Reducing Catheter Associated Urinary Tract Infection

Transcription

1 Reducing Catheter Associated Urinary Tract Infection Keywords: Values and Beliefs; Catheter Acquired Urinary Tract Infection; Context Assessment Index Duration of Project: November 2009 March 2011 Project Team: Elaine Glanville; Ward Manager Selma Mehdi; Infection Control Lead Contact Details: Summary of project Urinary tract infections (UTI) typically make up 20-40% of all healthcare acquired infections in hospitals and can lead to significant consequences in hospitalised patients. The most recent prevalence survey of healthcare associated infection (HCAI) in England (Hospital Infection Society, 2007) found 19.7% of patients in hospital had a UTI, the second largest group of HCAIs. Furthermore the survey found 31.6% of patients had a urinary catheter in situ at the time of the survey or during the previous seven days. The prevention of healthcare acquired UTIs may also help prevent or postpone the emergence of antibiotic-resistant urinary pathogens in hospital by reducing the overall incidence of UTIs and thus, the need for antibiotic therapy and a decrease in length of stay. This project aimed to reduce catheter associated urinary tract infections. Changes to practice to reduce infections were generated by the ward team themselves. Firstly, by visualising what the culture of the ward they worked would look like if they could change it to have an impact on their practice. This was followed a by a series of workshops in which each participating individual took responsibility to participate in audit, patient stories, observations of care and visiting other areas. Background The insertion of a urethral catheter is a very common procedure which is undertaken numerous times throughout the day in healthcare settings throughout the United Kingdom (UK). According to Nzarko (2009) approximately 25% of the 9 million people treated in the National Health Service (NHS) will be catheterised at some point in their journey. UTIs are one of the most common healthcare associated infections (HCAI) in hospitals. UTIs one of the largest group of HCAI, accounting for 20% of the total infection in UK hospitals (Smyth, 2006). Insertion of a urethral catheter bypasses many of the body s natural defences, including, presence of a foreign body, absence of a flushing mechanism, biofilm formation and epithelial damage. In 2008 the Microbiology Department carried out an audit of patients with urethral catheters within the Trust. The findings showed that 1 in 5 patients had a urethral catheter and highlighted that documentation relating to urinary catheterisation was poor. Although the audit findings suggested that catheter insertion was generally appropriate, it also found that the continued use of catheterisation was less frequently justifiable. Many urethral catheters were left in, inappropriately either because no one reviewed the situation or for convenience or both. It is well documented by numerous authors in various studies and guidance that catheterising patients increases their risk of urinary tract infection (Department of Health, 2007; Emmerson et al; 1996; Pratt et al, 2007). It was demonstrated by Emmerson et al (1996) that the two main risk factors for catheter associated urinary tract infection (CAUTI) Page 1 of 20

2 are at the point of insertion of the catheter and the subsequent length of time the catheter is left inserted. The longer the catheter is left in situ the greater the risk of HCAI. CAUTI associated with increased morbidity and mortality, length of stay, financial burden on the NHS as well as loss of patient dignity (Plowman et al., 1999). A report published by Plowman et al., (1999) states that it is estimated that 2-3 patients per 100 admissions will have HAI due to UTI and the predisposing factor is the presence of an indwelling urinary catheter. The financial implications associated with UTIs include the cost of antibiotic therapy, additional diagnostic testing and increased length of stay of between 2-5 days per patients. Additionally there are the cost implications to the patient in terms of increased morbidity and motility. In view of all the evidence healthcare professionals need to think progressively and implement strategies that will help to reduce the need for catheterisation. One way of doing this is to put in place guidelines to assist healthcare workers in deciding if the patient needs to be catheterised and if they do how this will be managed together with a recommendation for early catheter removal. Numerous publications (Department of Health, 2006, 2007; Pratt et al., 2007) ensure that there is evidence to enable the nursing fraternity to practice using research based evidence. The main points to be remembered in a bid to reduce CAUTIs are; to avoid insertion of catheters, use an aseptic technique on insertion, use evidence based practice for ongoing care and promptly remove catheters. Project Area The project lead was the ward manager of a 24 bed medical/rehabilitation ward for people, which was part of the elderly care unit based in a large teaching hospital in South West London. The ward has an ethos to admit patients over 65 years of age with complex medical and social needs. The ward had a substantive multi disciplinary team (MDT), which was made up of two consultant geriatricians, a group of doctors, physiotherapist, occupational therapist, matron, discharge facilitator, a ward manager and 31 nursing staff and other ancillary staff, all ward based. A variety of members of the wider MDT had a considerable input on the ward and included the infection control team, dietician, and speech and language team. Other disciplines were available and consulted as required. The staff on the ward have a wealth of knowledge in the field of elderly care and were constantly striving to improve the care that was delivered to all the patients. All three wards on the unit were involved in the project however the main focus was the project lead s ward. It is notoriously difficult to find a workable definition of what constitutes a CAUTI, therefore rather than attempt to define and measure the incidence of CAUTI it was decided to concentrate on implementing those measures known to reduce CAUTI as advised by the Department of Health s Advisory Committee on Antibiotic Resistance and Healthcare Associated Infection cited in the NHS Institute for Infection (2010a). This approach acknowledges that an improvement in practice would lead to a reduction in CAUTI. Continuing assessment of inappropriate use of catheters is used to measure success. This was in line with the thinking underpinning High Impact Actions for Nursing and Midwifery (NHS Institute for Innovations, 2010b). The nursing team together with the project lead were keen to explore nursing responsibilities, identify practice problems and develop a strategy to prevent HCAIs related to urinary catheters. The nursing team was keen to take this initiative forward and believed this project could result in significant benefits for all concerned and in particular patients. Aim of the Project The ultimate aim of this project was to reduce catheter associated urinary tract infection. It was envisaged that by reducing CAUTI the follow on benefits would include reduced Page 2 of 20

3 morbidity and mortality, financial costs, and less complaints. Benefits for the patient would include fewer invasive procedures, pain and distress and increased dignity and privacy. Objectives To identify the percentage of CAUTIs within the care of the elderly unit To implement changes that will reduce CAUTIs and catheterisation within the care of the elderly unit To build a positive and proactive team To improve communications/documentation skills To empower nurses to be proactive in the removal of catheter To achieve this aim the project needed to find and identify ways for the nursing staff to develop their knowledge, explore nursing responsibilities, identify practice problems and develop a strategy amongst the nursing staff to prevent HCAIs related to urinary catheterisation. Furthermore to facilitate achievement of these goals the workforce would need to take ownership of required changes. Methods and Approaches Brief Overview This project looked at reducing CAUTIs in hospital patients. Historically and traditionally nurses such as Florence Nightingale and Mary Seacole recognised that improving hygiene and cleanliness, led to less disease and patients spent less time confined to hospital beds. Nurses are consumers and producers of evidence that guides practice, education and instigators of further thought provoking topics which provides a continuous base for future evidence base practice (cited, Doordan 1998, p 3) This project was based on the naturalistic philosophic approach (Doordan, 1998). This approach enabled the project to focus on collecting information about perspectives and meanings of experiences from the viewpoint of individuals and groups directly living and exposed to the experiences. The nursing discipline involves complex relationships between the patients, nurses, health and the environment. To be able to develop knowledge that will educate and improve nursing practice it is important that these complex needs are understood. Therefore, it was agreed by the project leaders that organising workshops for the staff would encourage workplace innovation and reflections on practice. This method gave staff an opportunity to influence change by being proactive and adopted a bottom up approach. A number of approaches were used to facilitate these changes to practice. These included:- Snapshot audit Project team group Context Assessment Index Tool (CAI) Staff workshops Observation of practice Audits Snapshot Audit A snapshot audit was undertaken at the beginning of project on the three care of the elderly wards to establish baseline information on catheterisation (see Appendix A: Catheter Care Audit Form). The finding of the audit confirmed the findings of the hospital s 2008 audit, namely; documentation from insertion to ongoing catheter care was extremely poor the majority of catheterisations are at the beginning of the patients journey best practice was not followed for insertion or ongoing care Page 3 of 20

4 A further snapshot audit of all catheters in place was carried out across the Trust on 25 th August The data was gathered using an audit pro forma based on that used in the 2008 audit, but with some additional questions concerning the use of management plans and any ongoing treatment for CAUTIs as these were also areas that were identified for improvement. Data was returned to Clinical Audit for collation and analysis. Data was returned for 34 wards, including the wards taking part in this project. Trust wide 741 patients on the wards were audited and of these116 were catheterised (16%). 57 % of the patients with catheters were male. Table 1 shows the catheterisation rates for the wards involved in this project and compares the results to the previous audit. Table 1 Specialty Number Catheterised Total Patients % Catheterised % Catheterised in previous audit Care of the Elderly % 22% Project Team Group Following discussion the project leaders believed it would be beneficial to form a project team group comprised of representatives from the nursing teams of all the elderly care wards. From this group, a team leader was chosen for each ward who was given the responsibility for all aspect of the project within their ward. It was imperative that the group represented all grades of nursing staff, so the project leaders involved the senior nurses from the two other elderly care wards to identify the most appropriate nurses from their team, to whom an invitation was extended for them to join the group. The first meeting was to inform them of the project and its aim. Following from this it was agreed that ward based meetings would be held to share experience of how catheter care was managed and identification of CAUTI was challenged/ managed on each clinical area. Two nurses from varied grades were represented on the group. At the first ward team meeting the project was explained to all present as it was important that they were all willing and eager participants. During the meeting every one was given the opportunity to share their experiences of caring for patients with a catheter and any obstacles they may have encountered. One healthcare assistant (HCA) shared how she had been innovative in sending a urine sample to microbiology for a patient who had not been her normal active self even though the patient s vital signs did not show any reason for concern. The HCA proactively sent a catheter specimen of urine and informed the team of this but felt no one listened to her, despite several attempts to tell them her concerns. A few days later the patient spiked a very high fever and became delirious. By then everyone had become very concerned and following reiteration of her concern and that she had sent a sample of urine, the doctors were able to check the result to see she had a UTI and give appropriate treatment. Wells (2010) aptly stated that HCA s role in the clinical setting is an increasingly important role in the provision of patient care and they are also in the best place to witness and challenge poor care and to identify changes in patient medical status. Yet, often the HCA lacks the confidence to do so as they may not be taken seriously. Following the focus group meeting a vision for reducing CAUTIs was developed, see Appendix B. Page 4 of 20

5 Context Assessment Index The project leaders attended workshops facilitated by FoNS that brought together the project leaders from the all of the 15 projects within the programme. At the first workshop the project leaders were introduced to the Context Assessment Index, developed by McCormack et al (2009). The aim of the CAI is to enable health care professionals to assess the context within which care is provided in clinical areas. It can be completed by one person such as a specialist or ward leader, or the tool can be completed by each member of the team. It is recommended that one person coordinates the process (McCormack et al., 2009.) The project leaders discussed and agreed that using the CAI would be the appropriate way to engage staff, to provide them with a chance to participate and influence the development of changes. During the first project team meeting the CAI was discussed. Each ward team leader was issued with a folder and copies of the CAI to take back to their respective areas for the rest of the team to complete. Two weeks later the completed CAIs were returned to the project leader to collate the findings. A total of 29 staff across three wards completed the CAI. The six questions that scored the lowest marks were looked at in detail, identifying culture as the key area for development (see Appendix C). The results of the completed CAI were fed back to staff at workshops. Staff Workshops The first workshop was organised in collaboration with the facilitator of the FoNS programme. With guidance and support the project leader was able to plan and deliver a comprehensive day for those who attended. The workshop was well attended by a cross section of the nursing staff (approx 30 staff). The workshop began with an introduction to the days programme (see Appendix D). The next exercise encouraged participants to set their own rules for what behaviours would and would not be accepted for the duration of the day. The programme included a brief reiteration of how and why the project came about and the journey taken getting to the first workshop. At the workshop staff completed a values clarification exercise (Warfield and Manley, 1990) (see Appendix E) related to reducing HCAIs. A group discussion took place around values and beliefs and what they meant to the participants as individuals and as employees. During the discussion it was agreed that values are intensely held views that operate as guiding principles for each of us and the organisation. These form the basis for trust when they are acknowledged and followed. Left unstated they are inferred from observable behavior, when stated and if not followed trust is broken. It was agreed unanimously that our beliefs are constructs around which we organise our behaviours and may or may not be true. This process helped staff gain a greater understanding into how we develop our beliefs and values. This is illustrated by the Lily Pond diagram: The roots of the lily our beliefs, deeply held The low stalk our values, based on these beliefs The high stalk our attitudes towards the world The leaf on the surface our behavior, that others see (Attitudes, values and beliefs, Cheek, 2007) The key themes from this exercise were listed and displayed on the three wards as a vision for what the team were aiming to achieve within the project (see Appendix F). A discussion followed on how the results of the CAI were enabling or hindering the staff from meeting the vision in practice. Page 5 of 20

6 The participants were divided into three groups and given a topic and materials related to the topic to discuss and debate. They were asked to reflect on how this linked to their vision. The staff transcribed their discussion on to a flip chart. These ideas were then shared with the complete group and the discussion was then opened to everyone. A very healthy and provocative discussion took place and the remainder of the days sessions were as interactive as the first session. Discussion topics included: What is the purpose of reducing HCAIs? What factors reduce HCAIs? How will you know that you have reduced infection? What would a decrease in infection mean for staff? What is the patient s perspective of decreased HCAIs? What is the organisation s perspective of decreased HCAIs? What is our role in reducing HCAIs? At the end of the day each participant was asked to sign up to do at least two pieces of work to assist with the project (see Appendix G for example of one sheet). Participants were also asked to name one change they would make to their practice when next returned to work (see Appendix H). One statement that was so simple but stood out from the rest was practice would be changed by ensuring that patients with a catheter leg bag would always have them strapped to their thighs when in bed. Previously the reason for this was not understood and the rule in reducing infection from a single person perspective was deemed as not relevant and/or important. The final exercise of the day asked participants to list on sticky notes things that they had learnt during the day, this is summarised in Appendix I. One ward discontinued participation in the project prior to the first workshop due to staffing issues. Subsequent workshops followed and were greeted with the same enthusiasm as the first. Due to ward staffing pressures the second workshop was not as well represented, but no workshop had to be cancelled due to lack of participants. Observation of Practice, Audit, Patient Stories Following the workshops participants were supported to engage in the work they had signed up for during their individual workshop. The available topics included, auditing catheter care and documentation, patient stories and observation of care. Auditing was the most popular topic and was eagerly performed by those whom had signed up to do this. When other staff who had not yet attended the workshop saw the enthusiasm of the staff that were taking part and they too wanted to take part which meant most staff were engaged in the project. A series of mini workshops sessions took place for the staff. This was focused on preparing the staff to carry out the practice development activity they had volunteered for such as, observing practice and audit. Related Initiatives to Reduce Catheter Associated Urinary Tract Infection Whilst this project was underway a number of other initiatives aimed at reducing CAUTI were introduced within the Trust. These initiatives included the following: NHS Institute for Innovation and Improvement (2010) High Impact Action Programme for Nursing and Midwifery Standardisation of Urinary Catheters Introduction of a Catheter Insertion Pack Introduction of a Catheter Monitoring Form Monthly Catheter Audits The project leader successfully obtained ten bladder scanners, which were distributed throughout the Trust. These bladder scanners were used to measure the volume of urine in the bladder. This provided evidence to use when making decisions regarding catheterisation. This has led to a reduction in the number of patients with indwelling urinary catheters on the Page 6 of 20

7 project wards. An increase in intermittent catheterisation which is preferable was noticeable for those patients who are not able to completely empty their bladder. A change of catheter products took place and instead of using separate items for catheterisation, the Trust now uses a single catheter pack which contains all the necessary equipment required for the insertion of a catheter. Additionally, the Trust no longer uses two different sizes of catheter which means that staff will not be able to insert the incorrect catheter into a male patient. This system reduces catheterisation time from a nurse s perspective and the risk of infection. A catheter monitoring form (see Appendix A) was introduced by the Trust and trialled on elderly care ward taking part in this project, the layout of this was based on the visual infusion phlebitis score chart (Jackson, 1998). The chart requires that all patients who are catheterised must have this completed at the time the patient is catheterised and this then accompanies the patients on their journey. The forms ask for the patient details and the sticker from the catheter pack is placed on the chart, the chart prompts the staff to check the catheter at least daily. Staff are able to use this simple check list by just ticking the boxes to what are the relevant questions required to ensure that the use of the catheter is no longer required and if it is the after care is maintained. Another implementation was that monthly snap shot catheter audits were carried out Trust wide. The effect for the wards taking part in this project was that a reduction of catheter insertion was occurring month after month and there were months when the wards had no patient with a catheter, which is evidence of proactive management. Outcomes Following the workshops, staff were asked to complete a second CAI and values clarification exercise; the results of which demonstrated that the work place culture had changed. Nursing staff clearly felt more empowered to ascertain the reason why catheters were required. Nurses were more able to discuss other options open to them before it was decided a catheter was the best option. As a consequence when a catheter was inserted the need for this was clearly documented. Nursing staff on the wards participating in this project were also observed challenging colleagues from other areas when patients were transferred with a catheter without evidence to support the reason for catheterisation or an inappropriate reason was documented or there was no obvious plan of care. The need for the catheter to remain in situ was reviewed on a daily basis. Discussion within the multi disciplinary team (MDT) was led by the nursing staff who informed MDT members of the plan to remove the catheter. This led to a change of practice whereby the plan of care was then documented directly into the clinical notes, which are accessible to the entire MDT. Discussion Undertaking this project has allowed the nursing staff to spend time away from the ward environment during which they were able to explore their own beliefs and values and those of the organisation in which they work and the workplace culture. Staff were also able to examine those factors which contributed to and those which detracted from HCAIs and in particular CAUTIs. In the workplace staff were able to take the time to carry out audits, observations of practice, patient stories and to visit other areas to look at practice. In doing so nursing staff gained the knowledge required to change their practice. These changes to practice could be simple, such as ensuring catheter leg bags were always strapped to the thigh or more difficult such as challenging the need for a catheter to remain in situ. The nursing staff were empowered to take responsibility by developing plans of care for catheterised patients and documenting them in the patient s notes. A number of Trust wide initiatives to reduce CAUTIs were introduced during the project and ran concurrently. It is likely that the synergy achieved by the combination of this project Page 7 of 20

8 together with these initiatives led to a further reduction in the number of patients with urinary catheters and improvements in the care of those patients who were catheterised. The snapshot catheter audits provided evidence that urinary catheter use was significantly lower on the project wards, from this data it can be assumed that by reducing the number of catheterised patients a consequent reduction in CAUTIs will be achieved. The snapshot audits show that the percentage of patients with urinary catheters on the project wards reduced from 22% in the first audit to 8% in the second audit, a reduction of 14%. The Trust wide snapshot catheter audit found that patients on the project wards (8%) were 50% less likely to have a urinary catheter compared with patients on other wards (16%). Conclusion Guidance that is based on evidence, clearly states that urethral catheters should only be inserted when there is no other choice, this should be documented and a clear plan for management and removal is available and the time frame for removal should be as short as possible (Department of Health, 2006, 2007; Pratt et al., 2007). However it has to be acknowledged that there are times when catheterisation and the ongoing use of a catheter is justifiable (Jain et al., 1995). Nursing staff are best equipped to ensure that the catheter is introduced using an aseptic technique, that the ongoing care follows best practice and that the catheter is removed as soon as it is no longer necessary. It is evident from the staff that took part in the workshops that empowering staff from the bottom up affects how changes are accepted and maintained. Staff that have been empowered to practice knowledgeably will reduce the number of patients who develop a CAUTIs and the associated mortality and morbidity that these infections can cause. The monitoring form which was implemented helps staff to understand the reasoning for catheter insertion so that they can plan care and a timely removal. The purchasing of the bladder scanners has assisted in reducing the number of catheterisations that is performed. This project demonstrates the benefits of small ward based projects in making evidence based changes to practice and has had significant benefits for patients in terms of reducing catheter associated urinary tract infection. Recommendations Continue with monthly audits Bi-annual workshops for staff Audit of monitoring form Purchasing of further bladder scanners to ideally provide one per ward Use this approach to explore and change other areas of practice FoNS Funds The fund of 5000 was used to provide lunch and snacks for those attending the workshops, replacement of staff, staff attending associated workshop for project, typing of materials and the provision of some materials to facilitate the workshops. It is planned to use the remaining funds to celebrate and recognise the achievements the nurses have made. The plan is to give the nurses an evening of celebration and present them with a certificate of attendance for the work shops. Acknowledgement To everyone who as supported this project in whatever form. 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. Page 8 of 20

9 References Cheek, B., (2007) Attitudes, values and beliefs: Available from: (Last accessed 15th July 2010) Department of Health (2006) Essential Steps to Safe, Clean Care: Reducing Healthcare- Associated Infections. Department of Health, London Department of Health, (2007) Saving Lives: Reducing Infection, Delivering Clean and Safe Care. Department of Health, London Doordan, A. M (1998) Research Survival Guide, Lippincott s Need-to-Know: New York Emmerson, A. M., et al, (1996) The Second National Prevalence Survey of Infections in hospital overview of the results. Journal of Hospital Infection. Vol. 32. No.3: pp Hospital Infection Society, (2007) The Third Prevalence Survey of Healthcare Associated Infections in Acute Hospitals in England DH. London. Available at: pdf (Accessed 15th July 2011) Jackson, A., (1998) Infection control - a battle in vein: infusion phlebitis. Nursing Times. Vol.94. No. 4. pp68-71 Jain, P., Parada, J., David, A., et al, (1995) Overuse of the indwelling urinary tract catheter in hospitalised medical patients. Archives of Internal Medicine. Vol:155, No:13, pp NHS Institute for Innovation and Improvement, (2010a) High Impact Actions for Nursing and Midwifery. Available at: %20infection.pdf pp23. (Accessed 15 th July 2011) NHS Institute for Innovation and Improvement, (2010b) High Impact Actions for Nursing and Midwifery. Available at: %20infection.pdf (Accessed: 15 th July 2011) McCormack, B., McCarthy, G., Wright, J., Slater, P., and Coffey, A. (2009) Development and testing of the Context Assessment Index (CAI) World Views on Evidence Based Nursing. Vol.6. No.1. pp27-25 Nazarko, L., (2009) Providing effective evidence-based catheter care management British Journal of Nursing Vol.18. No.7. supplement pp4-12. Plowman, R., et al. (1999) The Socio Economic Burden of Hospital Acquired Infection. London: PHLS. Pratt, R., Pellowe, C., Wilson, J., et al (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection. Vol.65. supplement. pp1-64. Smyth, E. T. M., (2006) Healthcare acquired infection prevalence study. Presented at 6 th International Conference of Hospital Infection Society, Amsterdam. Hospital Infection Society, London Page 9 of 20

10 Warfield, C. and Manley, K. (1990) Developing a new philosophy in the NDU. Nursing Standard. Vol. 4. No. 41. pp Wells, A. (2010) How support staff can be helped to challenge unacceptable practice. Nursing Management Vol.18. No.9. pp Page 10 of 20

11 Appendix A Hosp No DoB Gender Catheter Care Audit: January 2011 WARD... Total No. of patients on ward on January 20 th Date of admission: /../ Was the patient admitted with a catheter in situ? Date of surgery (if applicable) No /../ Date Catheter Inserted Type of catheter: Where was catheter inserted? Urethral /../.. Number of days catheter in situ A & E Anaesthetic Room On this ward Any of the ICU Nursing home Home Who made the decision for a catheter? Doctor Nurse Don t Know What was the reason for the catheter WHEN IT WAS INSERTED? Unconscious patient Bladder irrigation Haemodynamic instability and fluid management Lack of mobility Fluid management in theatre and post theatre Patient request Incontinence and skin management No reason obvious Urinary retention What is the reason for the catheter NOW? Unconscious patient Bladder irrigation Haemodynamic instability and fluid management Lack of mobility Fluid management in theatre and post theatre Patient request Incontinence and skin management No reason obvious Urinary retention Does this patient have a catheter management plan? Yes No Has the need for a catheter been reviewed? Yes No Please give details: Is the review documented in the medical or nursing notes? Yes No Has this patient had a catheter removed and then required re-catheterisation at any time? Yes No Is the patient on antibiotics for a UTI? Yes No Please add any further relevant information here Page 11 of 20

12 Focus Group Vision Appendix B VISION for Reducing Catheter Associated Urinary Tract Infection Empowering staff to discussed with knowledge and confidence to their Reduce LOS Reducing financial implications Improve confidence in challenging others Reduce use of antibiotics Recognition as the Trust with the less % CAUTI To be open and readily accept criticisms of all types Reduce less invasive procedure and treatment for patients Maintaining dignity for patients Page 12 of 20

13 Appendix C Feedback of C.A.I. Questionnaire Weakness - Culture 14/29 staff members believe that staff did not receive feedback on the outcomes of complaints Evaluation 14/29 staff members do not believe that the organisation is nonhierarchical Leadership 11/29 staff members do not believe that Healthcare Practitioners (HCPs) in the MDT have equal authority in decision making Strengths Culture 27/29 staff members believe a proactive approach to care is taken Evaluation 29/29 staff members believe that care is based on comprehensive assessment Leadership 27/29 staff members believe HCPs provide opportunities for patients to participate in decisions about their own care These are the 6 questions that scored the lowest marks, therefore identifying culture as one of the key areas for development Staff did receive feedback on the outcomes of complaints (Q 9) A staff performance review process is in place which enables reflection on practice, goal setting and is regular reviewed (Q 12) Challenges to practice are supported and encouraged by nurse leaders and nurse managers (Q 21) The development of staff expertise is viewed as a priority by nurse leaders (Q 23) Staff use reflective process (e.g. action learning, clinical supervision or reflective diaries) to evaluate and develop practice (Q 24) Patients are encouraged to participate in feedback on care, culture and systems. (Q 33) Page 13 of 20

14 Appendix D Developing and Sustaining Cultural Changes to Empower Staff at Clinical Level Workshop Programme Feedback of C.A.I. questionnaire & group work to start the process of change 29 th July 2010, Room 20 Hunter Wing Level 5 Refreshment and Lunch Provided Welcome and coffee Programme and Workshop Introduction usage of cards to set the scene FoNs the Journey so Far slide presentation, this will incorporate the FoNs expectation Feedback of Questionnaire C.A.I. slide presentation of graph showing results of strengths and weakness, any questions Coffee Group Discussion - what is culture presentation, teams to discuss this further, completing C.A.I. in group Introduction into Values and Beliefs Lunch Feedback of V&B, Group work action plans to take this forward Group Discussion / Tea opportunity to share a few experiences for good and not so good practice Actions to take away/ next steps what they gained from the day what they will take forward and how they will begin to implement changes on the ward Evaluation / Closure Page 14 of 20

15 Appendix E Working with Values and Beliefs I believe the purpose of reducing hospital acquired infection in my workplace is; I believe this can be achieved by:- I believe our role in reducing hospital acquired infection is:- I believe the factors that will enable this are:- I believe the factors that will inhibit this are:- Other values and beliefs about reducing hospital acquired infections in my workplace are:- Page 15 of 20

16 Appendix F I Believe the Factors that will Inhibit Reducing Healthcare Associated Infections are: POOR HAND HYGIENE LACK OF KNOWLEDGE NOT FOLLOWING BELIEFS AND VALUES NOT COMPLYING WITH PROCEDURES AS PER POLICIES REFUSING TO ADAPT TO CHANGES FOR IMPROVEMENT OF GOOD PRACTICE Other Values and Beliefs about Reducing Healthcare Associated Infections in my Workplace are: BE ABLE TO CHALLENGE COLLEGUES IF THEY ARE NOT FOLLOWING THE RIGHT PROCEDURES ENSURE CORRECT DOCUMENTATION FOR AFTER CARE REVIEW REGULARLY IF NEEDED OR NOT BE COMPETENT AND CONFIDENT / COMFORTABLE APPROACHING RELATIVES/ MEMBERS OF STAFF (LIMITING VISITORS) ABLE PATIENTS TO BE THOUGHT ABOUT TO CARE FOR THE CATHETERS USE OF CHLORHEXIDINE SPRAY (PINK SPRAY USE OF GLOVES AND APRONS ENSURE THAT INFECTION CONTROL IS A TOP PRIORITY EMPTY CATHETER BAGS WHEN MLS CHECK AND DOCUMENT EVERY HOUR ENSURE BAGS ARE WELL SECURED AND NOT CUTTING OFF CIRCULATION OF PATIENT Page 16 of 20

17 Appendix G Developing and Sustaining Cultural Changes to Empower Staff at Clinical Level: Work Shop Sign Up Sheet (Sheet 1) Name Audits Observation of care Patients experience Others Madelyn Catheter valve Iveta Violet Estella Agnes Jenny Visit Vernon Allison Visit A&E Evelyn Visit other ward Dawn Bernadette Sharon Evelyn Ivy Para Bev Amanda Estriana Visit Vernon Eunice Amelia Jocelyn Joe Afua Daniella Louise Jonathan Rama Jane Viv Elvira Reading RCN guidelines on Catheters Ronell Loreta Nordia Achie ved Page 17 of 20

18 Appendix H What Changes to Practice You Will Make Next Time You Work? Proper documentation re: infection Communicate appropriately with team members- re knowledge of patient care Infection documented on handover sheet and date Feedback the good participation of ward staff to Ward Sisters and feedback to ward staff how well they have done. To appreciate themselves, gain appropriate information on patients Documentation: use appropriate language Not be afraid to speak up and ask questions Ask more questions, documentation Communication:- talk more to patients Check appropriate use of pads /catheters Page 18 of 20

19 Appendix I What You Have Learnt Today Concordance To adhere to policies to save money and time Time management Effective working with colleagues Importance/ knowledge of infection control We all want the same thing To celebrate more as nurses Good happy workforce to benefit patients Relaxed happy workshop Supportive Gain knowledge Impact of image on hospital Management of infection control Time management working as a team Lily pond Postcards different opinions Teamwork for the patients Atmosphere Being listened to Learning opportunities Log Good communication Page 19 of 20

20 Team working Different ways of infection control Importance of communication Working in a team with a positive attitude All here for our patients Good support Well valued members of the team Page 20 of 20