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

16

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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