Fabricius Hildanus first described for the clinical characteristics of pressure sores in 1593 (Defloor, 1999). Pressure sores be defined as “lesions on any skin surface that occur from unrelieved pressure and result in damage to underlying tissue” (Schultz 1999 pg 434). The factors, which influence pressure sores, can be split in to intrinsic and extrinsic factors. Intrinsic factors include nutritional status, mobility, and vascular status.
Extrinsic factors include pressure, moisture, friction and shearing (Thoroddsen, 1999). Pressures sore care/treatment has come along way in the last 20 years. There is a great deal of research, which has been done on the prevention of pressure sores. However the majority of this research is funded by company’s, which sell mattresses or creams therefore is probable that the research may have an element of bias.
Over the last 20 years numerous methods, which have been deemed ritualistic (unthinking) have been utilized to treat pressure sores. The methods have included using meths, oils, which according to Anthony (1987) cited in Walsh and Ford (1989) promotes breakdown of the skin by destroying normal flora therefore helping infection and skin necrosis. Other preventative measures that have also been used in the past also include talcum powder, creams and rubbing/massaging the skin for better circulation. These methods have not shown to reduce incidence of pressure sores and may have caused harm. The simplest way to prevent pressure sores is to remove the pressure. Exton-Smith (1987) conducted a study in a 100 at risk which patients were turned every 2 hours; the result was a reduction from a 19% incidence to a 4 % incidence of pressure sores.
This is study show’s a more evidence based/rational method than ritualistic method used in the past. However ritualistic practice is still seen in practice relating to pressure sore prevention as friction is a cause of pressure sores and even though it is not allowed draglifts that create friction are still being done with patients. As mentioned before the special mattresses are usually rippled and are believed to relieve the incidence of pressure sores.
However there are so many companies with different beds and each company says there bed is the best at preventing pressure sores that it is hard to know which is best. Exton-Smith (1987) indicates that these beds are only affective, if lying down. When a patient has been lying flat in practice I have observed 2 turning sheets with a blanket over the special mattress left under the patient this must reduce the preventative affect of the mattress. This ritualistic use of a turning sheet was a common occurrence.
If a pressure sore does develop then healing needs to commence. Walsh and Ford (1989) have found that pressure sores are often treated differently from other wounds, however if they were treated the same care would be more rationale. In the past piped oxygen and egg whites have been used to heal pressure sores. Today a more rationale treatment is practiced. The state of the pressure sore would determine the treatment, which the tissue viability nurse would recommend.
Observations are another ritualistic time consuming practice, which persists. The frequency of which observations e.g. temperature, blood pressure, pulse, respiratory rate need’s to be taken into account to not be termed ritualistic or a waste of nurse’s time depends for each individual. Temperature is a normal part of the immune response. Therefore temperature is one of the signs/symptoms of the presence of infection. Patient’s temperatures may be taken anything from every 4 hours to twice a day. However it is believed that it is a waste of time to take the temperature of apyrexial patients more than once unless the nurse observes other signs.
Samples et al (1983) studied 107 patients by monitoring their temperature over a 24hour period. They found that temperature has a natural cycle which peaks around 18.00 and so concluding that it would be enough to record temp at 18.00 only unless illness was suspected. However Biley (1997) states that having the ritual of temperature being taken despite no pathological reason for the action perhaps might result in greater feelings of empowerment and so enhance self-healing.
Additionally often when blood pressure is taken it is ritualistically taken as definitively correct event though the choice of arm can affect blood pressure as seen in a study by Kristensen (1982) cited in Walsh and Ford (1989) indicated that in 197 men and women 49% had differences in systolic blood pressure of greater than 10mmHg and 29% had differences between diastolic blood pressure. Also the position of the arm can affect blood pressure Webb (1980) cited in Walsh and Ford (1989) found that small movement of the arm up or down from heart level can raise and lower blood pressure between 5-6mmHg. Like temperature, blood pressure is often carried out regularly, and may possibly be a waste of nurse’s time.
Regarding the taking of the pulse a ritual that often happen is the taking of the pulse for 15 seconds then multiplication by 4 to represent the pulse rate for sixty seconds. Respiratory rate is even more ritually neglected than pulse rate as it is usually not counted at all and the number 20 is automatically written down which is odd as the normal resting respiratory rate is between 12-18. Drug rounds are seen as ritualistic practice due to the fact that the drug round has been around for along time and does not tend to represent individualised patient centred care, as the nurse if often not familiar with the patient. The drug round is a task-orientated ritual. The sight of a nurse with a trolley of drugs is a common sight.
As well as the drugs left on the locker or table for the patient to take later. Also the nurse will ritually give patients their drugs with out explaining what they are and explaining the side effects. Furthermore nurses may not be familiar with the patients for whom they are giving drugs therefore it is not patient centred. In addition the drug round does not leave the nurse room to monitor a patient for side effects.
Anthropology (the study of the human race, its culture and society and its physical development) can assist nursing in understanding the reasons and functions of ritual (Strange, 2001). Anthropologist’s perspective on ritual is that it is “those aspects of prescribed and repetitive formal behaviour which have no direct technological consequences and which are symbolic” (Philipin, 2002, pg 148).
Anthropologist and nursing literature also suggest that one of the purposes of ritual is the protection from anxiety for example drawing on ritual in situations where control is lacking. Another purpose more in anthropological literature is that ritual serves to maintain social order via reinforcing cultural and social structure. Both of these purposes are interrelated as protection from anxiety is achieved through the maintenance, of imposition of social order.
Most of the research and literature on this topic is quite old for example Walsh and Ford’s (1989) classic text, which all articles on the topic quote. Also the research on the topic is very limited. However there is a vast amount of knowledge in the articles/books what do exist. Although due to them being old there is uncertainty on what information contained within is out of date and still valid. The majority of research within the topic chosen reflects practice which is unscientific/unthinking in practice so hopefully it will reflect areas of nursing practice, which needs more research, to improve care practices.
My experience with the topic ritualistic care/practice on placement was regarding care of the elderly. Ritualistic care that I observed was with incontinence pads, which were put on patients even though many patients did not need them. Other ritualistic aspect of care that I noticed was regarding meal times, which were very rushed and very chore like. Drug rounds patients did not know what drugs they had and what they were for, rather they knew the colour of the pills. Also on many occasion I observed heals and buttocks being rubbed for circulation, this must cause friction and friction is a known cause of pressure sores. Also bed times were also ritualualised as everybody was woken up and dressed and washed before breakfast and around 6.00pm staff began to be put patients to bed.
The general consensus on ritualistic care in practice is that there is a lot of practices that are not evidence-based and therefore irrational/ritualistic. However even though there are numerous articles reproving of ritual practice are seen repeatedly ritualistic practice still persists (Strange 2001). This is most likely due to the numerous obstacles put before evidence-based practice. The obstacles that stop evidence based learning are the ones, which help ritualistic practice persist. The best/only way for ritualistic practice to become evidence-based is by making research/evidence based practice the new ritual.
Agarwel, A. et al. (1989) Fluid Deprivation Before Operation – The Effect of a Small Drink. Anaesthesia. Volume 44 No 8. 632-634.
Anthony, D. (1987) Are you in the dark? Nursing Times. Volume 83 No 34 pp 25 – 30.
Biley, F. Wright, S. (1997) Towards a Defence of Nursing Routine and Ritual. Journal of Clinical Nursing. Volume 6. pp 115 – 119.
Chapman, A (1996) current theory and Practice: a study of pre-operative fasting. Nursing Standard. Volume 10 No18. pp 33 – 36.