Nursing Leadership and Policy Development

Question: Discuss about the Nursing Leadership and Policy Development. Answer: Intoduction: Hospital-acquired infections are responsible for several deaths occurring in patients, which led to an emergence of the National Audit and standard infection control precautions in every country (Carrucan et al. 2015). Hospital-acquired infections effect the inpatient population thereby increasing the length of stay, hospital cost, morbidity and mortality. Literature evidence shows the link between "hand washing and transmission of infection." To prevent nosocomial infection in hospital setting hand hygiene practice is the single most effective method reported in literature (Dyson et al. 2013). The British government has introduced "Clinical governance" in 1998 (Trong 2013). It is recognized as a framework that refers to the accountability of the health organizations to ensure high standards of care and improve the quality of the care services (Newman et al. 2015). The essay is based on the clinical audit of adherence to hand washing in mental health setting using the standard audit criteria. The paper provides a brief literature review on clinical audit and its significance which was commenced after the start of the project. The essay suggests the improvement strategies for hand hygiene practices after the audit. Clinical governance laid emphasis on conducting the clinical audit to measure the implementation of the infection control policies and procedures (Spigelman and Rendalls 2015). According to Boudjema et al. (2014) clinical audit is a clinically led initiative to measure the health professional practices in the hospital setting. It is a tool to examine and modify the practices of clinicians to align with the established national standards and best available evidence. The benefits of auditing include infection control, improved quality of patient care and professional development (Nicholson 2014). In recent years, many hand hygiene practice audits have been conducted in various health care setting and have been documented. There are five stages of audit, and the first step is to select the topic for audit considering relevant questions (Szilgyi et al. 2013). For example- Is there any serious patient complaints on care quality? What is the priority of the problem to the organization? Is it amenable to change by investing effort and time? The purpose of auditing the hand washing practice in health care setting is because of the literature evidence linking hand washing and transmission of infection (Nicholson 2014) Hand hygiene is an essential practice to ensure infection control in the hospital setting. In most of the literature good compliance with hand washing protocol is found to depend on various factors (Jain et al. 2015). It is commonly documented that inappropriate facilities are the commonest barrier to good hand hygiene adherence (Boudjema et al. 2015). Therefore, assessment of hand hygiene technique performed by the health care staff is as essential as measuring when and how they perform it. One way to assess is by observation of hand washing technique periodically to know if the staff is using an adequate volume of gel, liquid soap or alcohol-based hand rub (White et al. 2015). The clinical audit helps to know if the staff is using the required product for hand wash for a sufficient period and if they are a voiding recontamination after hand wash. Such audit also helps to identify if there are adequate facilities in the health care setting to enable strong compliance with the good hand hygiene practice (Azim and McLaws 2014). Further White et al. (2015) stated that the hand washing behaviour among health workers is complex and is influenced by individual perception, attitudes, beliefs and institutional commitment. Consequently, the audit reveals that the practice is compliant or non-compliant which corresponds to the second stage of the audit (Szilgyi et al. 2013) The rationale for selecting the mental health setting for auditing the hand washing procedure because in much of the literature it is reported that it is challenging for the psychiatric facilities to implement infection control practice. This is attributed to the fact that mostly hand hygiene protocols are designed for acute care facilities (Gallo and Barlow 2012). This is because these facilities include areas and procedures where hands are soiled such as exposure to body fluid. The lack of hand hygiene guidelines in mental health setting is less likelihood of the nurses and the health professionals to engage and contact the patient intimately thereby minimising the need of hand washing (Stewardson et al. 2016). The cause of infection in mental health settings is patients with mental illnesses who do not care for themselves or maintain cleanliness. Therefore, it increases the risk of nosocomial infection and transmission (Wolf and Fazel 2016). The population chosen for hand wash aud iting includes nursing staff. The medical staff and the nurses are the agents of change in practice. They can promote and ensure infection control by sharing their good hand washing knowledge and practices with the qualified staff (White et al. 2015). The total number of participants who completed the questionnaire were 114 out of which 44% were registered mental health nurses and all of age 25-50 years, and 46% were unqualified staff including domestic staff and care workers. Demographic details are not shared to maintain anonymity. The facility studied in this survey provides care for elderly people with the range of cognitive problems. They are considered at risk for not strictly adhering to hand hygiene protocol and need regular prompts regarding the same. Before clinical audit is written consent was taken from the selected population for audit as mentioned by (Szilgyi et al. 2013). Also, the author has performed a thorough literature review to get insights into the standards set for audit. According to the recommendations of "World Health Organisation," hand washing is required for contacting a patient at five different points also known as five moments of hand wash (Appndix). These include exposure to body fluids, before the aseptic task, before and after the patient contact and also their surrounding (Chou et al. 2012). As per the "National Institute for Clinical Excellence" standards, after every episode of direct contact with a patient, hands must be decontaminated immediately (Rawlins 2015). In fact, in any case or different patient care activities that result in hand contamination, hand washing is recommended with "alcohol-based hand rub" unless the hands are visibly soiled. Yue et al. (2014) analyzed that alcohol-based hand rub has more efficiency when compared to antiseptic soap in decontamination of hand. The author uses these standards to design an audit plan for their measurement. The third stage of audit requires a collection of data from the current practice by the assigned examiner (Szilgyi et al. 2013). For this purpose, questionnaire is chosen as an instrument that will assist in collecting accurate data as mentioned in Appendix to determine the adherence of nursing staff to the hand hygiene practice. The audit tool was designed to contain two parts. In the first part of the questionnaire the respondents have to answer as YES/NO. Three questions were framed for the registered nurses In the second part of the questionnaire, 12 questions were framed (Appendix). After designing the audit tool, the examiner starts with the observation of practice particularly during the busy hours to identify any non-compliance. As per the data collected from the first part of the questionnaire, 80% of the participants used the correct procedure for hand wash. All the participants dried their hands thoroughly after hand wash. Hand hygiene before the patient contact was implemented by 40% of the nurses, and after patient contact, 100% of nurses implemented hand hygiene. As per the results obtained from the second part of the questionnaire, 92% of the participants answered that ABHR was always available in the work area with 8% answering that it was not available. Majority of the participants preferred ABHR over the use of soap and water. When asked they answered that soap was effective only when the hands were visibly soiled. This response was in alignment with 100% negative response to the question If your hands are visibly soiled do you cleanse your hands with ABHR? All the participants answered yes to the question do ABHR save time when performing hand hygiene. As per the results 90% of the respondents feel that ABHR adequately cleans their hands. When asked about the presence of alcohol/detergent impregnated wipes in the practice area for equipments like stethoscopes the participants were confused. As the nurses have busy schedule they tend to forget about the alcohol wipes. It was the reason why most of the participants could not recall if wipes were present. To this question only 58% answered true and 42% answered false. Among the participants, 50% agreed using alcohol/detergent impregnated wipes to regularly wipe their equipment, 92% agreed to have easy accessibility to hospital-supplied moisturiser and regularly used it 3 times a shift. The reaming 8% nurses could not access the moisturiser and could not answer where it would be placed otherwise. The remaining nurses who do not use moisturiser was due to time constraint and busy schedule although all the participants were aware of its benefits. Only 23% of the participants agreed that they have attended in-service on hand hygiene in the last 12 months but all of them have not completed the on-line learning package. 100% nurses believe that hand washing is an important feature for infection control. Nurses (44%) were aware of the guidelines related to "patient hand washing." However, only 38% of them could give the guidance details. It was evident from the results that there were no issues such as lack of washing facilities. When asked about the barriers to hand wash prevention the staff reported that there were low staffing levels; forgetfulness by staff, a size of washbasins, and lack of time. One of the nurses stated that hand washing was not required as they were not exposed to patients body fluid (urine or saliva) and because they were assisted by other staff. Only 83% of the nurses washed hands before donning gloves whereas all of them performed hand hygiene after removing gloves. The audit data was compared to the set standards to compare and determine if the nurses and staff met the hand hygiene practice standards. The results concluded that the hand washing standards were not fully met. The correct procedure for hand washing was implemented by only 80% of the registered mental health nurses. As per the guidelines of NICE, both before and after the patient, contact hands must be thoroughly decontaminated (Yue et al. 2014). However, in this psychiatric facility, sixty per cent of the nurses failed to practice hand hygiene before patient activity such as assisting with ADLs, applying oxygen masks, administering oral meds. This is an extremely low percentage of adherences to the hand hygiene standards. However, all the nurses performed hand hygiene after touching patient and after exposure to the body fluid of the patient and also after the risk of body fluid exposure. Only 35% of the nurses performed hand hygiene after touching the patients surrounding such as cleaning dining table or changing bed linen. Similarly the percentage of the nurses washing hands before any procedure such as opening a sterile material, instilling eye drops was found to be only 55%. According to the "Nursing and Midwifery Council," the staff must prevent any action that has the potential to harm them, other staff and their patients (Newman et al. 2015). When ten observations of hand wash were noted nine of the instances either followed or preceded with the patient contact. The overall percentage of registered nurses who demonstrated a correct hand hygiene technique was found satisfactory. This is the matter of grave concern as majority of the nurses did not follow the hand hygiene protocol despite being aware of its effectiveness in the infection control. Since the results are analysed, we commence with the fifth stage of an audit which is suggestions for improvement. It is suggested that regular training session on "correct hand hygiene procedure" should be organized. It should be carried out by trained nurse for infection control practice and with a stringent maintenance of attendance records of those attending the training. This will enhance the hand hygiene awareness among the staff and will educate them about the correct technique and time (Stewardson et al. 2013). There must be hospital policy of regular audit (every six months for four hours) implemented to evaluate the effectiveness of the training. Further, there is a need of emphasizing hand hygiene more before and after the patient activity. All the healthcare professionals are advised to update their clinical audit knowledge by attending seminars and workshops (Huis et al. 2012). The barriers to hand washing in several cases were reported to be patient's aggressive behaviour (Wolf and Fazel 2016). For this study simple audit tool was chosen due to time constraints. Since most of the ha nd hygiene campaigns are mostly targeted to acute care setting; these survey findings may change this attitude. The proposed outcome of this study may be reinvigorated campaigns targeting psychiatric settings. References Azim, S. and McLaws, M.L., 2014. Doctor, do you have a moment? National Hand Hygiene Initiative compliance in Australian hospitals.Med J Aust,200(9), pp.534-7. Boudjema, S., Dufour, J.C., Aladro, A.S., Desquerres, I. and Brouqui, P., 2014. MediHandTrace: a tool for measuring and understanding hand hygiene adherence.Clinical Microbiology and Infection,20(1), pp.22-28. 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