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Title: The Social Organization of Wound Clinic Work: An Institutional Ethnography
Author: Waters, Nicola Ruth
Advisor: Rankin, Janet
Keywords: Nursing
Abstract: The care of wounds (broadly defined as any break in the surface of the skin) is considered a foundational component of nursing knowledge. Whilst most wounds resolve with minimal intervention, today’s aging population and rise in chronic disease have seen a rapid escalation in the number of people living with wounds that are challenging to heal. Nurses have played an integral part in initiatives to address the identified burden of chronic wounds. Efforts centred on developing evidence-based protocols intended to simplify selection of new wound-related technologies expected to improve clinical outcomes. In contrast to these expectations, anecdotal evidence, a limited number of published critiques and a recent focus in the literature on patient “wellbeing” suggest that wound care may be a contested place of nursing practice. This research interrogates the discourse of “advanced wound care” that presupposes wound healing as a linear, predictable event dependent on objective, quantifiable outcome measures. It troubles standardized approaches to wound care that require nurses to focus on physical characteristics of wounds rather than patients’ experience of living with a wound. Developed as an institutional ethnography, the study provided a way to articulate tensions that arise for nurses working in outpatient wound clinics. My analysis began in descriptions of everyday wound work. By empirically tracing links embedded in the textual records clinic nurses complete I explicate how biophysiological models organize nurses to practice as though wounds can be abstracted from the individuals living with them. This problem is amplified when translated into the algorithmic decision-making tools of an integrated health system wherein patients are managed as cases, referred to others for intervention, and provided with information to self-manage their care. I show how, as clinic nurses participate in the ruling relations of case management, their consciousness of what wound care is and how they are able to respond to their patients has been organized in line with managerial priorities. These findings call into question the foundations on which today’s wound care knowledge is built and open up for future dialogue and research the work of nurses and others committed to the care of people with chronic wounds.
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