Formation of subjective frames on palliative wound care by wound care nurses
This study conducted a factor analysis for the data collected in the study, leading to the formation of four Q-factors. The explanatory power of each Q-factor was 28% for Q-factor I, 18% for Q-factor II, 15% for Q-factor III, and 8% for Q-factor IV, cumulatively explaining 70% of the total variance. Furthermore, the P-samples for each type were 13, 8, 10, and 9 participants, respectively, and the eigenvalues for each type were 11.34, 7.37, 6.09, and 3.23, respectively. Q-methodology is designed to identify types, but not to understand the proportional distribution of each type. In Q-methodology, a Q-factor could sufficiently be explained with 4-5 participants in each Q-factor and that Q-factors with an eigenvalue of 1.0 or higher are statistically significant with explanatory power [17]. As the Q-factors identified in this study each had more than 5 participants and the eigenvalues of each Q-factor were higher than 1.0, the Q-factors were considered significant.
As shown in Table 2, the P-sample characteristics of each Q-factor were generally evenly distributed. The participant with the highest factor loading values for each Q-factor can be considered as the participant who is representative of that Q-factor, demonstrating its most typical characteristics.
Table 2
Characteristics for the P-sample
Q-factor
|
Ⅰ (n=13)
|
Ⅱ (n=8)
|
Ⅲ (n=10)
|
Ⅳ (n=9)
|
Age (years)
|
31.38±3.07
|
31.63±1.85
|
37.40±4.33
|
37.11±2.26
|
Gender (n)
|
Female
|
13
|
8
|
10
|
9
|
Male
|
0
|
0
|
0
|
0
|
Education (n)
|
BSN
|
7
|
3
|
0
|
0
|
MSN
|
6
|
5
|
7
|
8
|
Doctorate
|
0
|
0
|
3
|
1
|
RN experience (years)
|
6.92±3.09
|
7.25±2.05
|
13.20±4.21
|
12.44±2.51
|
WCN experience (years)
|
1.15±1.28
|
3.88±1.13
|
7.90±2.13
|
7.78±2.77
|
Abbreviations: BSN, bachelor’s degree in nursing; MSN, master’s degree in nursing; RN, Registered nurse; WCN, wound care nurse |
Analysis of subjective frames on palliative wound care by wound care nurses
The four subjective frames on palliative wound care by wound care nurses are as follows: “Focusing on care within the boundary of current patient demands,” “Comparing continuously the priorities on wound healing and disease care,” “Preparing and preventing from worsening via tracking care in advance,” and “Moving forward with a clear direction by confronting the declining condition.”
Q-factor Ⅰ: Focusing on care within the boundary of current patient demands
Q-factor I included the P-samples of 13 participants; Q-statements with which this group strongly agreed were 4(+4), 5(+4), 6(+3), and 10(+3), and the Q-statements with which this group strongly disagreed were 3(-4), 7(-4), 24(-3), and 31(-3) (Table 1). This Q-factor type does not include the belief that any two patients are the same; while patients may have the problem of wounds in common, the nurses consider that the Q-factors influencing the wounds all differ and take a therapeutic approach that considers the conditions and feedback of individual patients. Furthermore, as the purpose of palliative wound care is patient well-being, this type places the foremost priorities on patient demands and convenience and on ensuring that the patients are comfortable. At the same time, they do not consider standardized knowledge, such as guidelines and recommendations, as important. This suggests that rather than focusing on such formulas, they concentrate on the treatment of inconveniences felt by the patient and that their approach to palliative wound care is centered on the alleviation of symptoms rather than on the treatment of wounds.
The reasons that participant 25, who had the highest Q-factor weightings in this type, chose the cards of strongest agreement and disagreement are as follows:
When managing pain throughout symptom management, I rearrange schedules if the patient tells me that they cannot do it on that day due to too much pain, even if (new) dressings were scheduled for that day. If there is anything that the patient asks for, telling me, ‘This is what I find comfortable,’ I try to do as the patient says as much as possible, even if it really does not make sense.
Q-factor Ⅱ: Comparing continuously the priorities on wound healing and disease care
Q-factor II included the P-samples of 8 participants; the Q-statement with which this group strongly agreed with was 18(+3), and the Q-statements with which this group strongly disagreed with were 31(-4) and 33(-3) (Table 1). This type considered the systemic conditions of the body to be an important component in wound care and sought methods of wound care depending on the body’s conditions. However, they also demonstrated avoidance of the situation, as they felt guilty that they were unable to actively engage in wound care since patients at the end of their lives faced a declining ability to heal wounds. This type found interactions with patients difficult, whether it was disappointing the patients when directly explaining their circumstances or giving them hope by talking to the patients positively. Furthermore, they tended to engage in wound care in accordance with the patients’ body conditions.
The reasons that participant 8, who had the highest factor weightings among this type, chose the cards of strongest agreement and disagreement are as follows:
There are times when what we think and what the caregivers and the patients think differ. The patients and caregivers tend to focus on wounds that are visible on the surface when their internals are becoming even more ruined. Even if the pressure injury is treated actively, the patients will not recover if their body conditions do not improve. Curing the pressure injury is not what is important right now. I think that the best method for wound care is to monitor the patient’s body conditions and tailor the treatment methods to the monitoring results.
Q-factor Ⅲ: Preparing and preventing from worsening via tracking care in advance
Q-factor III included the P-samples of 10 participants; the Q-statements with which this group strongly agreed with were 12(+3) and 13(+3), and the Q-statements with which they strongly disagreed with were 21(-3) and 32(-3) (Table 1). This type seeks to identify in advance factors or problems that may affect wound care for patients as they reach the end of their lives. They place importance on cooperation and the exchange of opinions, not only between patients and caregivers, but also with various healthcare personnel, such as nutrition teams and home nurses. Therefore, this type tends to have an open attitude towards patients, caregivers, and other healthcare personnel, shares opinions with them, and attempts to resolve issues that may arise in the future.
The reasons that participant 1, who had the highest factor weightings among this type, chose the cards of strongest agreement and disagreement are as follows:
When it comes to palliative wounds, reevaluations are necessary when pathological situations of patients change—sometimes retrying chemotherapy, changing the types of drugs, and more. Wounds are impacted by these changes in medical conditions, and it is necessary to have multidisciplinary communication about the patient. It is also necessary to consider nutrition and home care that will later become problematic at the patient’s end of life and helping the patients to adapt to them early on. Therefore, I believe our role is to use diverse resources to actively assess, intervene, and connect with the patient.
Q-factor Ⅳ: Moving forward with a clear direction by confronting the declining condition
Q-factor IV included the P-samples of 8 participants; the Q-statements with which this group strongly agreed with were 3(+4), 24(+4), 22(+3), and 31(+3), and the Q-statements with which they strongly disagreed with were 27(-4), and 7(-3) (Table 1). This type believes in the proper treatment of palliative wounds based on clear guideline for wound care. Therefore, they also believe that patients should be fully aware of their conditions. To ensure clear and efficient judgment regarding wound treatment, wound care nurses believe that they should provide proper guidance since they possess the most knowledge, especially compared to patients or caregivers who may be emotional.
The reasons that participant 27, who had the highest factor weightings among this type, chose the cards of strongest agreement and disagreement are as follows:
I tell the patients from the beginning rather than lying or evading details about their progress. I think that psychological well-being involves difficulties and resistance until patients can face their condition and accept it, but once patients accept it, patients are able to see it directly and be prepared, so I think we should be firm with the patients. It is very important to accurately describe the current condition of the patient and to give the options of various wound care methods. Wound care nurses should do their best to give wounds a chance to heal with expert knowledge.