Post-insertion Catheter Care Audit

Portfolio Activity 1

Permissions and ethics considerations

This audit is a part of quality assurance (QA) that aim is to assess the adequacy of existing practice about the post-insertion catheter care against the standards, in order to minimize the central venous catheter related infections (CVCRIs) in a medical ward. This QA activity will possesses a negligible risk (NHMRC 2015) because the data will be analyzed for the purpose of maintaining standards and data will not be gather beyond that which is collected routinely from the participants (NHMRC 2014). That includes assessing nurses’ practice about the central venous catheter (CVC), its dressing skills, and patient’s CVC condition. Therefore, this audit will own more benefits than harm and will not require human research ethical committee (HREC) permission (NHMRC 2014). However, permission will be obtained from non-HREC.

Informed consent:

The opt-out approach will be used to recruit the participants into this audit, where the general information about this audit will be shared to all participants and their involvement. Those participants who are not willing to participate will notify the auditor; otherwise their participation is presumed (NHMRC 2015a).

This audit information will be posted on the unit notice board a week before the actual audit starts. The poster will only contain the general information about the infection control audit and will not specify, which infection control policy is going to assess. The reason for not disclosed all the information to participant is to obtain the true data of staff practice about the CVC, because if participants get familiar with the audit aim, they will intentional started to behave differently (NHMRC 2015a). Moreover, before starting of the each shift, auditors will notify participants that those nurses, who are going to perform CVC dressing skills, will accompany auditors. But auditors will not permit participants’ to know what aspect of dressing skills will be assessed. However, once audit will finish, its aim and method will be shared and posted on the unit notice board.

The data about the condition of CVC and nurses ‘dressing skills will be obtained by assessing the patients’ CVC site and nurses’ practice about the CVC dressing on patients. Thus, auditor will also take the verbal consent from the patients. Patients’ who are highly dependent on medical care or not capable of making decision, consent should be sought from participant’s guardian (NHMRC 2015b).

Privacy and confidentiality:

Participants’ confidentiality will be maintained (HREC 2008). The collected data will not contain any personal identifying information about participants. Collected data will be shared, once it get analyzed without disclosing the participants’ name to staff, head nurse, clinical nurse instructor, manager, director of nursing services and infection control committee (ICC) in order to develop the action plan based on identified needs.

While assessing the patient CVC site and nurse’s practice about the CVC dressing, auditor will ensure patient privacy (HREC 2008). Moreover, to maintain the patient privacy, two auditors will be selected from the ICC, from which one would be male and other would be female. Female auditor will assess the female patient CVC site and same goes with male auditor.

Infection Control Committee (ICC):

Permission will be obtained from the ICC because they have following responsibilities: to manage infection control programs; to monitor hospital acquire infections through frequent audits; to facilitate in continuing education and ongoing training programs for HCWs to prevent and control all aspect of infections. Moreover, ethical issues about this audit will be discussed and modified after ICC feedback.

Nursing Director and Manager:

Permission will be obtained from nursing director and manager because they are responsible for safety and quality of their hospital; staffing; employee satisfaction; consumer satisfaction; and budgeting.

Head Nurse (HN):

Permission will be taken from the unit HN because they have a responsibility to manage their unit; to assure the quality care to all patients. Moreover, HN assists and conducts education and training programs for their unit staff.

Portfolio Activity 2:

Barriers and Facilitators: Impact on clinical practice change

Elements of practice that assist my project:

The element that will assist my project are the dominant organization culture leaders that includes the nursing directors, manager and ICC have significant impact on the ability of head nurse and clinical nurse instructor (CNI) to bring about the changes in nursing practice (Helfrich et al. 201).

ICC will be involved in this audit as a stakeholder (ECDC 2013), facilitator to bring changes on staff practice and sustainability of that project. Because they are:

• Expert in infection control field.
• Responsible to develop, revise and implement the infection control policies based on standard guidelines.
• Conducting audits to evaluate the practice and performance of health care workers with standards and participate in those activities that improve compliance by monitoring parameters with regard to process or outcome.
• Identifying barriers to adherence with policy and procedure, by involving health care workers.
• Facilitate clinical care organization to implement infection control guideline, e.g. through proper training of employees about the infection control and prevention.

Unit HN and Clinical Nurse Instructor (CNI) will be involved during the process of change management and sustainability of that project because both are responsible to regularly conduct the unit rounds. During the unit rounds, they will assess the staff performance and practice about the CVC on regular basis; reinforce staff to follow the ICC guidelines; and conduct the training session for their staff based on identifying needs particularly about the CVC.

Elements that become a barrier for my project:

Jeffery & Pickler (2014) have identified the following barriers to become non-compliance with CVC guideline could be the cognitive and contextual factors.

Cognitive barriers:

• Nurses are working with the many competing priorities of patient needs that lead them to prioritize their activities. Therefore, they are skipping those activities which they considered least important.
• Nurses are not following the guidelines when they do not see evidence of harm; understand the rational of policy’s; and want to waste the resources.
• Lack of knowledge and forgetfulness about the policy.
• Nurses do not wash their hands frequently, when they are continuously using patient’s CVC site.

Contextual barriers:

• The organization is placing an importance to such activities that staff consider least valuable. These priorities includes aspect of documentation (staff feels that they are documenting more than providing care), frequent changes in practice, and lack of training.
• Shortage of staff, resulting in taken shorts cuts.
• Unavailability and inaccessibility of supplies and equipments.

Strategies that assist staff and sustain to change their practice:

Jeffery & Pickler (2014) have mentioned some strategies that assist staff to change their practice are as follows:

• Commonly supplies and equipment should be readily available.
• Training and education about the infection control policy should be offered to all staff.
• User-friendly documentation system should be made.
• Sanitizer should be available on patient’s bedside.
• Staffing should be adequate.

Other strategies stated by SA Health (2012a) & SA Health (2012b) could be:

• Surveillance and auditing programs should be frequently performed by ICC.
• Ongoing feedback or appraisal should be given to staff to improve their practice.
• Ensure that online infection control policy should be accessible to all the staff or posted on the notice board.
• Encourage staff to use incident reporting system to notify any breeches in infection control practice.
• Elect the infection control nurses (ICN) from each shift that will be responsible to monitor the infection control practices in their own groups. So in this way, unit staff will start taken the responsibility to prevent and control the rate of infections from their units (Kitson & Straus 2013).

To conclude, this audit will only achieve its aims and significant outcome, when organization will understand the staff barriers and take some actions against those barriers, which staffs are facing at interpersonal, intrapersonal and organizational level, results in sustainability of this project.

References:

European Centre for Disease Prevention and Control (ECDC) 2013, Core competencies for infection control and hospital hygiene professionals in the European Union, Stockholm, ECDC.

Helfrich, CD, Yu-Fang, L, Sharp, ND, & Sales, AE, 2009, ‘Organizational readiness to change assessment (ORCA): Development of an instrument based on the Promoting Action on research in health services (PARIHS) framework’, Implementation Science, vol. 4, no. 1.

Human Research Ethics Committee (HREC) 2008, Quality Assurance Guideline, viewed on 27 May 2015, < http://www.newcastle.edu.au/research-and-innovation/resources/human-ethics/policies-and-guidelines?a=28875>

Jeffery, AD, & Pickler, RH 2014,’ Barriers to Nurses’ Adherence to Central Venous Catheter Guidelines’, The Journal of Nursing Administration, vol. 44, no. 7/8, pp. 429-435.

National Health and Medical Research Council 2014, Ethical Considerations in Quality Assurance and Evaluation Activities, viewed 26 May 2015, <https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/e111_ethical_considerations_in_quality_assurance_140326.pdf>

National Health and Medical Research Council (NHMRC) 2015, Chapter 2.1 Risk and Benefits, viewed 22 May 2015, < http://www.nhmrc.gov.au/book/chapter-2-1-risk-and-benefit>

National Health and Medical Research Council (NHMRC) 2015a, Chapter 2.3: Qualifying or waiving conditions for consent, viewed 23 May 2015, <http://www.nhmrc.gov.au/book/national-statement-ethical-conduct-human-research-2007-updated-december-2013/chapter-2-3-qualif>

National Health and Medical Research Council (NHMRC) 2015b, Chapter 4.4: People highly dependent on medical care who may be unable to give consent, viewed 23 May 2015, <http://www.nhmrc.gov.au/book/chapter-4-4-people-highly-dependent-medical-care-who-may-be-unable-give-consent>

South Australia Health 2012a, Healthcare Associated Infection (HAI) Action Plan 2012 – 2014, viewed 23 May 2015, < http://www.sahealth.sa.gov.au/wps/wcm/connect/7ec93b004d4617539bc8dbf08cd2a4a7/Clinical+Directive_HAI+Action+Plan+2012-2014_Oct2012.pdf?MOD=AJPERES&CACHEID=7ec93b004d4617539bc8dbf08cd2a4a7>

South Australia Health 2012b, Health care associated infection prevention: Strategic Framework, viewed 23 May 2015, < http://www.sahealth.sa.gov.au/wps/wcm/connect/fa5710804d461a0f9c0adff08cd2a4a7/Clinical+Directive_HAI+Strategic+Framework_Oct2012.pdf?MOD=AJPERES&CACHEID=fa5710804d461a0f9c0adff08cd2a4a7>