Introduction
In this assignment the author will identify a situation from a clinical
placement where the author found there to be a gap between the current
practice and the best practice. The author will critically analyse the situation
to identify any quality improvement issues. The author will then explore how
best practice may be achieved, and explain and justify the proposed changes
to achieve the best practice.
Scenario
The situation to be discussed involved a busy general medical ward
where the author was a student nurse on placement. Whilst working on this
ward it became apparent to the author that there was a lack of hoists although
there was ample other moving and handling equipment. Due to this
equipment shortage many members of staff were manually lifting patients.
The key reason for this was that the only hoist was being shared between
three wards, (See appendix 1).
In order to critically analyse the situation in question the author used a
concept map, (See appendix 2), to bring out all the issues surrounding the
possible causes for the gap between the current practice and the best
practice. As shown by the concept map there were many possible areas
where there was a gap in practice, however, for the purpose of this
assignment the author will focus the discussion on the areas that she feels
were the most pertinent causes.
The author has chosen three issues for discussion, these are, the
quantity of moving and handling equipment, staff training and support, and the
importance of effective communication. It is felt that these issues were the
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greatest cause for the poor practice and that it is necessary to look into and
address these issues.
Quality health care
Nurses today are often the key to quality in the health care delivery
system; they hold an important role as the coordinators of care and often take
charge of quality issues, carrying out quality surveillance and monitoring. In
the health service quality is concerned with the effectiveness, efficiency, and
appropriateness of care, (Huber, 2000).
In the N.H.S. there is a strong need for continuous quality
improvement, this is the process by which the quality of care is improved by
continually gathering data on performance and using multidisciplinary teams
to analyse the system, collect measurements and propose changes, (Huber,
2000).
Quality improvement should be continually monitored to ensure
it is successful. Sliefert (1990) as cited in Huber (2000) developed a cycle for
monitoring quality improvement. The first step in the cycle is to establish
standards for which quality can be evaluated against, next methods to meet
the standards are identified. Using this information a tool is developed to
measure the existing practice. The data collected from following the first two
steps must then be analysed and interpreted, and any deficiencies that are
identified should be corrected, (Huber, 2000).
Audit and Clinical Governance
Audit has been described as ‘the measurement necessary to provide
practitioners with information on whether improvement is required’, (Norman
and Redfern, 1989) as cited by Goodwyn (1996). Audit has been around for
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many years but was mainly focused on medical care, more recently it has
expanded to include all health care professionals, (Cooper, 2004).
A recent government initiative called ‘A First Class Service: Quality in
the new NHS’ renewed the need for audit with the introduction of Clinical
Governance. Clinical Governance is defined as ‘a framework through which
NHS organisations are accountable for continuously improving the quality of
their services and safeguarding high standards of care by creating an
environment in which excellence in clinical care will flourish’, (Department of
Health, 1998).
One of the aims of clinical governance is to integrate the past
fragmented approaches to quality by using audit as a vital part of this process,
(Cooper, 2004).
Audit is usually described as a cycle of standard setting, current performance
measurement and comparison between current practice and set standards of
practice to identify the need for change and change implementation. It is then
necessary to complete the cycle again to see if the implemented changes are
being carried out and make a difference, (Kinn, 1995).
Audit allows the identification of key areas in practice where an
increase in knowledge and skills can help and enhance patient care, we need
to perform audit to ensure that our practice is of the standard we think it is,
(Swage, 2000).
However audit is not seen by all as useful, there is a large amount of
research taking place to evaluate audit and how useful the findings of audits
really are. From the ever increasing information on audit, guidelines have
been developed to increase the effectiveness of audit. However some people
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believe that it will never be known whether policies on clinical audit have been
effective or not and whether the money spent on these could have been better
spent else where. They feel audit will always be an act of faith; a product of
personal values, experience, professional loyalties and anecdotal evidence,
(Lord and Littlejohns, 1997).
In order to change nursing practice it is necessary to find out what and
how much (if any) change is needed. Audit is often undertaken as a locally
specific and patient focused activity, this means that topics for audit are
selected on the basis of the patient population and identified needs at a local
level. Audit should have explicit focus on patient care and where possible
should involve patients in the audit process, (Havey, 1996).
In the situation being discussed it would be necessary to carry out an
audit in order to ‘prove’ there was a gap between best practice and actual
practice. To do this it may be necessary to enlist the help of fellow staff
members or key handlers if there were any in the clinical area. The support of
a good nurse manager or leader would also be very beneficial.
Leadership and Change management
Leadership can be defined as the process of influencing people to
accomplish goals. Hersey, Blanchard and Johnson (1996) as cited by Huber
(2000) define leadership as the process of influencing the activities of
individuals or groups in an effort to achieve goals in any given situation,
(Huber, 2000, p50).
Hersey and Blanchard (1982) developed the situational leadership
theory in the late 1970’s. This theory suggests that there is no single
leadership style that is best but that it is the individual’s ability to adapt their
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leadership style to the situation that will determine how effective they are as a
leader, (McNichol, 2000).
Staff nurses often need support from their nurse managers or leaders;
it is believed that N.H.S trusts should avoid employing managers who have an
autocratic management style and managers who pay little attention to their
staff, (Alexis, 2002).
There are however other theories and leadership styles; one such
other style is ‘transformational leadership’. A transformational leader has the
ability to create and inspire a shared vision for the future; they have the ability
to engage others in the change process to work towards the attainment of the
groups goals and to provide the support necessary to reach these goals. The
transformational leader strives to empower and motivate those that they lead
and in turn gains motivation from those they lead, (Hocker and Trofino, 2003).
One of the most obvious results of good leadership is the production of
a good working team, (Thomas, 1998).
Teambuilding can be defined as the system by which a person or
person’s bring together and establish a group of people into a working unit so
that set goals can be attained, (Huber, 2000).
The ability to work well in a team is vital. Nurses must be able to work
collaboratively with other nurses, their nurse manager and also with others
who do not have the same professional background, (Huber, 2000).
In the creation and maintenance of an effective team the leader holds many
roles and responsibilities. They are responsible for their human, financial and
material resources, they must be active in setting goals and direction, use the
appropriate methods and conduct themselves in such a way as to gain the
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commitment from all other members and maintain a high standard of personal
performance, (Thomas, 1998).
Effective change management requires a manager to possess self-
confidence, knowledge of the change process, and the interpersonal skills to
aid participants in the acceptance of change and allow them to see the
process as a natural progression. If a planned change to practice is pushed
forward by an authoritarian leader then the seeds of discontent and
unwillingness will be sown. The manager implementing a change should
explain the rational for the change so that individuals understand why it is
necessary; they should also allow emotions to be worked out. The manager
should provide each individual with any information they require and offer
them support to help them cope with the change, (Huber, 2000).
With an effective team, support system and leader changes can be
made more easily to achieve best practice.
Best Practice
Many hospitals have their own best practice statements and policies.
The Royal College of Nursing (RCN) also have codes of practice or guidelines
for many areas of nursing, patient handling being one. The RCN has a
‘working well’ initiative that has a Code of Practice for Patient Handling,
published in 1999. The aim of their safer handling policy is to eliminate
hazardous manual handling. They say that where possible patients should be
encouraged to assist in their own transfers and that if handling aids can
reduce the risk of injury then they should be used. Great care should be
taken when supporting patients and any pushing or pulling should be kept to a
minimum. Manual handling of patients should only continue when it does not
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involve the lifting of most or all of the patient’s weight. This code of practice
also gives six factors which may predispose nurses to a back injury, these
are; the lifting of patients, working in an unstable and awkward position, lifting
loads at arms length, lifting loads that start or finish near the floor or overhead,
lifting unbalanced loads where the weight is mostly at one side and finally the
handling of an unco-operative or falling patient. The code also calls for any
risky manual handling to be avoided ‘so far as is reasonably practicable’,
(Royal College of Nursing, 1999).
The RCN code of practice lays out various employer responsibilities
which include, the employer must ensure that employees are not exposed to
foreseeable risks of injury for manual handling as set out in the Health and
Safety at work act 1974 and the manual handling operations regulations 1992,
the employer must develop, implement, and communicate a policy and any
local codes of practice that apply to manual handling in the workplace. The
employer should employ a knowledgeable, capable person such as a back
care advisor, consult with occupational health experts when the develop their
policies, carry our formal handling or risk assessments, minimise risks by
implementing measures relating to the working environment and draw up an
action plan and budget for any new measures that are required, (The Royal
College of Nursing, 1999).
In order to develop best practice and evidence based practice health
care professionals need to identify areas in the practice area from which clear
clinical questions can be formulated. Practitioners should identify good
related evidence, critically appraise the evidence for validity and then
implement the findings into practice. This needs to have ongoing
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measurement of performance compared to the expected outcomes. This way
the applicability, validity, and effectiveness of the findings for best practice will
be tested. Of course this needs to be audited and re-audited to ensure
practice and behaviour changes in applying best practice are maintained and
improved with clinical efficiency and effectiveness which shall then improve
clinical outcomes, (Tingle and Cribb, 2002).
Scenario
Having used the concept map (appendix 2) to identify the possible
causative issues for the poor moving and handling practice and selected three
of the key issues the author will identify, discuss and analyse the next steps
that could be taken to identify the underlying problems and the causes and
find steps that could be taken to solve these issues.
Most audits need to begin with the identification of a problem, in health
care there is often a suspicion of a deficiency in an area of care which needs
to be confirmed and refined. The suspicion of a problem may arise from a
combination of clinical experiences, published reports or from the analysis of
data collected from patients being treated in that clinical area. To confirm that
the problem is real and warrants attention may mean that more data needs to
be gathered, (Crombie, Davies, Abraham and Florey, 1993).
If it was decided that an audit was needed it would be important to
decide who would be involved with and carry out the audit. It would also be a
good idea to make contact with a local or trust audit committee, they will have
information regarding the preparation and funding, (Centre for Medical
Education and Clinical Resource and Audit Group, 1995).
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In order to carry out an audit on the identified problem of why staff are
manually lifting patients a method of audit would need to be chosen and an
audit sample would need to be chosen, this could be patients or staff or a
combination of both, (Cooper and Benjamin, 2004).
Methods of Audit
There are three types of audit and it is necessary to identify which type
would be carried out for this scenario. The three types are audit of structure
which is concerned with looking at the level of facilities and man power and
how they are organised. Audit of process, which is concerned with looking at
what is happening in a clinical area, the kind of care being given and how it is
delivered. The third is audit of outcome; this is concerned with the results of a
clinical intervention and its effect on the patient or client. It is not necessary to
carry these audit types out individually, they can be combined together,
(Centre for Medical Education and Clinical Resource and Audit Group, 1995).
Having looked at these three types of audit the author feels that an
audit of process would be appropriate in this situation. This is because it
looks at how the care is being delivered in the clinical area, therefore it would
be able to look at how patients are being moved by staff and why.
The method of data collection should also be decided at this
stage, again there is more than one method. Traditionally a retrospective
analysis of patients’ records was used as the method of data collection. Now
it is recognised that it is more beneficial to gather data from a multitude of
sources, for example, from nurses, patients, carers, and documentation. This
can be done using a range of methods, such as, observation, interviews,
record reviews, and questionnaires. The basic principles of research should
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be used when applying these methods of data collection to audit. It should
also be remembered that just like research, audit should include ethical
considerations particularly with methods like patient questionnaires or
observation, (Morrell and Harvey, 1996).
During the audit process and particularly the assessment phase,
research methods should be give great consideration for use in the collection,
analysis and interpretation of data. This data forms the basis for the
comparison of current practice against the pre-determined standards of
practice, (Harvey, 1996).
The requirements of an effective data collection method are that high
quality data can be obtained and at a reasonable cost. To decide on the best
method for this scenario, a critical assessment of the data needed could be
done, this would help decide on the most effective data collection method,
(Crombie, Davies, Abraham and Florey, 1993).
In order to discover the core reasons for why staff are manually lifting
patients the author feels that staff interviews or questionnaires would be good
methods of data collection as these both give the staff opportunity to discuss
or state the reasons they feel they have for manually lifting patients.
The next stage would be to carry out the audit with the chosen method
on the chosen population sample.
Data Analysis
Once all the data has been gathered it would have to be summarised in
a meaningful way. This could be done quite simply with the use of a chart or
graph, the important thing is to ensure that everyone understands what you
are trying to show. The audit data should be compared meaningfully with the
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previously set standards of practice. It is then necessary to decide whether
the standards of practice are being met, and if they are not, why not. It will
then be necessary to decide why standards are not being met, it may be that
the existing standards or policies are outdated or it may be that a change of
practice is needed, (Cooper and Benjamin, 2004).
However, there is one important aspect of data interpretation that
should be taken into consideration, that is, the possibility of error. Errors often
occur for a number of reasons, it may be that information has been
inaccurately recorded on forms, that instruments have been misread or that
subjective assessments of clinical conditions are inaccurate. Whatever the
cause the question that needs to be asked is whether the size of the error is
large enough to affect the conclusions gleaned form the audit, (Crombie,
Davies, Abraham and Florey, 1993).
Identify and Implement Change
From the comparisons between the audit findings and the standards of
practice conclusions should be drawn about the practice areas that require to
be changed. The entire audit team should discuss this and come to joint
decisions regarding the changes that need to be made. It should also be
remembered to give praise where a standard has been met. Agreement
should be made on an action plan of who will do what, when, and how, and
then a report should be drawn up, (Cooper and Benjamin, 2004).
At this stage of the audit process the audit team would present their
findings to their ward manager. As identified previously some of the
underpinning reasons for staff lifting were lack of equipment, lack of staff
training and poor communication between the wards that shared the hoist. If
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this was what was found following an audit then recommendations would be
made for change to rectify these problems.
The implementation of change is often the most troublesome stage of
audit as many people do not like change, especially if they do not understand
it, (Cooper and Benjamin, 2004).
Change is often defined as the process of moving from one system to
another. Change also needs to take place in people’s attitudes and culture
before change can take full effect in a system. In the NHS, which is focused
on people, culture and attitudes must be addressed fully before any functional
change can occur, (Goodwyn, 1996).
It is imperative that the change process is lead by someone and not
just left to chance, this is where good change management is important. The
changes should be broken down into manageable tasks and achievable
targets. Good leadership, communication and reassurance are essential to
give staff the encouragement and motivation to sustain change, (Cooper and
Benjamin, 2004).
Upholding Change
This is the last but very important step in auditing; it is the step back to
stage one of the audit cycle. Re-auditing will determine whether or not the
implemented changes have occurred and will hopefully show that practice has
been improved, (Cooper and Benjamin, 2004).
Research is also an effective method of objectively valuating the
outcomes and effects of audit in practice. The RCN has undertaken a number
of research studies on audit through their Quality Improvement Programme.
These types of studies reinforce the need to develop the process of audit in
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relation to the implementation, education, and promoting actions on the
results of the audit, (Harvey, 1996).
Conclusion
By reflecting upon this essay the author can see that there are many
issues and complexities involved in the provision of quality health care and
auditing. Progress towards better quality health care is a never ending path;
no single health care professional can be responsible for creating change
towards quality. Behind the scenes each individual working towards
improving the quality of patient care is being supported by a network of new
information, fellow staff members and good management. It is vital to realise
that audit is carried out to improve practice which ultimately will improve
patient care. This essay has highlighted that the improvements in quality are
related to leadership, development of staff knowledge, and the continued
endeavour for better practice.
APPENDIX 1
Gibbs (1988) Reflective Cycle
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(Burns and Bulman, 2000, p83).
DescriptionWhat happened?
EvaluationWhat was good/ bad about the
experience?
Action Plan
If it arose again what would you
do?
AnalysisWhat sense
can you make of the situation?
ConclusionWhat else could you
have done?
FeelingsWhat were
you thinking/ feeling?
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LEGAL IMPLECATIONS
LEGAL IMPLECATIONS
PHYSICAL IMPLECATIONS
PHYSICAL IMPLECATIONS
FINANCESFINANCES
STAFF
SHORTAGES
STAFF
SHORTAGES
LEADERSHIPLEADERSHIP
TIME
MANAGEMENT
TIME
MANAGEMENTTEAMWORK
TEAMWORK
COMMUNICATIONCOMMUNICATION
BEST
PRACTICE
BEST
PRACTICE
KEY
HANDLER
KEY
HANDLER
STAFF
TRAINING
STAFF
TRAINING
LACKOF
EQUIPMENT
LACKOF
EQUIPMENT
NOMANUALLIFTING
NOMANUALLIFTING
MOVING&
HANDLING
MOVING&
HANDLING
Appendix 2
Reflective article.
Through out this reflective article I will be reflecting upon an incident
that occurred during a second year placement I had in a medical ward. To
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reflect I will be using the Gibbs (1988) reflective cycle, (Burns and Bulman,
2000).
I was in my first week of the placement and was still getting to know the
ward and the staff. An auxiliary nurse and I were about to wash and dress a
new patient but the lady needed to be hoisted on to a commode. The
auxiliary nurse asked me to go and get the ward hoist from the store; I went to
the store but could not find the hoist. I reported this to the auxiliary who told
me that it may be in the ward next door as it was a shared hoist. This
surprised me as I had never heard of this before and thought that for a ward
of twenty patients, mostly elderly, they would have their own hoist. However I
dutifully went off next door and asked where the hoist was but they said they
did not have it and that I should look on the ward up stairs as they ALSO
shared it. By this point I was very surprised, this meant that three wards with
a total of nearly sixty patients shared one single hoist. I eventually found the
hoist upstairs on the other ward and took it down in the lift, by the time I got
back to the patient I had been assisting I had been gone for ten minutes.
Luckily there had been no emergency for the hoist on this occasion and the
patient was fine.
The second stage of the Gibbs cycle asks us what we were feeling. I
initially felt mostly surprise, but later on I spoke to a trained member of staff
about it and she told me that the reason for only sharing the hoist was
because none of the wards needed the hoist for more than one or two
patients each day so therefore they could not justify buying a hoist for each
ward. When I thought about this later that day and throughout the rest of my
time on that ward it made me feel somewhat angry that due to penny pinching
some staff members were manually lifting patients thus putting themselves
and the patients at risk of injury.
The aspects that I felt were bad about the situation were the
obvious risks both physically and legally to the people involved in the manual
handling. I also thought that even though sharing the hoist with another ward
on the same floor was bad enough, sharing one with a ward on a separate
floor was awful, what would happen if the lift was broken for any length of
time? All the aspects that go with not being able to hoist a patient
immediately that they require to be hoisted are bad. For example, an elderly
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patient who needs hoisted on to the commode to go to the toilet but who has
a weak bladder and cannot wait for more than a few minutes, does this patient
have a catheter inserted even though it is not needed? Do they just have to
wear an incontinence pad and risk their skin breaking down?
I did not feel that there was really anything good about the situation
apart from the chance it gave me to question the long standing procedures on
the ward and ask myself and the other staff what implications this had on the
patients well being.
I did understand that each ward has a tight budget and that the hoists
are expensive to buy and maintain but I feel that they are an essential part of
everyday nursing equipment. I still do not fully understand why the ward did
not have its own hoist, other than financial reasons, and wish I had asked the
ward manager about it more specifically. I also feel that the staff had poor
communication between each ward; better communication would at least
have solved the problem of not knowing where the hoist was.
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