes this experience from the patient’s point of view. The aims of the study were to describe patients’ experiences in a below knee cast, establishing common themes and determining how the themes identified could inform nursing practice. A purposive sampling strategy was used; selecting participants who had been in a lower limb cast for at least 4 weeks, were over 18 years of age, treated as an outpatient and previously mobile. Data were collected using unstructured interviews which were recorded and transcribed. Individual manuscripts were analysed using interpretive phenomenological analysis. Common themes were identified and related to the literature. Seven main themes were identified: ‘hard work’ illustrated how difficult everyday tasks became; ‘it gets you down’ described how the participants began to feel frustrated and sorry for them selves; ‘different circumstances’ showed how participants put their situation in context in order to cope. Other themes were: ‘making it better’, ‘back to normal’, ‘pain’ and ‘getting through it’. The data were further explored in relation to the Roper, Logan and Tierney’s (1996) model for nursing and Davis’ (1997) adaptation, illustrating how the five main elements of the model inter-related so that difficulties in one dimension affected the others. c 2010 Elsevier Ltd. All rights reserved.
Plaster; Experience; Phenomenology; Roper
Editor’s comments The sheer volume of casts applied in any orthopaedic department can lead us to forget the impact a cast can have on the daily lives of those who have to live with them – often for several months. This patient-orientated study acts as a timely reminder that patients with casts need information and support in coping with the often sudden and significant impact the cast and its implications can have on their ability to carry out activities they do not normally have to think about. JS
Introduction * Tel.: +1 633 234408. E-mail address: [email protected]
Research related to limb immobilisation using plaster casts has strong and weak points. Research
1878-1241/$ - see front matter c 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2010.03.007
The patient’s experience in a plaster cast relating to the effectiveness of new products and methods in terms of fracture stability or wound healing are fairly easy to find. However, references to the patient’s experience of this process beyond comfort and length of treatment are limited. Anecdotal evidence has suggested that being in a plaster cast is, at best, frustrating and, at worst, a disabling and life-changing experience. In an attempt to hear the patient’s story, a smallscale phenomenological study was undertaken because, as McKenna (2004) explains: in order to care for patients in particular circumstances, it is essential to understand what life is like for them; what is their lived experience?
133
Plaster of Paris has been used to immobilise fractures and treat orthopaedic conditions since 1850 when it was first used in the Dutch army (Large, 2001). Nowadays, there are a variety of alternative materials such as resin impregnated bandages, ready-made orthoses and external fixators. An essential element of fracture healing is to maintain the bony alignment of the fracture in order to promote healing and enable maximum function of the limb once the fracture has healed. In many fractures bony alignment can be effectively maintained using a plaster cast (McRae and Kinninmonth, 2002).
using an air-stirrup brace rather than a cast. The long-term results were no different in the two groups but an earlier return to activity and the ability to remove and reapply a brace may be appealing during the treatment period. Wykes et al. (2003) demonstrated that the benefits for the patient and health providers in terms of an earlier return to work and normal function off-set the initially high cost of a pneumatic brace. Petty and Wardman (1998) compared a focused rigidity casting technique (FRC) with traditional plaster of Paris or synthetic casting. This trial compared clinical and functional outcomes for patients in a variety of casts and considered overall costs. An emphasis was placed on performing activities of living (ALs) during treatment which were measured using the Bradford Criteria (Petty and Wardman, 1998), indicating that the patient’s journey is important as well as the final outcome of treatment. From reviewing these studies, it appears that the benefits of new casting techniques and functional stabilisation, whether by cast or splint, lie in the patient’s experience during treatment and early recovery rather than long-term clinical results. A growing picture emerged of a need to adapt treatment to suit individual patient needs as well as providing good clinical results. In order to address these needs, a deeper understanding of the patient’s experience in these situations is important.
Literature
Qualitative research
Quantitative research
Qualitative research is widely recognised as being able to provide in-depth accounts of the patient’s experience in a variety of circumstances. It can be used to evaluate effectiveness, appropriateness and quality in healthcare and as such is an important component of evidence-based practice within clinical governance (Gray, 2001). This type of research in nursing is interested in the patient journey; their experience of illness in all dimensions and therefore providing theoretical and practical knowledge to facilitate making decisions regarding care provision (Holloway and Freshwater, 2007). Qualitative research directly related to the patient in a plaster cast is not common but there are a few studies that may have transferability to this phenomenon. Griffiths and Jordan (1998) used patient diaries and semi-structured interviews to explore the experience of patients admitted to hospital for surgery following lower limb trauma. The use of patient diaries provided a longitudinal record
Background
Quantitative research has been used with good effect to compare different treatment methods and outcomes related to treatment of fractures or other trauma using plaster casts. Quantitative methods are well suited for comparing different treatments and producing numerical data (Parahoo, 2006). In a randomised controlled trial (RCT) comparing weight-bearing orthosis with non-weight-bearing plaster cast treatment for ruptured Achilles tendon, Costa et al. (2006) advocated careful patient allocation to either treatment with a weight-bearing orthosis or with a non-weight-bearing plaster cast. Using an orthosis requires the strict following of a treatment protocol and may encourage some patients to return to strenuous exercise too quickly. Enabling patient choice where possible is suggested by Beynnon et al. (2006) who showed an improvement in short-come outcomes when
134 which enabled exploration of the patient’s journey to recovery. As the data were analysed, the three main themes arising (stress and uncertainty, seeking control and returning to normal) were found to concur with the cognitive appraisal model of stress and coping (Lazarus and Folkman, 1984): this model was then used by Griffiths and Jordan (1998) as a theoretical framework for further analysis and discussion.
The patient’s story In addition to information obtained from formal research methods, including the broad spectrum of qualitative approaches, nurses can listen to the human experience described through various methods of story-telling. The emergence of the internet as a source of information has meant that access to certain patient’s stories is easily possible by looking at sites such as www.bbc.co.uk/health and www.patient.co.uk. Headland (2006) suggests that these stories are in the public domain, have been freely given and represent an unbiased account of illness and healthcare experiences. Exploration of these web-sites to seek patient stories relating to plaster casts or fractures revealed a substantial discussion area related to Achilles tendon rupture. One recurring theme from exploring these messages is a level of confusion, or dissatisfaction, with information given by doctors and, in particular, a lack of complete information to enable informed decision making. It can be seen, therefore, that while a number of researchers (Bone et al., 1997; Vioreanu et al., 2007; Oakley et al., 2008) advocate informed patient choice, this is not consistently available in practice. Another emerging theme was the consolation taken by patients that their injury could be ‘more serious or permanent’, they ‘feel lucky really’ (when compared to a colleague with a broken back) and ‘never forget it could be worse’ (Patient UK, 2008). Dewar and Lee (2000) have described this way of coping as ‘boosting’ where patients boost their self-esteem by comparing their situation with others. It has been suggested previously that many factors combine to determine the eventual effect of disease or injury on the individual such as social, environmental and personal factors (Dekkers and Søballe, 2004). The patient’s story and illness narratives, therefore, add to the depth and breadth of available knowledge both for individual patients and for nursing as a profession that is concerned with holistic care.
M. Williams
Methods Since nurses holistically care for patients, nursing research requires an approach which encompasses the whole human experience (Polit and Hungler, 1995). Qualitative methods, and particularly phenomenology which explores the ‘integrated whole’, are well suited to this approach (Speziale and Carpenter, 2007). Interpretive phenomenological analysis (IPA) was chosen as a guide for analysis of the data in this study. IPA combines elements of descriptive and interpretive phenomenology. Although the aim is to describe the participant’s experiences, this is done through the interpretive work of the researcher in creating themes from the data collected (Quinn and Clare, 2008). Although IPA is not intended to be prescriptive and is enriched by the individual researcher’s interpretive process (Smith et al., 1999), the stages described in Fig. 1 were used as a guide to enable the analytical process to take shape. The quality of the analysis will be improved by repeatedly returning to the text to check emerging themes (Quinn and Clare, 2008). This iterative process results in ‘layers of analysis’ and involves reflexivity as the researcher acknowledges their own influence on the data (Carter, 2004). The process of analysis is cyclical and moves from contextualised original data to data reduced to a form where conceptualisation and theory building can occur (Carter, 2004). Smith et al. (1999) describe an idiographic process where the researcher starts by analysing one transcript and then works up to include the other transcripts and culminates in the development of over-arching themes. The concept analyses and theory generation that can result from this process add to the transferability of the study. A purposive sampling strategy was used (Speziale and Carpenter, 2007). This study sample comprised the first four subjects who fulfilled the inclusion criteria and were willing to be interviewed who presented to the researcher in the Stages of IPA Analysis (from Quinn and Clare 2008 pp 378-380) 1 Reading the transcript 2 Making margin notes 3 Summary list of margin notes 4 Grouping of margin notes into thematic areas 5 Left margin codes 6 Full listing of theme summaries 7 Grouping of theme summaries 8 Recoding transcripts with overall themes 9 Final list of themes with extracts 10 Writing up the findings
Fig. 1 Stages of IPA analysis (from Quinn and Clare (2008, pp. 378–380)).
The patient’s experience in a plaster cast plaster room of a Welsh district general hospital in June and July of 2008. The inclusion criteria were that the participant should have received plaster cast treatment of a lower limb injury for at least 4 weeks, be over 18 years of age, treated as an out-patient with no surgical intervention and previously fully mobile. The exclusion criteria were: being admitted to hospital for surgery, a pre-existing wound under the plaster, previous use of walking aids or wheelchair and mental incapacity. Permission for the study was gained from the University Research Review and Ethics Screening Committee, the Trust Research Scrutiny Committee and the Independent Research Ethics Committee. Participants were recruited who had finished their plaster treatment in order to reduce bias as participants who require further treatment might withhold pertinent information in a ‘desire to please’ the researcher (Polit and Beck, 2006). Although it is important to the researcher to find common patterns in the data, this must not be achieved at the expense of acquiring each individual’s unique story (Holloway and Wheeler, 2002). To this end, participants were encouraged to talk about what was important to them while in a plaster cast by asking a general question ‘What was your experience of living with a plaster cast?’ Interviews were tape-recorded and transcribed verbatim as soon as practicable, including indications of pauses, emotion and any particular emphasis given to specific subjects by the participants. These are all included so that the transcript reflects the interview as accurately as possible (Morse and Field, 1996).
Results During data analysis seven main themes emerged which are shown with their associated sub-themes in Table 1. The sub-themes reflect the progression within IPA analysis from listing to grouping of theme summaries (Fig. 1). These themes reflect the participants’ own words in order to keep the analysis as close to their original stories as possible; different participants are indicated with the pseudonyms Frank, Alan, Kate and June. Underlined words reflect particular emphasis given by the participants. ‘Making it better’ describes circumstances that helped participants cope with life in a plaster cast. Alan, who lived with his wife, describes the support he had from his wife, despite her own health problems: She’s absolutely brilliant, you know, because she’s not the strongest of girls, she only
135 Table 1
Main themes and sub-themes.
Theme
Sub-themes
Theme 1: making it better
I just came home It made a difference They held my hand Same attitude? How do they cope? Better than I am You find it difficult It was a mission Hard going Just the little things Why me? Sitting round all day Sorry for myself Asking for help On my feet Relieved when the plaster came off Didn’t know where to put my leg Still swollen Painful In all my years Do the job I managed I had no choice Got through it
Theme 2: different circumstances Theme 3: hard work
Theme 4: it gets you down
Theme 5: back to normal Theme 6: pain
Theme 7: getting through it
weighs about seven stone. But, no complaints, she did wonders. While discussing things which had made a difference to their individual experience, participants were also keen to describe situations where they may not have coped so well. This is shown in theme 2, ‘different circumstances’. Here the participants made social comparisons, mainly with people who they would consider to be ‘worse off’ than themselves. Kate reflected on those people who need to be in a plaster cast for a long period of time: I think if it had been any longer than 6 weeks, like I know some people do, I don’t know how they cope. I think if it had been any longer than 6 weeks, I would have lost the will to live, I would have gone insane. Despite various favourable circumstances and, as Kate says ‘I know, and everyone knows that’s not the worst thing in the world’, all four participants described some times when the experience was simply ‘hard work’ (theme 3). Frank vividly describes the complexities of trying to have a cup of coffee and a sandwich:
136 you can make a cup of coffee by standing on your crutches or whatever in the kitchen, but you can’t get your coffee somewhere where you can drink it! I found that I was walking round with a sandwich stuck between my teeth, trying to get back to the lounge. All the participants had times when they felt ‘down’ (theme 4). Alan, who lives in a first floor maisonette, was unable to get out of his home once the ambulance men had taken him there: very fed up . . . because all I could really do, all the time I had the plaster on, was to get up from the chair, very gingerly, and look out the window . . .. And you’d see the youngsters running around, people laying out there sunbathing . . ., and I’m stuck in here. He goes on to say that it was not a big problem but that (I) felt more sorry for myself than probably should’ve done. And ‘why me?’ type of thing. These times which ‘got them down’ were tempered by the fact that there would be an end to the experience and this is expressed in theme 5, ‘back to normal’. Since interviews were conducted a few days after removal of the plaster casts, the participants could describe how they felt once the cast came off: I was just so relieved, so very relieved when the plaster came off. just the fact that I could put my foot down and walk properly . . . just to be able to walk, to get back to work. (Kate) The theme of pain was common to the three older participants. None of them had been in a plaster cast before and they considered it to be very different from previous illness experiences: then they put me in plaster, and I wouldn’t wish that on my worst enemy, it is the most uncomfortable thing that I think I have ever experienced. (Alan) I’d never had a plaster in my life, never experienced anything like that. (June) These topics of pain, discomfort and swelling were frequently discussed along with the various coping mechanisms discussed in themes 1 and 2 and the suggestion that it was something that had to be put up with in order to achieve the desired result: this is explored in theme 7. Three of the participants talked about resigning themselves to a period of time in plaster:
M. Williams if that’s what you got to do, that’s what you got to do. (Alan)
Discussion A number of themes and issues raised by the participants could be identified in the existing literature. Participants expressed frustration and embarrassment at having to ask others to help them. The extent to which this is necessary in different injuries and treatments could be quantified in future work by using the Enforced Social Dependency Scale, as described by Morris (2000). In their seminal work, Lazarus and Folkman (1984) suggest that an individual’s ability to cope in various situations may well be far greater than they expect. All the participants, in quite varied circumstances, found ways of coping with their immobility by using strategies such as ‘boosting’ (Dewar and Lee, 2000) and accepting help from others. The theme ‘hard work’ describes similar issues to those identified by Helm and Dickerson (1995) in their theme ‘just the everyday things’. Here, their participant described her frustration at being unable to do what she considered to be the simple things in life such as brushing her children’s hair. She also found it difficult to allow others to do those things that she considered to be her role as a mother and wife. Two participants spoke of their need for more information to improve the experience in a plaster cast. This was also a common theme in the online material from Patient UK (2008); these patients frequently recounted conflicting information from different health professionals which resulted in possibly unnecessary confusion and stress. As the data analysis progressed, the relationship of the emerging themes to the Roper, Logan and Tierney model of living became apparent (Roper et al., 1996).
The Roper, Logan and Tierney model This model consists of five inter-related concepts: activities of living, life span, the dependence/independence continuum, factors influencing the ALs and individuality in living (Roper et al., 1996). The ALs will be familiar to many since they have been widely adopted for use in patient care plans. The other four concepts which complete the model may not be so widely known. It would be difficult to write about each part of the model in isolation as a problem which affects
The patient’s experience in a plaster cast one aspect of living will often affect others; a view which Roper et al. (1996) anticipated. Therefore, as the various aspects of the model were considered in relation to the study’s findings, other interlinked concepts were highlighted. The first AL is ‘maintaining a safe environment’, which is reflected in the theme ‘hard work’. Using crutches or a walking frame to keep body weight off the injured limb can mean that what would normally constitute a safe environment for an individual becomes unsafe (such as rugs on the floor). Kate described having to ‘crawl up (the stairs) on my knees and my hands like a kid’ in order to be safe. It can be seen immediately that this one issue that also impacts on the AL of ‘elimination’ as it will take longer than usual to reach the toilet. Kate’s reference to ‘like a kid’, one that she repeats again in the interview, points us to the lifespan element of the model because her injury has made her more child-like. ‘Communicating’ as an AL was not directly affected for these participants but problems could potentially arise for patients with a cast on their arm who might use their arms and hands to communicate. For example, users of sign language or those who communicate regularly via electronic media. ‘Breathing’ was affected for Alan who has asthma. He described how using the walking frame ‘was taking up all my breathing’. This problem was addressed by him and his wife when they rented a wheelchair, expressed in the theme ‘making it better’. This highlights that assessment of mobility needs cannot be limited to assessing the injury. ‘Eating and drinking’ featured in the theme ‘hard work’. Activities, such as having a cup of coffee, required forward planning and ingenuity. For Frank, his usual position on the independence/ dependence continuum of the Roper–Logan–Tierney model was altered because he was unable to sit at the dining table to eat his meals: I didn’t get up to the main meal table. I had one of those little tables that you slide in, you know? ‘Elimination’ was potentially affected by at least two factors; increased time and physical effort to get to the toilet and the effects of reduced exercise on the elimination functions of the body, such as constipation (Rutishauser, 1994). In the theme ‘hard work’, participants described the forward-planning required to get to the toilet. The AL of ‘personal cleansing and dressing’ was affected in a number of ways for these participants. Obviously, they were unable to wash or
137 attend to the skin underneath their casts and this was evident in Kate’s account where she describes her leg as ‘minging’ when the cast came off (indicated in theme 5 ‘back to normal’). Showering and bathing is also a problem even if a waterproof cover is available because of problems trying to balance on one leg or if the shower is too small for a seat or a plastic chair. Alan’s account of changing his usual routine of showering every other day to showering every fourth day gives an indication of the extra effort, help and forward-planning required to perform this activity. This contributed to the theme ‘getting through it’. None of these participants related problems with actually dressing. This may be because their casts were on their legs and dressing becomes more of an issue with an arm in plaster. Beaule ´ et al. (2000) and MacDermid et al. (2003) both show difficulties in dressing activities such as doing up buttons and tying shoe laces for patients with distal radius fractures. Problems with ‘controlling body temperature’ were not obvious in the transcripts from this research. The potential for loosing heat due to lack of movement or rapidly increasing body temperature during moving with crutches or a walking frame are both possible. The AL of ‘mobilising’ is probably the one most frequently associated with a fracture, particularly of the lower limb, as the individual will have problems moving from one place to another; this in turn impacts on other aspects within the Roper, Logan and Tierney model: ‘eating and drinking’, ‘elimination’, ‘breathing’, the ‘independence/dependence continuum’, ‘lifespan’ and ‘maintaining a safe environment’ (Roper et al., 1996). The accounts gathered from these participants all give indications of how problems with mobility have affected many other areas of their lives, as suggested in the themes ‘hard work’, ‘it gets you down’ and ‘getting through it’. In the themes ‘different circumstances’, ‘back to normal’ and ‘getting through it’ there is an indication of how important being able to continue with ‘normal’ work and social activities was for the participants. The AL ‘work and play’ reflects this in the Roper, Logan and Tierney (1996) model. The effects are manifested in different ways for different individuals. For example, Frank was glad to be able to go to work: where I could do my, I won’t say my job, but, part of my job, and be worthwhile. June, also was determined to continue to do what she considered to be her work:
138 I could do my own washing, my cooking, my cleaning, I could manage everything with the plaster on, but I was that much slower. Expressing sexuality has many facets and aspects can be affected by illness or injury (Roper et al., 2000). Personal dressing and grooming are related to this AL as how we dress reflects our sexual identity (Roper et al., 2000). Relationships between couples can also be affected by reduced mobility as the usual patterns of dependence on one- another may be altered. Problems with sleeping were mentioned by June and Alan – getting in a comfortable position to sleep was one issue, along with pain or discomfort preventing sleep. Alterations in daily routine and depression can also affect sleep patterns (Roper et al., 2000). June displayed a classic symptom of depression when she describes, in the theme ‘it gets you down’, waking early in the morning (Douglas, 2002). Although none of the participants in this study displayed problems that related to the AL of dying, it is important for nurses to be aware of this important aspect of living. Occasionally, patients receiving treatment for fractures will have been involved in major trauma where they or others have been critically ill or even died. Similarly, the feeling of isolation for someone recently bereaved could be exacerbated by the enforced immobility that life in a plaster cast can bring. ‘Lifespan’ is the second concept of the Roper, Logan and Tierney model used to reflect the inevitable progress of an individual from birth to death (Roper et al., 2000). Kate and Frank would be seen to be in the adulthood stage where work and family are the important focus. Both these participants were affected by being unable to work as normal and having to rely on others to help them in activities where they were used to independence. This contributed to the theme ‘it gets you down’. June and Alan would probably be perceived as being in the ‘old age’ stage, where increasing illhealth often affects ALs. In Alan’s case we see his chronic asthma making the use of walking aids more difficult than for a healthy adult. For June, her husband’s ill-health gave her increased concerns as she needed to be available to assist with his needs as well as her own. The ‘dependence/independence continuum’ is closely linked to lifespan. In infancy, the baby is totally dependent on others. As the child grows, independence increases and is encouraged through to adulthood where most people will be completely independent in addressing ALs (Roper et al., 2000). It can be distressing for an adult to accept
M. Williams help with ALs following illness or injury, particularly those of a personal nature (Dekkers and Søballe, 2004). As the individual moves into the ‘old age’ end of the continuum, dependence in various ALs will increase. An appreciation of those factors which can affect the ALs helps nurses to asses for, plan, implement and evaluate individualised nursing care. These factors are described under five headings by Roper et al. (1996). These headings are: biological, psychosocial, sociocultural, environmental and politico-economic factors. An awareness of biological factors would have been useful in Alan’s case. His chronic asthma meant that the usual provision of crutches or walking frame was not adequate. Alan rented a wheelchair so that he could move around without becoming breathless. Psychosocial factors which may influence the individual’s ability to perform the ALs include forms of depression, which was alluded to by some participants. There are also potential problems with individuals who are emotionally immature, poorly educated or unable to express themselves adequately (Roper et al., 2000). Children and vulnerable adults were excluded from this particular study but the importance of accurate assessment of these individuals when being placed in a plaster cast should not be underestimated. Sociocultural influences include religious and societal factors. Kate experienced the effects of society’s expectations of a 25 year old woman when she wanted to use an electric wheelchair in the supermarket. Firstly, the shop assistant was reluctant because Kate was not ‘old’ and secondly, Kate noticed how people treated a ‘disabled person’: You know you feel quite strange because people do look at you, they look at you so much differently. The main environmental factor relevant for these participants was the built environment, in particular their homes. The presence of stairs, the location of the bathroom and toilet all played a major part in these individuals’ experiences. Environment has an important part to play in the individual’s experience of the out-patient department. The noise from the oscillating cast saw can be distressing (Prior, 1997; Harness, 2006) and patients should be prepared for this in advance. The use of a cast saw can also be avoided by the use of new materials and progressive techniques (Wierzimok, 1996). The accessibility of the clinic is also crucial along with suitable seating.
The patient’s experience in a plaster cast Politico-economic factors affecting the ALs were discussed at length by one participant, Frank, who is concerned that aids which made his life tolerable in a cast may be out of reach of some patients. In particular, he discusses the use of waterproof covers for showering, which have to be purchased by the individual, and the fact that he had a stair-lift and plenty of space in his house. Another participant was able to make use of a hired wheelchair. Individuality in living results from a combination of all the elements previously discussed: ALs, lifespan, independence/dependence continuum and influencing factors. For example, religious beliefs can influence ALs such as personal cleansing and dressing or eating and drinking; these then contribute to the individuality in living for that person.
A model for orthopaedic nursing Davis (1997) describes a model for orthopaedic nursing which is based on the problem-solving approach of Roper et al. (1996) but also incorporates Parse’s view of health and illness (Sarter, 1992) and an ‘ethos of self-empowerment’ (Davis, 1997, p. 46). These concepts are combined in a model with mobilising as its central concept. Mobilising in this context refers broadly to physical mobility including upper limb, rather than the restrictive use of mobility to refer solely to walking. The effects of reduced physical mobility on social or psychological aspects of an individual’s life can then be assessed alongside the effects of reduced mobility on other aspects of the original model such as the ALs. Davis (1997) adds to this a self-empowerment framework. This framework relies as much on the attitudes and beliefs of the nurse and the nursing profession as on the individual. Davis (1997), therefore, includes a list of beliefs that will lead to selfempowerment. This list includes ‘every individual is unique, valuable and worthy of respect’ through to ‘everyone has something to teach and something to learn’ (Davis, 1997, p. 45). Petty and Wardman (1998) discovered how empowerment was important for their clients during their RCT. They realised that a change of attitude among the staff was required to move from a traditional role of knowing what was best for the patients to a new role which involved patients in the decision-making process so that ultimately the patient took responsibility for using removable casts appropriately.
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Conclusions This study sought to describe the patient’s experience in a plaster cast. The participants’ journeys from injury to removal of the plaster cast can be seen in terms of a balancing act; on the one side are factors which could potentially be seen as stressors (Lazarus and Folkman, 1984); identified in themes of ‘pain’, ‘hard work’ and ‘it gets you down’. On the other side are the various coping mechanisms that the participants used; seen in ‘making it better’, ‘different circumstances’, ‘back to normal’ and ‘getting through it’. All the participants managed to balance the negative factors with positive actions or thoughts. There may be circumstances where this delicate balance is altered and these occasions need to be recognised in practice. Being in a plaster cast can be seen as a frustrating, often painful experience. The experience is made bearable by seeing it as a means to an end with a time limit; making social comparisons to other groups and support received from others. The ability to see the role of the nurse in this process is vital. Nurses and orthopaedic practitioners have essential roles to play as trained specialists in casting techniques alongside holistic patient assessment. Since we may only have a very short time to interact with these patients in the out-patient setting, the quality and usefulness of that interaction is paramount. An awareness of potential problems for the patient will aid accurate patient assessment. As Davis (1997) suggests, compromised physical mobility will affect other aspects of the Roper, Logan and Tierney (1996) model. Addressing the issues from a self-empowerment perspective enables us to promote the beliefs in ourselves and others which will lead to self-empowerment and its eventual benefits (Davis, 1997). This study has identified some of the problems that this group of patients faces. Now that the problems have begun to be identified, there is scope for quantitative research to attempt to measure the extent of the problems among a larger population (Closs and Cheater, 1999). The Enforced Social Dependency Scale used by Morris (2000) is just one example of a measurement tool that could be considered for further research in this population. Embracing the concepts of individualised assessment and care, self-empowerment and evidencebased practice are just some of the challenges faced by nurses in all settings and specifically, as indicated in this study, nurses in the fracture clinic.
140 The provision of detailed information for patients in a cast could address some of the issues raised by these participants. Information related to how they may feel when they return home, how being in a cast may affect various aspects of their life and how to access additional help and advice would be a useful addition to the usual cast care and emergency contact details provided. As a result of this research, a clearer picture has emerged of what information may be of use to patients in coping with life in a plaster cast. Systems of individualised holistic assessment, grounded in theory and reflecting a departmental philosophy need to be developed locally in order to reach these objectives. Models such as the Roper, Logan and Tierney model (1996) or the Davis (1997) model provide bases from which to develop a model suitable for the situation. During this research, the focus has been on the patients’ priorities in this particular situation. It has been interesting to consider their thoughts in relation to the common perceptions of staff within the fracture clinic. These results can now be used alongside other forms of evidence by the multidisciplinary team to ensure that we provide the best available care for our patients.
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