Developing a Culture Where Nursing Practice is Consistent with Infection Control Prevention

Transcription

1 Developing a Culture Where Nursing Practice is Consistent with Infection Control Prevention Key words: Ward context, hand hygiene, staff ownership Duration of the project: November 2009 March 2011 Project team: Tina Jegede, Matron Elderly Medicine Fiona Paterson, Practice Development Nurse Contact details: Tina.Jegede@whittington.nhs.uk Project summary This project was carried out on Cavell ward, one of the wards within the Jeffery Kelson Unit (Care of the Older Person). The original focus of the project was on peripheral line cannulas; however, measures by the Trust had led to a significant reduction in MRSA bacteraemia. Therefore, the aim of the project changed to focus on creating a culture where there was sustained reduction of infection, regardless of the source of risk. The ward team engaged in various practice development activities such as observations of practice to raise their awareness of current practice and identify areas of infection control practice that could be improved. One of the key areas of development was staff gaining confidence and skill to challenge colleague s practice. A DVD was produced as an aid to raising practitioner s awareness of the importance of infection control. The evaluation shows that practice had improved and that staff had an increased awareness of their roles and responsibly in infection control and prevention. Project background The Whittington Trust had various measures in place to improve infection control practice. A particular success has been the Visible Leadership Team launched in This involves the Trust s senior nurses being present, in uniform, on the wards every Monday. They undertake audit and teaching on hand hygiene, cleanliness, peripheral line care, urinary catheter care and point prevalence scores for identifying the need for isolation facilities. Results of the audit are fed back to the ward staff and shared throughout the Trust, including the Trust Board, as part of Ward to Board, an information flow process. Where audit results show practice needs to be improved, specific Trust based measures are put in place. For example, the rolling out of hand hygiene training to staff; refresher training on cannula management for all registered nurses, midwives and doctors; and training on the correct procedure for the taking of blood cultures. These measures have led to a reduction of infections, in particular methicillin-resistant Staphylococcus aureus (MRSA) bacterium. With infection control being high on the Trust s agenda, they were keen to explore other means to further reduce infection rates. This led to an application to the Foundation of Nursing Studies (FoNS), to develop practice aimed at reducing healthcare associated infections (HCAI). The Trust was awarded 5000 from FoNS to carry out a project. A meeting was then organised with the infection control team to inform them of the Trust s successful bid. The team consisted of the microbiologist, specialist infection control nurse, infection control matron and the infection control specialist nurses. The project team It was agreed that the project team would consist of a matron (project lead and author of this report), a professional development nurse and a ward manager, with executive support from an assistant director of nursing. The project team was selected because of their remit within the organisation and, it was felt they had the appropriate skills to lead, influence, support, facilitate and sustained the project. 1

2 Project team structure Project Sponsors NHS London Project Support Foundation of Nursing Studies Trust Related Project Infection Control Action Plan Trust wide infection control training Executive Lead Veronica Shaw Project Team Tina Jegede (Project Lead) Rose Bockarie (WM). Fiona Paterson (PDN) Tricia Nolan (ICT) The project area Cavell ward, one of the wards within the Jeffery Kelson Unit (Care of the Older Person), was the main focus for the project. This ward was chosen for a number of reasons; incidences of acquired MRSA bacteraemia had occurred and staff felt unsure about infection control practices on their ward. This became apparent during discussions with staff following the infection incidents. The project offered an opportunity to address the practical issues within the environment, staff attitudes and staff ownership of infection control. It was envisaged that any lessons learned could be disseminated to promote good practice on other wards. Initially, the focus of the project team was on peripheral line cannulas; however, measures by the Trust had led to a significant reduction in MRSA bacteraemia. Therefore, the aim of the project changed. The project team felt the focus of the project should be on creating a culture where there was sustained reduction of infection, regardless of the source of risk. The team felt this was achievable if staff were supported to, and were engaged in, taking individual/ward/team ownership for infection control. Therefore, the aim of the project shifted from a focus on cannula related objectives to a broader focus, working with staff to recognise their role and responsibilities in relation to infection control measures within the ward. There was a particular emphasis on hand hygiene as this was known to be the most effective way of reducing transmission of infection. The following were the agreed aims and objectives. Aim: To develop a culture of sustained infection reduction, regardless of the source of risk. Objectives: To work with staff in a way that helped them engage with and own the project, leading to staff wanting to improve practice themselves To involve patients in a way that helped staff understand the implications of poor infection control practice To ensure that staff were provided with the opportunity to reflect and learn about the different aspects of infection control practice To develop reflective resources/tools that could be used across the Trust to engage, support and develop staff around their role in relation to infection control Measures of success It was believed that the project aim and objectives would be met if the following were demonstrated in the evaluation outcomes. 1. Nurses expressing beliefs and values that relate to good infection control practice 2. All members of staff understanding their responsibility to safeguard patients against infection 2

3 3. Team ownership of the infection control agenda and all members of staff considering infection control to be their business 4. Ongoing evaluation of practice in the ward in relation to infection control 5. Team gaining insight into the culture of the clinical area and how this impacts on good practice Project outline An emancipatory practice development approach (EPD) was considered to be most relevant overall approach for the project. This is an approach to practice development based on critical social science, which aims to achieve sustainable change through emphasis on the development of individuals, teams, culture and context (McCormack et al., 2010). The project team took part in five workshops facilitated by FoNS where they developed skills and knowledge in practice development. They were introduced to a number of tools to aid development of practice. Knowledge gained from the workshops, and a further review of the literature, informed the choice of tools. Those considered most suitable were agreed and later informed the action plan. The following practice development tools were included in the project: Values clarification (Manley, 1997) Workplace Culture Critical Analysis tool (WCCAT) (McCormack et al., 2009a) Short snap shot observational tool Context Assessment Index (CAI) (McCormack et al., 2009b) These were used, along with patients experiences and ongoing Trust infection control audits, to provide data to inform the progression of the project. Values clarification It was important to begin with clarifying the beliefs and values of the staff and developing a shared vision from these. The values clarification exercise is a tool often used for practice development (Warfield and Manley, 1990; Manley, 1997). It was relevant to this project as it assists development of effective team working, a significant overall objective for this project. Values clarification is also a useful means to change embedded culture in the work environment as our beliefs and values are known to influence our behaviour (Manley, 1997). Boomer et al. (2008) claimed that knowing the beliefs and values of staff at the beginning of the process can help lead to positive change. Putting beliefs and values into practice involves overcoming barriers in ourselves as well as those that exist in the workplace. Dismantling these barriers and recognising the gaps between what we say we believe in, and what we say we do, and what we actually do is essential to bring about awareness. This, in turn, influences practice. The Context Assessment Index (CAI) The CAI provides information through which healthcare professionals and teams can assess the context within which care is provided in clinical areas. Context is comprised of the three key elements; culture, leadership and evaluation of the workplace. The CAI assesses all three of these elements and each of these has characteristics that can be assessed along a continuum from weak to strong. For an effective context that is receptive to change and has person-centred ways of working, the three elements all need to be strong (McCormack et al., 2009b). The project team explained to the ward staff that using the CAI, would enable them to assess whether the context of Cavell ward was conducive for person-centred practice, and whether there was a level of openness to change and development on the ward. Essentially, it provided information which informed the action plan and took the project forward, helping achieve a stronger context on the ward. The guide for using the CAI was followed and it was noted that there are no right or wrong answers, in that the responses reflected individual experiences of working within the clinical area/team. 3

4 Workplace Culture Critical Analysis Tool (WCCAT) The WCCAT was developed to assist those involved in practice development to carry out observational studies of work place settings, in order to inform changes in practice (McCormack et al., 2009a). This tool was relevant for this project because a key objective of the project was to engage staff in a way that brought about change through developing awareness of their environment and care delivery practices, along with promoting empowerment and ownership of the project. Observation is one of the key tools used in emancipatory practice development as it is concerned with challenging the culture and context of practice to raise awareness of practices and assumptions that would otherwise be taken for granted (Manley and Cormack, 2004). The WCCAT was therefore used to undertake an observational study of Cavell ward. The aim of this was to provide the staff within the ward the opportunity to observe the following factors; the physical environment, communication, privacy and dignity, patients involvement in their care and team effectiveness. Essentially, the aim was to raise staff awareness of embedded practices within the ward that they would otherwise not have noted. It was felt that the WCCAT, though very useful, was quite long and a number of staff found it a challenge to complete. For this reason, a shorter snap shot observation tool was also used. This tool required staff to review aspects around the ward environment in relation to, what they smelt, what could be heard, what could be seen and how the staff member undertaking the observation was feeling. The staff member was also asked to write down anything they observed that came as a surprise, as well as what stood out for them. Infection control and trust audits The Trust already undertook a number of infection control audits that provided infection control performance information. These Trust wide performance audits were conducted into isolation of patients, the use of the personal protective equipment, i.e. the use of gloves, aprons etc., the screening of patents on admission for MRSA colonisation, and the correct use and management of both cannulas and catheters. Audits were also conducted into staff adherence to hand hygiene, the environment and the cleanliness of commodes. These audits were carried out on a rolling basis, results of which were sent to the different ward/departments and discussed by the Trust infection control committee. The results of these audits provided useful data to indicate if outcomes improved over the course of the project. Patient stories Patient stories were considered by the project team as a form of fact finding and a means through which patients could have their voice heard, in relation to infection control. Generally, they are intended to serve as a feedback mechanism for clinical staff. The aim was to use the patients stories in the form of an educational DVD. A structured and approved process for recording patient stories was followed which included gaining signed consent to take part in the educational DVD from the patients who agreed to tell their story (NHS Institute for Innovation and Improvement, 2009) The aim of collecting patient stories was to inform staff of the impact of healthcare associated infection from the patients perspective, in the way that clinical audits are unable to do. This process would enable staff to both hear and see the narrated impact of acquired infection on the patients and their relatives. Moreover, it was also a way of providing patients an opportunity to express what they required of staff, in relation to infection control. Initially, the team proposed to interview three patients admitted onto Cavell ward. However, this was not feasible and other patients from other wards within the hospital were approached. These patients were approached because of their availability and willingness to tell their stories. The patient stories were gained by the project team rather than the Cavell ward staff. Unfortunately, this meant that the original aim of gaining patients stories from Cavell ward was not met and staff were not able to hear the experiences of patients from the ward or have the opportunity to collect these patient experiences. A ward sister whose father had died from MRSA was also invited to share her experience thus serving to illustrate the impact on relatives. In addition, one of the patients filmed was videotaped at home so that staff could see the ongoing impact of acquired infection. 4

5 Initial project findings The findings from the different tools were collated and are described or illustrated below. Values clarification Fifteen ward based nurses (qualified and non qualified) took part in the values clarification exercise. As the initial focus of the project was on preventing cannula related infection, the values clarification exercise was drafted to reflect this. Review of values and beliefs about cannula care suggested that staff attitude was positive towards the use of cannulas and the importance of aseptic technique with cannula insertions etc. was mentioned. Staff saw it as their role to apply Trust policy and recognised the importance of hand hygiene, education, documentation, and checking for early warning and timely removal of cannulas (see Appendix 1 for details of the feedback). These factors were the focus of Trust wide teaching and had seemingly informed staff values and beliefs in relation to cannulas. Some of the barriers staff noted included; no proper handover, documentation not completed, not cleaning the site and not removing cannula when not in use. The staff had the opportunity at a meeting to discuss the outcomes of this exercise. This gave them time and space to share their values and beliefs which was a new experience. The impact was observed by the project team in the ward area where staff talked more about infection control practice, suggesting that the process had raised their awareness. The Context Assessment Index (CAI) The CAI was completed by 14 staff members. The responses were compiled and expressed in an excel spread sheet (see Appendix 2). The responses showed interesting variations across respondents. In particular questions related to empowerment to change practice, proactive care planning, availability of guidelines and protocols and reflective processes, show wide variations across the spectrum of responses. It was a cause for concern that 43% of staff did not believe that patients have choice in assessing, planning and evaluating their care and treatment. Taken overall, the responses seemed to indicate that the ward demonstrated a weak context for developing practice. Staff demonstrated insight into factors which enhanced, or hindered their practice and learning but they did not feel empowered to change. They felt a traditional type of command and control leadership limited their ability to initiate changes in practice. Added to this was a strong view that the organisation was hierarchical. There was very little proactive infection control management. Staff felt that although regular audits were carried out, very few were carried out by the ward staff themselves. As a result, there was limited ownership of the results. Audits were often seen in a negative light and may not have been used by ward staff to improve practice to the fullest extend. It was a top down approach and could be symptomatic of a blame culture within the Trust. The staff noted that at ward level, there were no opportunities to reflect on what the results meant to their practice. Heavy reliance on formal teaching methods was noted. Staff felt a dissonance between how they would like to practice and how the workplace culture forces them to practice. They felt unable to put their professed values and beliefs into practice and were perpetuating a culture that was not receptive to new ideas and working practice. Practices were noted to be task orientated with little or no regard for patient choice or patient centred care. Workplace Culture, Critical, Analysis Tool (WCCAT) The observations using the WCCAT were conducted by the ward manager, alongside the practice development nurse and seven ward staff. The observations enabled reflection on the different challenges within the ward which could hinder or enable good infection control practices, identifying gaps between the staffs values and beliefs and practice. The WCCAT was useful in that a number of the staff had an opportunity to stand back and observe the ward area. This enabled them to consider the different aspects of the ward and care delivery that they otherwise may not have noted. As one person stated: Saw things that you might not have noticed 5

6 It was clear from the values clarification exercise and the outcome of the CAI, that what the ward staff believed was not always reflected in practice. Feedback that staff provided from the observations, were themed by the practice development nurse. The key themes included: 1. Environment: the floor in the linen room was dirty, there was clutter around patient s bed, food and drinks were left lying around, rubbish was not thrown away appropriately, radio left on etc. 2. Communication: patients addressed as darling, frustration evident in several periods of communication, the patient referred to as a bed number or by diagnosis, separate conversations at handover, loud voices. 3. Privacy and dignity: toilet and shower doors left open, curtains not closed properly. The observations suggested there was a lack of clarity of purpose, little evidence of a collaborative approach, no ownership of local problems and that the staff did not work in a person centred way on the ward. Though many of the observations were not directly linked to infection control, they did highlight the context of the ward and were therefore likely to impact on infection control. Feedback of the findings to the ward staff The findings from the practice development tools were fed back to Cavell ward team at a meeting that was organised by the ward manager and a healthcare assistant. Efforts were made to ensure that as many staff as possible could attend and backfill of staff was organised. One to one and small group discussions took place on the ward for those staff that couldn t attend. Although all the ward staff could not attend, there was a good representation of both qualified and non qualified staff. A total of 15 staff attended and included the ward manager, the ward sister, qualified nurses, health care support workers, the ward clerk and the matron. The half day meeting was facilitated by the project leader/matron with support from FoNS. The purpose of the meeting was to: 1) Discuss the findings from the values clarification exercise with the staff 2) Review the outcome of both the long and short observational study 3) Discuss the perceived culture of the ward and look at how the team could be engaged in practice improvement within their ward 4) Determine the team action plan and the way forward One of the key aims of the facilitated session was to allow the staff a forum through which they could reflect on the difference between their values and beliefs and the outcomes of the observations. The staff were engaged and openly shared their views and perspectives, expressing that they were not entirely surprised that their values and beliefs where inconsistent with what was observed in practice. They talked through practices that were taken for granted on the ward. This triggered a discussion about the factors that staff considered a hindrance to infection control. The staff acknowledged the project as a means, it seemed, at last to address issues that they had in the past felt disempowered to address. This was an important achievement as it served to engage the staff and to help them take ownership. They were freely offering up ideas on how issues could be effectively managed both as individuals, and collaboratively as a team. Feedback was captured on a flip chart. The engagement of the team enabled a shared vision to be discussed and agreed. The staff stated that they recognised their role in relation to infection control specifically in relation to hand hygiene, taking of swabs for the prompt identification of infection, appropriate use of resources available on the ward, and of education/knowledge and being role models. Similarly, they identified adequate resources, good staff education and attitudes of staff, available guidelines, and informed staff who adhere to infection control policies, as a way to minimise infection on the ward. Staff felt that high patient turn over and poor handover as hindrances to good infection control practice. 6

7 Some staff were unhappy and this had an impact on how they felt and therefore practiced. One person stated; How can you create a happy working environment if you are not happy The staff felt that the culture of the ward needed to change and that they needed to work as a team in order to improve practice on the ward and move away from focussing on their individual tasks. They felt some staff did not work as a team but took the approach of; It s not my job, it s not my patient Moreover, they stated that it was not part of the ward culture for staff to challenge bad practice and therefore challenging staff practice was often not well received. The staff also perceived the wider multidisciplinary team as outsiders rather than as part of the team. Importantly, the staff stated they had found the observational exercise relevant and useful as they were in the position to identify factors that they would otherwise have not noted. They commented that during working times it was not always possible to see those things that were not carried out correctly. The meeting enabled staff to draw up actions to resolve issues they had identified as a hindrance to good infection control; these related to change of attitude, team working and practice. They are listed below: 1) Develop staff skills to challenge practice appropriately. Staff felt they needed to be open to being challenged and to be able to challenge appropriately, in order to promote a ward culture where staff do not remain silent if poor infection control practice is observed. The staff believed this level of openness was crucial for infection control prevention. 2) Speak up, as it was felt that staff who were quiet should be encouraged to speak up. 3) Look at documentation as it was not well completed. 4) Look closely at practice. It was important that everybody made infection control practice their business. 5) Take responsibility for keeping the patient area clean including lockers. 6) Enable and encourage staff to find solutions to problems that they may be experiencing. 7) Observe and listen to patients. The ward vision The vision for the project was elaborated upon at the staff meeting following the facilitated meeting. Staff agreed that the vision to be: All staff on Cavell ward will work together to ensure that no patient admitted to their ward will acquire any form of infection as a result of poor infection control practices The action points were drafted into a plan and were followed through at the monthly ward meetings. These meetings were used as a forum for feedback and to discuss progress. It was at one of these meetings that the decision was reached to develop a DVD as a tool through which good practice could be demonstrated. This idea was discussed further and it was agreed that this was a positive way forward. Why an infection control DVD? The Cavell ward project suggested there was a need to focus attention on staff attitude and behaviour to achieve and sustain the project aims. It was therefore agreed that the video should not focus on procedures that have high infection risks but should attend to staff responsibilities and attitudes and that the DVD should reflect the responsibilities of the wider multidisciplinary team (see Appendix 3 for the notes from discussions to create the content of the DVD). Also, despite the fact that staff were informed about policies and guidelines, they did not have a forum to reflect on the outcome of lapses in infection prevention measures. It was felt that if staff were aware of the impact of 7

8 infection, this would help change and improve infection control behaviour. The production of the video was also seen as an opportunity to engage the wider team in the goal of making infection control everybody s business. The production of the DVD facilitated a degree of team building, which the project team believed was initiated by a sense of common purpose that later informed the achievement of the action plan. This was important for Cavell ward. Changing practice using the DVD The main infection control video was approximately 11 minutes in length. It was agreed that the DVD would be split into three sections to address the different aspects of infection control awareness. The DVD focussed on hand hygiene as this is known to be the most important aspect of infection prevention. It was shown to all nursing staff on Cavell ward and was later to support the overall Trust training on infection control. To support change in attitudes and awareness of the importance of good practice, the DVD was used in a forum where discussion and reflection could be encouraged. There is a break in the video that allows for reflection and discussion about the different aspects of infection control prevention. However, most importantly, it provided an opportunity for staff to appreciate how easy it is to spread infection, to hear patients stories and to appreciate the effect of acquired infection on a person. Evaluation of project To measure the project s success, various evaluation processes were agreed by the project team at the beginning of the project. These enabled a comparison from the beginning of the project to the findings of the evaluation and included the following approaches: Show the video to all Cavell staff members in a ward based facilitated session Repeat the CAI Repeat values clarification exercise Repeat the observation exercise Repeat ward based audits The video was shown to all staff on Cavell ward (including the wider multidisciplinary team) and following this, the CAI, values clarification exercise and observation exercise were repeated. The Context Assessment Index (CAI) The CAI (see Appendix 5) was completed again by 14 staff working on Cavell ward. They were different grades and had differing remits. As with the initial CAI, the findings were compiled in an excel spreadsheet. Interestingly, the findings again showed disparity across the respondents; however, there were significant improvements in areas that had previously been alarming. For example, question 30 (staff empowerment to change practice), the initial score of 72% had increased to 100%, 36% of staff responding strongly agreed and 64% agreed that they were empowered to change practice. Again, 100% of the staff strongly agreed or agreed that they are pro-active in care planning. In relation to question 27, 93% of the respondents strongly agreed or agreed that evidence based knowledge is available to staff as opposed to 65% previously. A number of the questions were not completed. In particular, question 36 had a small number of respondents (n=7). This suggested that some of the staff were either unsure of or simply did not know the meaning of the term hierarchical. Despite this, a comparison of the initial and subsequent CAI suggested that the culture of the ward had improved and context for developing practice had strengthened a great deal. The leadership on the ward had also changed with the focus now on facilitation rather than the traditional style of leadership the staff had once known. In addition, it would seem that the practice development processes had facilitated staff learning about each others roles, with 50% (n=7) (strongly agree and agree) of respondents stating that they recognised each others role. In the initial CAI 50% (n=7) stated that they did not. This had increased to 76% (n=10) strongly agree/agree with 24% disagree/strongly disagree. However, it is unclear whether this understanding was in relation to each other s roles generally, or more specifically about roles in relation to infection control. 8

9 Values clarification The repeated values exercise (see Appendix 4), completed by nine members of staff suggested that staff were aware of the factors that largely contributed to reducing the risks of healthcare associated infections. Most stated that the purpose of infection control was prevention (n=7). There were varied beliefs about how improved infection control could be achieved and whilst hand hygiene, education of staff, adequate resources and communication were mentioned frequently, other beliefs although mentioned less, seemed equally relevant. Interestingly, unlike the initial values clarification exercise completed about cannulas, the staff were more open about factors that both enabled and inhibited good infection control practices. Good adherence to infection control policies (n=5) was mentioned by a number of the staff. One member of staff wrote all staff members are acknowledging the importance of infection control. Equally, poor adherence to different aspects of infection control (n=7) was seen as a factor that hindered infection control on the ward. In particular, some staff recognised and mentioned factors that were outside the control of the ward (n=2). These concerns were mainly around the nursing of patients with MRSA next to those who are not colonised. As a result of the project and other measures, staff became more pro-active about moving colonised patients into side rooms or areas of the ward where cross infection was minimised. Importantly, some key points from the video were mentioned on the response i.e. infection control is everyone s business (n=3), and poor practice must be challenged appropriately (n=2). The outcome of this exercise would suggest that the team had developed a greater insight into the values and beliefs they held around infection control and the vital role they played. Observation of practice The post intervention observation using the snap shot tool demonstrated a very positive outcome; seven staff members completed the exercise. The environment was reported as clean (n=2); more importantly, there was no mention of clutter around the ward nor were lockers observed to be cluttered. Good infection control practices (n=5) were noted by the ward staff, with one staff member stating how observant patients were about infection control. Significantly, a number of staff (n=5) mentioned to those observing that they felt happy and that team work had improved. This was a substantial achievement given the results of the previous observation exercise. Ward based audits Ward based Trust audit was a useful way of measuring the impact of the project. The audit outcomes demonstrated significant improvements in ward performance in relation to patient screening and adherence to MRSA protocol. The cleanliness on the ward had also improved significantly. The audits were also now conducted by members of the ward staff and this had served to engage staff and support team ownership of outcomes. Reflections of the project leader Many lessons have already been learned from and by all staff involved in this project. It has been a challenging process for the key project team. To lead a practice development project whilst doing an already challenging job needs careful consideration as it was a huge task. Whilst practice development is necessary to ensure that service delivery responds to an ever changing health care system and a need for improved patient care, it requires a certain level of skill and expertise. However, with support, it is possible to develop the level of knowledge and understanding around practice development necessary to support change within the clinical area. Moreover, whilst the project was a challenge, it was also extremely rewarding to see disempowered staff positively changing and taking forward changes on their own ward. The project triggered ongoing discussion about other aspects of care that staff believed required change. The project informed my own knowledge about practice development. I have developed a better appreciation of facilitation, alongside how to encourage and engage staff through effective facilitation. This enabled me to engage and support staff to make the video. Conclusion The success of this project was reflected in the achievement of the objectives. The main outcome of this project was that staff, regardless of grade, had increased awareness of their roles and responsibilities in relation to the reduction of infections on the ward. Infection control was now considered to be the business of every member of staff. 9

10 It is well documented that, regardless of how good an action plan is, there are many potential barriers to prevent action from happening in practice (O Neal and Manley, 2007). It was and will remain necessary for staff to understand and positively react to potential barriers. The staff agreed that the monthly ward meeting would be a good forum to revisit how the ward was doing. The ongoing development work was handed over to the ward staff and though led by the ward manager, outcomes were and are team dependent. The outcomes of the values clarification exercise, the observations exercise and the repeated CAI showed a positive improvement in the culture and context of Cavell ward. Moreover, the video and the ongoing action plan resulted in a positive change towards infection control. An important outcome was that staff were more proactive, and were working together to come up with solutions to address key infection control issues they encountered. Fundamental to the success of this project was the ward team taking ownership of the action plan. This served to change the culture of the ward from one where infection control practice was not always adequate, to a culture with infection prevention at its centre. This project was supported by the FoNS Developing and Sustaining a Practice-based Strategy for Reducing Healthcare Associated Infections Programme in partnership with NHS London. 10

11 References Boomer C., C. Colin, I. and McCormack, B., (2008) I have a dream : a process for visioning in practice development. Practice Development in Healthcare. Vol. 7 No. 2 pp Manley, K. and McCormack, B. (2004) Practice Development: Purpose, Methodology, Facilitation and Evaluation. In McCormack, B. Manley, K. and Garbett, R. (2004). Practice Development in Nursing. Oxford: Blackwell Publishing. Manley, K. (1997) A conceptual framework for advanced practice: an action research project operationalizing an advanced practitioner/consultant nurse role. Journal of Clinical Nursing. Vol. 6. No. 3. pp McCormack, B., Henderson, E., Wilson, V., Wright. J. (2009a) Making Practice Visible: The Workplace Culture Critical Analysis Tool (WCCAT). Practice Development in Health Care. Vol. 8. No. 1. pp McCormack, B., McCarthy, G., Wright, J., Slater, P. and Coffey, A. (2009b) Development and testing of the Context Assessment Index (CAI). World Views on Evidence Based Nursing. Vol. 6. No. 1. pp McCormack, B., Dewing, J., Breslin, C., Coynen-Nevin, A.,Kennedy, K., Manning, M., L., Peelo-Kilroe, C., Tobin, P. and Slater (2010). Developing person centred practice: nursing outcomes arising from changes to the care environment in residential setting for older people. International Journal of Older Peoples Nursing. Vol.5 pp NHS Institute for Innovation and Improvement (2009) Experience Based Design using patient and staff experience. Coventry: NHS Institute for Innovation and Improvement. O Neal, H. and Manley, K. (2007) Action planning: making change happen in clinical practice. Nursing Standard. Vol. 21. No.35. pp Warfield, C. and Manley, K. (1990) Developing a new philosophy in the NDU. Nursing Standard. Vol. 4. No. 41. pp

12 Appendix 1. Initial Values Clarification Exercise I believe that the purpose of cannula care is: Stop infection It prevents infection It reduces infection risk, Ensure appropriate function of cannula To reduce infection an complications To be removed if not necessary prevent infection/minimise risk of infection To make sure that the cannula site is clean No infection, no injury To prevent the patient developing phlebitis I believe the purpose can be achieved by: Regular assessment of the site and regular review of the cannula Regular checks monitoring, cannula care plan Documentation, removing cannula after 72hrs Accurate documentation, ensure policy is applied To prevent infection and thrombophlebitis To make sure that the site is checked regularly Checking regularly, safe for cannula to be in place I believe that my role in good cannula care is: Daily checks, each shifts, use aseptic techniques Use aseptic technique when insert cannula To check the cannula 6hrly and record outcome on the checklist To teach students and other staff about the importance of good cannula care To teach with the understanding of the importance of cannula To make sure the site is not red or swollen Keep regularly eye on cannula, not only to what chart is saying, using gloves, clean hands To remain updated To adhere to hospital policy Review need for cannula, avoid unnecessary cannulas, assess site at ward rounds and educate staff Good documentation, communication to colleagues, cannula care plan completion Education of staff, ward leads, regular checks, audits I believe that the factors which enable me deliver good cannula care are: Open environment, both to visualise and to educate staff Time, adequate handovers, good patient rapport to encourage patient to speak up if there is discomfort check site during handover, ensure time and date is recorded, remove cannula after 72hrs and recannulate if needed That I have knowledge about the purpose of insertion of cannula To know how important it is to prevent infection To make sure that I checked the dates are correct and not to leave more than 72hrs on the patient Looking after patient in all ways, infections, less money for hospital if patient are injured, home early as possible To have care and concern for the patient I believe that the factors which prevent me delivering good cannula care are: Understaffing and heavy workload 12

13 When documentations are not completed, also ensuring cannulas are removed when not being used Not making sure that the site is clean and reporting any changes with the cannula No proper handover When I find a patient with cannula without a proper checklist My values and beliefs about cannula care are: Cannula are often required for treatment but we need to consider if the treatment can be effective by another route All nurses must check cannulas at the end of their shift Common themes: I believe that the purpose of cannula care is: Reduce the risk of infection (n=6) I believe the purpose can be achieved by: Regular checks (n=5) Documentation (n=3) I believe that my role in good cannula care is: Education (n=4) Regular checks (n=5) I believe that the factors which enable me deliver good cannula care are: Variable no common theme identified I believe that the factors which prevent me delivering good cannula care are: Variable no common theme identified My values and beliefs about cannula care are: Cannula checks Only 2 response to this question and focused on Low cannula used only if required and regular checks for infection 13

14 Appendix 2. Initial Context Assessment Index Response SA A D SD Question Total responses % SA %A %D %SD % 79% 7% 0% % 21% 50% 0% Question asked Personal and professional boundaries between HCPs are maintained Staff have explicit understanding of their own attitudes and beliefs towards the provision of care % 29% 50% 0% HCPs and healthcare support workers understand each others role % 46% 15% 0% Challenges to practice are supported and encouraged by nurse leaders and nurse managers % 62% 8% 15% Discussions are planned between HCPs and patients % 38% 46% 0% Organisational management has high regard for staff autonomy % 36% 29% 0% HCPs feel empowered to develop practice % 43% 21% 0% Structured programmes of education are available to all HCPs Total % 44% 28% 2% % 31% 46% 0% Decisions on care and management are clearly 2 documented by all staff % 31% 0% 8% The nurse leader acts as a role model of good practice % 57% 29% 0% There are good working relations between clinical and non-clinical staff % 79% 0% 0% There is high regard for patients privacy and dignity % 57% 14% 0% Care is based on comprehensive assessment % 69% 8% 0% Staff welcome and accept cultural diversity % 57% 21% 0% HCPs share common goals and objectives about patient care Total % 55% 17% 1% % 36% 29% 0% A proactive approach to care is taken % 62% 15% 0% HCPs provide opportunities for patients to participate in decisions about their own care % 50% 14% 14% HCPs in the MDT have equal authority in decision making 14

15 % 71% 7% 0% Patients are encouraged to be active participants in their own care % 54% 15% 0% HCPs and patients work as partners providing individual patient care % 43% 36% 7% Patients have choice in assessing, planning and evaluating their care and treatment % 62% 23% 0% Clinical nurse leaders create an environment conducive to the development and sharing of ideas % 54% 38% 0% Patients are encouraged to participate in feedback on care, culture and systems Total % 54% 22% 1% % 38% 23% 0% All aspects of care/treatment are based on evidence of best practice % 21% 14% 14% Education is a priority % 46% 15% 0% Audit and/or research findings are used to develop practice % 54% 31% 0% The management structure is democratic and inclusive % 46% 23% 8% The development of staff expertise is viewed as a priority by nurse leaders % 36% 29% 7% Evidenced-based knowledge on care is available to staff % 50% 21% 0% HCPs have the opportunity to consult with specialists % 38% 38% 0% Guidelines and protocols based on evidence of best practice (patient experience, clinical experience, research) are available % 46% 31% 0% Resources are available to provide evidence-based care % 36% 50% 7% The organisation is non-hierarchical Total % 41% 28% 4% % 29% 43% 7% Staff receive feedback on the outcomes of complaints % 46% 31% 0% A staff performance review process is in place which enables reflection on practice, goal setting and is regularly reviewed % 43% 29% 0% Appropriate information (large written print, tapes, etc) is accessible to patients % 43% 29% 14% Staff use reflective processes (e.g. action learning, clinical supervision or reflective diaries) to evaluate and develop practice % 40% 33% 5% Total

16 Collaborative Practice Evidence informed practice Respect for persons Practice Boundaries Evaluation 16

17 Appendix 3. Notes from Discussions to Create Content of DVD Introduction by Bronagh Scott (Director of Nursing) What key messages are being delivered by Bronagh Scott? Patient safety is everybody business The Trust is required to report on the number of acquired infection Both CDiff and MRSA are dangerous to patients Anybody can spread infection Preventing infection is about keeping patients safe Adhere to Trust policies and guidelines keep/maintain standards Coming in with fresh eyes could mean that there are practices that you observed which are not conducive to infection control practices Feel comfortable to challenge other staff and escalate issues if you feel that support to maintain standards are required Hand Hygiene What are the key messages around good hand hygiene practices? Gel your hand before coming in contact with patients and after coming in contact with patient Wash your hands in the case of diarrhoea Hands naturally have bacteria There are a number of surfaces where bacteria dwell both at home and at work. At work it includes door handles, telephones, toilet seat, keyboards Pay attention to the areas you might miss when gelling or washing your hands What are the implication of touching these areas/items and not washing your hand? What would you do differently? Always follow infection control procedures, make hand hygiene a priority Challenge other members of staff Transmit infections and cause harm to patients Patient Stories What are the key words that the patients in the video used to describe their viewpoint about infection control? Considered it important Instil confidence What are the keywords used to describe how the patient felt feel when they see good hand hygiene practices? First thing I look for Reassuring Infection can kill What is the statistic around MRSA bacteraemia (MRSA infection in the blood stream)? What other impact does infection rate have on the hospital? Patients can lose trust in the hospital It affects patients physically and psychologically What do you noticed about the ward environment? Clutter free, Lockers are clear easy to clean - clutter free lockers Clean Relating Awareness to Practice What would you do differently in relation to your practice around infection prevention? What would you do differently in relation to other staff practices? How can you contribute to infection control prevention in your area?

18 Appendix 4. Repeated Values Clarification Exercise I believe that the purpose of infection control is: To prevent cross/spread of infection To eliminate bad practice around infection To promote awareness to everyone Reduce patient hospital stay I believe the purpose of infection control can be achieved by: Doing it, every individual - staff patients, family visiting patients etc. should do their part for example, washing of hands. 'This is a big help for preventing' infection Hand hygiene Uniform washing facilities Regular audits Regular cleaning of equipment Following proper hand hygiene and following precautions Washing hands before and after dealing with patients Staff communication with infection control Education of staff and ensuring adequate resources Team work Health promotion campaign I believe that my role in infection control is: To follow strictly the guidelines of the hospital about infection control To maintain a good standard of hand hygiene To make sure that equipment are cleaned following proper procedures To educate other staff if they are not following correct procedures Making sure that the environment is clean and safe for all patients Wearing appropriate apron and gloves when required, ward cleanliness Adhering to the hospital policies, updating myself Be a positive role model, vital and important Observe cannula site and catheters I believe that the factors which enable good infection control are: Check the ward toilet, commodes etc. if clean Regular updates from the hospital Reminders of hand hygiene techniques Regular training Good work dynamic and respect amongst staff Adequate supply of staff Adequate resources Regular checks making sure everywhere is clean Infection control is everyone s business Full assessment of patients Cleanliness throughout all the clinical areas Proper disposal of laundry Good practice in isolation of patients High staff moral, 'a Yes we can do culture' Visible leadership Education of staff I believe that the factors that will inhibit infection control are: It's everyone job, especially the staff to prevent infection Poor facilities - lack of resources to maintain good practice e.g. lack of Alco wipes, hand gels etc. Poor work dynamics - staff feeling they could not correct other and other staff members Poor hand hygiene by patients, staff and visitors Using barrier nursing where appropriate 18