Journal of Orthopaedic Nursing (2004) 8, 151–159

Journal ofOrthopaedic Nursing

www.elsevierhealth.com/journals/joon

Using a patient narrative to influenceorthopaedic nursing care in fractured hipsq

Emma Pownall, RN (Staff Nurse)*

King’s Mill Hospital, 32 Fisher Lane, Mansfield Notts, Nottinghamshire NG18 2SB, UK

Summary This study critically appraises a patient narrative reflecting on aspectsof care delivery and debating potential improvements in contemporary practice.Patient narrative enquiry, a qualitative approach, was utilised in this study in aneffort to understand further the nature of personal experience. The narrative wasacquired as part of a routine nursing evaluation and helped to illuminate nursingcare issues through the eyes of the patient.

�c 2004 Elsevier Ltd. All rights reserved.

KEYWORDSPatient narrative;Hip fracture;Orthopaedic nursing;Practice improvement

Editor’s commentThis study is powerful in that it explores nursing care issues raised by the patient and not the health care professional. Oftenpatients have different priorities in care than nurses. The approach is derived from a developing field of qualitative researchloosely referred to as ‘patient narrative’ but in this study no formal research is carried out as all the information gathered was aspart of the routine nursing evaluation of care through questioning that nurses do not always have time to complete. PD

Introduction

Frank (1994) states that patient narratives providethe truth of personal experience in the patient’sown voice in distinction from the medical accountof the experience. Hawkins (1993) maintained thatthe popularity of illness narratives, or pathologies,is a reaction to our contemporary medical model,one so dominated by a biophysical understanding ofillness that its experiential aspects are virtuallyignored. Narrative representations of illness andhealing provide powerful means for communicatingand giving meaning to experience (Mattingly and

qThis study was completed as part of a post-registrationorthopaedic pathway degree programme at the University ofNotingham.

* Tel.: +44-1623-458671.E-mail address: emma.pownall1@ntlworld.com.

1361-3111/$ - see front matter �c 2004 Elsevier Ltd. All rights reserdoi:10.1016/j.joon.2004.06.009

Garro, 1994). All pathologies share a common mo-tive; the individual’s need to communicate apainful, disorientating and isolating experience.Thus making sense of the experience by bindingtogether the events, feelings, thoughts and sensa-tions that occur during an illness into an integratedwhole (Hawkins, 1993).

Sakalys (2000) suggests that it is critical to notethat illness is experienced in relation to a partic-ular configuration of cultural ideologies, practicesand attitudes. Patient narratives expose this cul-tural configuration, demonstrating how culturaland social meaning shape the illness experienceand the identity of the sick, illuminating conflictbetween patient and health care cultures, andexpressing cultural and political critique. Narra-tives are a practical reminder that ethical andcompetent practice requires knowledge of the lit-erature as well as the life (Chinn, 1994).

ved.

152 E. Pownall

The patient

For the purpose of this patient narrative, a 60-year-old lady has been chosen and to maintain confi-dentiality the patient will be referred to as Ann.Ann originally presented to the accident andemergency department following a simple falldown a step at home. She fell on to her right side.On admission she was experiencing pain in her rightgroin area, pain associated with hip fracture isgenerally severe and located directly over the hipregion (Delee, 1991). She was unable to weightbear following the fall; her right leg was shortenedand externally rotated with reduced range ofmovement. Physical examination of patients withhip fracture often reveals shortening and externalrotation of the affected limb. However, if the in-jury is intracapsular, these findings may be absent(Geiderman, 1996).

Ann lived alone in a ground floor flat and had twochildren one of whom lived close by. Prior to ad-mission she was fully independent.

On admission to A&E an intravenous cannulawas inserted and bloods obtained these includedfull blood count, urea and electrolytes, glucoseand cross-match. An ECG was also performed. Anintravenous infusion of normal saline was com-menced. Fluid and electrolyte management inelderly patients should be monitored regularly,and should begin in A&E to avoid dehydration(Scottish Intercollegiate Guidelines Network,2002). A fluid balance chart was commenced onthe ward.

A X-ray was performed to aid diagnosis, radio-graphic examination is mandatory and must includeboth anteroposterior and lateral radiographs of theproximal femur (Unwin and Jones, 1995). FollowingX-ray a diagnosis of intracapsular fracture to theright neck of femur was made. An intracapsularfracture can cut off blood supply to the femoralhead completely, leading to aseptic necrosis, non-union, or both. Because the fracture line is insidethe capsule, blood is contained within it. This rai-ses the intracapsular pressure and damages thefemoral head further. It also prevents visiblebruising because blood cannot reach the subcuta-neous tissues (Dandy and Edwards, 1998).

Ann was chosen for this study because of theincreasingly high incidence of fractured neck offemurs (Audit Commission, 1995), and hip fracturesare one of the leading causes of morbidity andmortality among the elderly (Lappe, 1998).Therefore by recognising the factors that have hadan impact on Ann’s hospitalisation it might improvethe care of future patients.

Narrative

Ann’s care was evaluated prior to discharge fromthe acute trauma and orthopaedic ward. She wasasked to reflect on her experiences and percep-tions of her care and health problems.

A list of questions provided a structured ap-proach but these were not rigidly adhered to, thusallowing the patient to lead the content and di-rection of the interview. The patient was informedthat confidentiality would be maintained at alltimes and information used only to promote andimprove practice. The list of structured questionswere:

• What did you feel about requiring hospitalisa-tion?

• What were the good aspects of your hospitalisa-tion?

• What were the bad aspects of your hospitalisa-tion?

• What do you feel could be improved?

Below are some of the patient comments:

• I couldn’t understand why I had to wait so long inA&E, they had done the X-ray, it was broken theX-ray person told me that. So why did I have towait?

• The pain was unbearable; I didn’t care what hap-pened or what was said I just wanted to get ridof the pain.

• The staff were so kind, they couldn’t do enoughfor me.

• Initially I couldn’t understand why they (thestaff) wanted to keep checking my bottom, Iwas comfortable why keep moving me?

• It was terrible to be kept nil by mouth the firstday, I didn’t feel like eating but I really wanteda drink.

• It was such a disappointment to be told my op-eration was cancelled; I just wanted to befixed.

• When I came back from theatre I really needed adrink, but I couldn’t reach my glass. I didn’twant to bother the staff they looked so busy.

• It was a relief to come back from theatre and beable to press a button and get pain relief, but itwas taken away the next day when the physio-therapist came. So I had to keep asking for painkillers.

• The staff are so busy no-one has time to sit andexplain things to you.

• I could hear the nurse explaining the operationto my son, but what about me I needed to know.

Using a patient narrative to influence orthopaedic nursing care in fracture hips 153153

• It was frightening to wake up from the operationand see that I was having a blood transfusion,no-one said that I might need a transfusion. Itmakes you feel something has gone horriblywrong.

• I couldn’t believe it when they wanted to mobi-lise me the day after my operation, even my sonwas shocked to see me out of bed.

Commentary

Lack of explanation and communication on thenurses’ part was apparent throughout the inter-view. Communicating effectively is essential tonursing practice. Good communication skills un-derpin the processes involved in assessment, careplanning and the development of a therapeuticrelationship between the nurse and patient (Ar-nold, 1999; Ryan, 1999). Arnold (1999) suggeststhat therapeutic conversation will give an oppor-tunity for the exploration of emotions and feelings,to talk about problems and find solutions. Ortho-paedics is a speciality in which the effectiveness ofcommunication can have a considerable impact onpatients’ experiences of healthcare (Edwards,2003). Throughout the interview there was no in-dication that a therapeutic relationship had notbeen established, although there appeared to belack of explanation and not enough time spent withthe patient.

Another aspect highlighted in the interview wasthat of pain and pain management.

The key to good management of pain resides in asound understanding of the principles of pain andpain management (McCaffery et al., 1994; Field,1996). A review by McQuay et al. (1997) supportsthe view that both doctors and nurses need im-proved pain management abilities.

Ann initially received analgesia in the A&Edepartment, but she did not receive any furtheranalgesia until she arrived in the trauma assess-ment unit at least 2 h later. During this time shewas moved from a trolley to a bed, and she wasturned to check her pressure areas. Ideally Annshould have been given analgesia prior to trans-fer. Ann may have appeared comfortable whilstat rest, but pain assessment should also occur onmovement. In a study by Feldt and Oh (2000)pain report with movement was significantlyhigher when compared with pain at rest. Thismay hold serious implications, as hospitalisedpatients are often resting quietly when assessedfor pain.

Nurses need to ask pain questions and watch fornonverbal pain-related behaviours during transfersor patient care activities (Feldt et al., 1998), as theeffective assessment of pain is a fundamental partof nursing care (Lawler, 1997).

Post-operative pain management was also anaspect emphasised by Ann.

Effective post-operative pain control is of cru-cial importance in the course of a patient’s hos-pital stay. Adequate pain control allows for earlyambulation, facilitating transition to a lower levelof care, and preventing post-operative pulmonaryand neurovascular complications (Nussenveig,1999).

On return from theatre Ann had intravenouspatient controlled analgesia via a cannula into herright ante cubital fossa. The use of opiate infusionsis advocated, as it is known that the analgesic ef-fect of administering these drugs via this routegives a rapid and predictable result (Coniam andDiamond, 1994).

Patient controlled analgesia (PCA) has become apopular method of postoperative analgesia sincethe The Royal College of Surgeons (1990) publisheda report entitled ‘Pain after Surgery’. PCA allowsthe patient to self-administer small doses of opi-oid, usually via an intravenous infusion (Chumleyet al., 2002). Patients do not have to wait for an-algesia or convince nursing staff they need painrelief, which may result in suboptimal pain man-agement, due to lack of time, staff shortages andincreased workload (Schafheutle et al., 2001). Ifpatients gain a sense of control over their pain,they usually have fewer postoperative complica-tions, mobilise quicker and are able to rest andsleep more easily (Heath, 1995). Peat (1995) ad-vocates that many patients have demonstratedthat less opiate medication is required when theyare allowed to control it themselves.

However, Ann did not have a background infu-sion on her PCA. Studies have shown that patientsatisfaction has been diminished when there is nobackground infusion in the PCA. This is becausetherapeutic levels fall overnight when the patientis asleep, allowing breakthrough pain to occur(Nendick, 2000). Pain medication should be givenand its effects monitored to ensure that the pa-tient does not endure ‘breakthrough’ pain, whenpain becomes unacceptable despite being on reg-ular analgesia. A disadvantage of PCA is that it mayrestrict movement, thus it is advantageous on theday of surgery, but it may restrict movement oncemobilisation is commenced. In practice the phys-iotherapist will often request that the patient becommenced on oral analgesia so that mobilisationcan occur.

154 E. Pownall

Ann also commented on the amount of timespent in A&E. In A&E Ann was nursed on a trolleyfor 3 h. However, occasionally fractured neck offemur patients are ‘fast tracked’ to the ward. Ryanet al. (1996) indicate that evidence on pressurecare suggests that fast tracking is a good standardof clinical care. Patients should be transferred tothe ward within 2 h of their arrival in A&E (ScottishIntercollegiate Guidelines Network, 2002). Al-though in contrast the Department of Health (2000)states that by 2004 no-one should be waiting morethan 4 h in A&E from arrival to admission, transferor discharge. In an attempt to prevent this fromoccurring a trauma assessment unit has been es-tablished. Suspected fractured necks of femurs arefast tracked to the unit.

Ann also highlighted the amount of time waitingfor theatre and the fact that she was cancelled.Ann was eventually taken to theatre approximately30 h after admission, Scottish IntercollegiateGuidelines Network (2002) indicates that patientsshould be operated on as soon as possible prefer-ably within 24 h, if their condition allows. As wellas causing distress to the patient, delay in opera-tive fixation is associated with increased morbidityand mortality, and with reduced chance of suc-cessful internal fixation and rehabilitation. In a 5-year retrospective study, fractured hip patientswhose surgery was delayed greater than 72 h had asignificant decrease in survival when compared tothose whose surgical fixation was done earlier(Rogers et al., 1995). Timing of surgery may affectthe rate of postoperative complications, functionalrecovery and independence, and length of hospitalstay (Orosz et al., 2002). Hefley et al. (1996) sug-gest that early surgery (within 24 h) reduces therisk of deep vein thrombosis and Perez et al. (1995)suggest that it also reduces the risk of fatal pul-monary embolism. Delay in surgery may also leadto an increased incidence of pressure damage(Bredahl et al., 1992).

Ann also mentioned lack of understanding of whystaff checked her pressure areas. Ann was nursedon a trolley in the A&E department, currently thereare no pressure relieving mattresses available inthe department. One of the problems created byreduced mobility is the risk of impaired skin in-tegrity, the potential or actual disruption of skinlayers resulting in a pressure sore (Davis, 1994).Ann’s pressure areas were checked on transfer thenon each shift, since neither a patient’s generalcondition, nor risk status is static, reassessment isnecessary on a regular basis (Land, 1995; Deeley,1997). Explanation should have been given as pa-tient education is described as a prevention strat-egy to avoid the formation of pressure sores

(Deeley, 1997). Ann would then be self-empow-ered, empowerment occurs by promoting health(Davis, 1997).

Ann also commented on being kept nil by mouthand that she was unable to reach her drink. Porterand Johnson (1998) state that in the treatment ofhip fracture patients they should have a good nu-tritional status and only have short periods offasting, as elderly patients with hip fracture areoften malnourished on admission (Scottish Inter-collegiate Guidelines Network, 2002). Watson andRinomhota (2002) indicate that pre-operativefasting times are too long and have more to do withtraditional practice than research evidence.

On admission Ann was of average body weight,her nutritional score was assessed. Avenell andHandoll (2002) suggest that postoperative careshould include nutritional support. PostoperativelyAnn’s appetite was reduced and due to the timingof surgery she spent some time without food. Hernutritional score worsened postoperatively there-fore she was referred to the dietician, because asLappe (1998) states nutritional status can impacthealth outcomes, poor nutrition can lead to mentalapathy, muscle wasting and weakness, impairedcardiac function and lowered immunity toinfection.

One important aspect of prevention of hipfractures is calcium nutrition. Adequate calciumnutrition is essential for the development andmaintenance of a normal skeleton (Lappe, 1998).There is abundant evidence that increasing dietarycalcium intake decreases bone loss and preventsfracture (Heaney, 1993). The best source of cal-cium is a well-balanced diet. The richest sources ofcalcium are dairy foods such as milk, yoghurt andcheese (Lappe, 1998). Individuals can also obtainadded calcium by adding powered milk to foods,such as pudding and gravy (Lappe, 1998). Heaney(1993) further suggests that high amounts of die-tary sodium cause loss of calcium in the urine andincreases one’s risk of osteoporosis.

Low protein appears to have a distinct detri-mental effect on the causes and complications ofhip fracture. Low protein intake is associated withlower bone mass in the hip, poor physical perfor-mance and hip fracture itself (Geinoz et al., 1993).Studies indicate that the clinical outcome after hipfracture is significantly improved with the use ofdaily oral nutritional supplements, such as Ensure,that normalise protein intake (Delmi et al., 1990).Scottish Intercollegiate Guidelines Network (2002)suggest that supplementing the diet of hip fracturepatients in rehabilitation with high-energy proteinpreparations containing minerals and vitaminsshould be considered. Protein supplementation

Using a patient narrative to influence orthopaedic nursing care in fracture hips 155155

also reduces further bone loss in elderly patientswho have sustained a hip fracture (Tkatch et al.,1992).

Although vitamin D is necessary for healthybones, many people have low levels of serumvitamin D (Lips et al., 1996). This deficiency isdue to a combination of factors such as de-creased sun exposure and/or use of sunscreen, alow synthesis of vitamin D in ageing skin, and alow dietary intake. Vitamin D deficiency is espe-cially prevalent in institutionalised persons(Lappe, 1998). Sources of vitamin D include milk,egg yolk, liver and fish liver oils (Lappe, 1998).Another important source of vitamin D is sunexposure. Ten to 15 min/day of hand/face ex-posure is adequate (Lappe, 1998).

Ann was advised by the dietician to increase herdairy product intake with milk, yoghurts andcheese. She was encouraged to drink milk insteadof tea and coffee. She was also advised to reduceher salt intake. ‘Ensure’ protein drinks were alsoprescribed twice daily. Her nutritional intake wasthen monitored daily on a nutritional intake chart.Patients’ food intake should be monitored regu-larly, to ensure sufficient dietary intake (ScottishIntercollegiate Guidelines Network, 2002).

Preoperatively Ann was prescribed intravenousfluids as she was nil by mouth from admission,patients should have clinical and laboratory as-sessment of possible hypovolaemia and electrolyteimbalance, and deficiencies appropriately andpromptly corrected (Scottish IntercollegiateGuidelines Network, 2002).

Electrolyte imbalances, particularly hyponatra-emia and hypokalaemia, are common in the post-operative period (Incalzi et al., 1993). Ann was alsoprescribed intravenous fluids for the postoperativeperiod, these were to continue until the results ofher day one postoperative blood results wereavailable.

Ann commented on her surprise on how early shewas mobilised. Footner (1992) describes that theaim of treatment is early ambulation to preventcomplications. Early mobilisation may preventcomplications such as pressure damage and deepvein thrombosis (March et al., 1999; Parker, 2000).Early mobilisation in combination with pre- andpostoperative physiotherapy may be of value inreducing pulmonary complications (McKenzie,1994). If the patient’s overall medical conditionallows, mobilisation and multidisciplinary rehabil-itation should begin within 24 post-operatively(Scottish Intercollegiate Guidelines Network,2002). Ann was mobilised at day one, her check X-ray was performed on return from theatre, a re-quirement of hospital policy.

Weight bearing on the injured leg, except forcement-less prostheses, should be allowed (Scot-tish Intercollegiate Guidelines Network, 2002). Annmobilised full weight bearing, she was initially re-luctant to weight bear on the right side. At day onetransfers were performed, but at day two shemobilised short distances with a rollator frame.Patients need to ambulate to the bathroom early intheir stay. This crucial skill will enable a patient toreturn home. Accomplishing this critical goalshould motivate the patient toward continuedprogress (Robinson, 1999).

Once mobilisation had been commenced thendischarge planning began. Early assessment bymedical and nursing staff, physiotherapist and oc-cupational therapist to formulate appropriatepreliminary rehabilitation plans has been shown tofacilitate rehabilitation and discharge (Parkeret al., 1991; O’Cathain, 1994). Premorbid mentalstate, mobility and function are the most reliablepredictors of the success of rehabilitation and canbe used as screening tools to assess a patient’searly rehabilitation needs and potential (Ensberget al., 1993; Heruti et al., 1999). Ann was assessedby the physiotherapists, occupational therapists toplan discharge home. However, because Ann livedalone it was felt that she would benefit from somefurther rehabilitation in an orthopaedic rehabili-tation ward. Jones et al. (2002) suggest that withsuch poor outcomes, it becomes apparent thatpatients with hip fracture require intensive reha-bilitation and care to ensure a return to the qualityof life that they experienced before the hip frac-ture. With increasingly shortened hospital stays,postoperative elders are often transferred to skil-led nursing facilities or rehabilitation settings tocomplete physical therapy (Feldt and Gunderson,2002).

The initial emphasis in rehabilitation should beon walking and activities of daily living, e.g.transferring, washing, dressing and toileting. Bal-ance and gait are essential components of mobilityand are useful predictors in the assessment offunctional independence (Ensberg et al., 1993; Foxet al., 1998).

Prior to transfer in preparation for dischargethe occupational therapist made a home visit. Herhome was assessed for environmental hazards andany necessary home modifications facilitated.Home modifications to reduce environmentalhazards are often included in the list of inter-ventions for prevention of falls among older peo-ple but their effectiveness is unproven (Cumminget al., 1999). However, home visits by occupa-tional therapists may lead to changes in behav-iour, which enable people to live more safely in

156 E. Pownall

both the home and external environment (Cum-ming et al., 1999).

Discussion

The patient narrative raised several points thatindicate the potential improvements in practiceand whilst these findings cannot be generalised toall patients receiving hip fracture treatment theyshould be considered as relevant to allpractitioners.

An area for potential improvement is that ofcommunication, there appears to be a lack of ex-planation and patient education. Communicationcould be improved by ensuring that all staff areeducated in communication skills, with regulartraining. Communication training and clinical su-pervision, for example, can provide the opportu-nities for nurses to practise, discuss and receivefeedback about personal communication styles.Nursing staff can then examine strengths andweaknesses of communication skills. Time man-agement could also be addressed to ensure thattime is utilised effectively. At times the stress of abusy shift can dictate the amount of time that isspent with a patient, so it is crucial to be able touse that time effectively.

Pain management could also be improved. It hasbeen suggested that pain assessment should nottake place during drug rounds and should be for-malised (Carr, 1997). However time is lacking andthe drug round provides good opportunity forquestioning (Carr, 1990). Schafheutle et al. (2001)imply that another possibility to relieve nurses ofsome of the responsibility they have for regularpain assessments would be to prescribe regularanalgesia rather than on a PRN basis, although theeffectiveness of such analgesic regimens would stillneed to be assessed. This might be beneficial tosome patients; but some patients do not alwaysrequire all the analgesia that is offered to them.Therefore it must be reiterated that analgesia canbe declined. Therefore all patients should haveregular analgesia prescribed as well as on a PRNbasis. Patient education is paramount in painmanagement. Increasing patient awarenessthrough education reduces overall length of stay(Messer, 1998).

Another way of relieving nurses of some of theresponsibility of pain assessment is patient in-volvement. They could record their own painscores, and possibly self-administer analgesia. Thisis partly achieved by the use of patient controlledanalgesia. Patients should be empowered with the

correct knowledge and allowed as much involve-ment in their pain management as they wish(Nendick, 2000). Patients need to be taught pre-operatively how to effectively control their painpostoperatively and to communicate their needs tostaff. Patient education is usually deliveredthrough bedside teaching or patient informationleaflets (Chumley et al., 2002).

Ann was given a brief explanation relating toPCA prior to theatre, she was also given a patientinformation leaflet. Although criticisms have beenlevelled at patient information leaflets (Kluger andOwen, 1990; Kluger and Owen, 1991) as the benefitof these leaflets written either by professionals ormanufacturers of the pumps, has not been studiedand their value to patients is unknown (Kluger andOwen, 1991). A method of improving the contentand design of these leaflets is to use focus groups assuggested by the King’s Fund (Coulter et al., 1998).In a study by Chumley et al. (2002) they achievedthis and were able to produce a leaflet in con-junction with patients that was clearer and moreinformative.

There is evidence that pre-operative informa-tion giving can reduce patients’ anxiety regardingsurgery. However, it might be better to providethis information before patients are admitted tohospital, as they are more likely to be able to takein information if they are not already feeling anx-ious, although this can only be applied to electivesurgery. To provide better patient care, membersof the peri-operative team should work together toprepare patients for the psychological and physicalconsequences of surgery (Hughes, 2002).

There also needs to be formal documentationfor the assessment of pain. The current pain as-sessment tool could be modified. Although the toolallows the patient to state the intensity of painusing a numerical scale, McCaffery et al. (1994)state that some patients are unable to use a nu-merical scale to rate their pain. They suggest that achoice of descriptive words would be useful suchas; no pain, a little pain, a lot of pain and too muchpain. The tool does not allow for re-evaluation, thepatients’ pain must be assessed regularly. Oncepain is assessed there is no indication for when thepatient should be assessed again. Evaluation is es-sential so that the effectiveness of the interventioncontinues or is modified, replaced or discontinued(Long et al., 1995).

It is essential that fractured neck of femur pa-tients are assessed promptly and transferred to theward. On admission to A&E all fractured neck offemur patients should be fast tracked to the trau-ma assessment unit or ward. To improve this ser-vice it could be done under the supervision of a

Using a patient narrative to influence orthopaedic nursing care in fracture hips 157157

specialist emergency nurse practitioner, specialistorthopaedic nurse or trauma coordinator.

It is standard protocol for A&E staff to obtainbloods, ECG and commence fluids. To reduce A&Ewaiting times these could be performed in thetrauma assessment unit, providing a fractured neckof femur has been confirmed by an X-ray. However,this is difficult if the patient is transferred straightto the ward due to lack of time and skills of theregistered nurse on duty. Within the trauma as-sessment unit, nurses are trained to perform all theabove activities.

Ann referred to feeling hungry and not under-standing why staff checked her bottom. Nutritionand pressure ulcers are identified as two of theeight crucial areas that are fundamental and es-sential aspects of nursing care in ‘Essence of Care’(Department of Health, 2001a). Both are areas inwhich a high standard of care has to be maintained.

Patients at high risk of developing pressure sorescan be identified using assessment tools (Water-low, 1998), to identify which factors may predis-pose the patient to pressure sore development.Cullum et al. (1996) doubt the validity of pressurerisk assessment tools and suggest that most as-sessment tools have been developed ad hoc; and itis unclear which scale is most accurate. They alsopoint out that there is little evidence that using apressure sore risk scale is either better than clinicaljudgement, or that it improves patient outcomes.

Scottish Intercollegiate Guidelines Network(2002) guidelines suggest that ‘at risk’ individualsshould not be placed on a standard foam mattress.Patients judged to be at very high risk should ide-ally be nursed on a large-cell, alternating-pressureair mattress or similar pressure-decreasing surface.Cullum et al. (1996) propose that although thesemattresses are more effective than foam and sili-cone-based surfaces in preventing and healingsores, their cost effectiveness is not proven.

The skin and underlying tissues are unlikely toremain healthy if the nutritional status is poor(Davis, 1994). Therefore a nutritional assessmenttool is also useful for identifying patients at risk ofunder-nutrition. Practice could be improved byimplementing a protocol relating to pre-operativefasting based on recent research and not tradi-tional methods.

Conclusion

This patient narrative has enabled the practitionerto reflect on and analyse some aspects raised bythe patient during interview.

Clinical Governance and evidence based prac-tice have been on the health agenda for some time.Patient narratives involve an aspect of quality as-surance and performance, clinical effectivenessand clinical audit. Therefore patient narratives canhelp assist in ‘improving the quality of health careservices and safe guarding standards of care byhelping to create an environment in which clinicalexcellence will flourish’ (Department of Health,1998).

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