Clinical governance: implementing a change in workplace practice
Wendy Reid, BN, RGN, Dip Adv Nurs Stud.
Charge Nurse, Medicine and Cardiovascular Group, Tayside University Hospitals NHS Trust, Ninewells Hospital, Dundee
To contribute to modernising the NHS and ensure clinical quality within it, the Government introduced the concept of clinical governance, to be applied to all patient services (Scottish Office, 1997; 1998; Scottish Executive, 2000).
Practitioners can integrate the key elements of clinical governance into their practice by developing and implementing clinical practice guidelines. Developing best practice using this approach involves:
The draft guideline related to reliable and effective methods of confirming nasogastric tube placement. The gastroenterology nurse specialist recognised the need for such a guideline and initiated a multidisciplinary group whose members had relevant knowledge and clinical experience, to explore and question current practice. The group also considered risk factors associated with nasogastric tube placement. The absence of local and national guidelines does not make it easy to operate homogeneous or clinically effective practice. The previous guide to practice within this clinical area was an outdated ward guideline. The Royal College of Nursing (1997) suggests factors such as these indicate the need for guideline development.
To define and reinforce good practice, the guidelines had to be based on the best available evidence. To develop the guideline the gastroenterology nurse specialist initiated a literature search of publications since 1990, using, among others, the Medline and Cinahl (Cumulative Index of Nursing and Allied Health Literature) databases. Key words used to search included: nasogastric/enteral feeding, positioning/confirming, feeding/nasogastric tube placement. The evidence informing the draft guideline resulted from research undertaken, and/or recommendations made by Metheny et al (1993; 1998; 1999); Neumann et al (1995) and Colagiovanni (1999).
There was recognition that practice can become both ineffective and inefficient without benchmarking against best evidence. Therefore, since this aspect of care is frequently undertaken within the clinical area, practice needed to be updated and based on best available evidence; the draft guideline provided this evidence (Table 1).
The Royal College of Nursing (2000) stipulates the need for clinicians to be involved in and use risk assessment and prevention strategies to facilitate the development of good practice, reducing the occurrence of harmful or adverse events. The initiation of prompt action was stimulated by being confronted with evidence that suggested that current practice created a potential clinical risk. The strategy for managing clinical risk within the ward area involved the dissemination and implementation of the draft guideline (Box 2).
Leadership and the creation of a culture that promotes lifelong learning through ongoing development of knowledge and skills were considered to be significant factors in the dissemination and implementation of the guideline. According to Adams (1999c), to persuade others to make a change the change agent must be influential. As a senior nurse within the workplace the author was considered to be in an influential position to lead change; personal practice would also need to change. The role of leadership at all levels within nursing makes a vital contribution to ensuring high standards of clinical care and developing evidence-based practice (Scottish Executive, 2001). At the core of effective leadership and change is effective communication with those team members who are involved and affected by it.
Enquiries were made about the equipment needed and the necessary supplies were ordered - availability of essential equipment was a crucial factor.
Communication was central. Ward meetings were used to discuss the risks of not initiating a change in practice, once the need for the new guideline had been established and the principles introduced. Offering the reasoning for a change in practice is just as important as defining the risk of not changing (Plummer, 2000). In this case, changing practice would not only enhance quality of care, it would promote trust, confidence and involvement between staff and patients, whereas the risk of not changing practice was the potential clinical risk to patients.
The plan for changing practice incorporated a normative-reductive strategy: a change in knowledge, attitudes and behaviour enabled planned change to become as acceptable as the previous practice. Successful long-term change is achieved when restraining forces are weakened or eliminated; the focus should not only be on strengthening the driving forces (Swage 2000). When change has succeeded team members’ actions and statements are in congruence; they demonstrate the new attitude or behaviour consistently, or speak about it positively (Bernhard and Walsh, 1995). Informal monitoring of daily practice of staff has revealed the following:
Although the action plan initiated for changing practice succeeded, it was not as theoretically based or as systematically planned as current literature might suggest. In future the following tools and models could be considered:
This enables a vision of the broader issues that can influence change (Adams, 1999c)
After disseminating and implementing evidence-based guidelines, it is necessary to measure and monitor the practice change formally, to evaluate whether the actual practice meets that recommended in the guidelines; quality improvement does not end with implementing change (Garland, 1998). Measuring and monitoring quality of care are essential to achieve the goals of clinical effectiveness, as well as being a requirement of clinical governance (Scottish Executive, 1999b). Besides being inherent in the political agenda, evaluation is also an opportunity for nurses, as accountable and responsible practitioners, to provide evidence of the standards of care provided (Morrell and Harvey, 1999). Consequently the contribution of nurses in maintaining and ensuring optimum quality of care can be reflected and recognised.
Clinical governance and its relationship to practice can become a reality, as indicated in this project. Integrating the key elements of the clinical governance framework can facilitate safe and effective nursing practice. This project clearly identifies the influential and significant role of nurses within the multidisciplinary team, and how they take forward the clinical governance agenda. The value of culture, leadership and the emphasis on staff learning, development and empowerment throughout the duration of this project - requirements that the clinical governance framework advocates - cannot be underestimated.
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