Behind the Rituals

A study, summarised in Nursing Times this week, identified a marked rise in the risk of medicines administration errors in patients with dysphagia compared to those without the condition. A further increase was noted when patients with an enteral tube. The study found the main causes of error was the wrong formulation and incorrect preparation of medicines.

A second paper describes the evaluation of an individualised medication administration guides for people with dysphagia. The results suggest that nursing practice could be enhanced by easy access to medicines information.

An article on the administration of medicines via an enteral feeding tube provides useful tips on safe practice.

We are discussing this issue in more detail in Putting it into Practice and on the Student Nursing Times section, Perfecting your Practice.

Public health workers have been told that patients may respond better if they are encouraged to achieve a “healthier weight” rather than being labelled obese, under draft guidance issued by the National Institute for Health and Clinical Excellence (NICE).

The advice is included in NICE’s paper entitled Obesity: Working with Local Communities and urges health professionals to use “appropriate language” to help obese patients.

It said: “The term ‘obesity’ may be unhelpful - while some people may like to ‘hear it like it is’, others may consider it derogatory.”

It continued: “Directors of public health and local government communications leads should carefully consider the type of language and media to use to communicate about obesity.

“For example, it might be better to refer to a ‘healthier weight’ rather than ‘obesity’ - and to talk more generally about health and wellbeing or specific community issues.”

Tam Fry, of the National Obesity Forum, told the Daily Telegraph: “There should be no problem with using the proper terminology. If you beat around the bush then you muddy the water.”

• NICE warn against ‘derogatory’ use of obese (2012) Nursing Times. Published online 9 May 2012.

Nurses who work predominantly with older patients are still not seen as specialists, despite the increasingly complex nature of care in this area, according to a study on international nursing opinion.

Angela Kydd, a senior lecturer at the University of the West of Scotland, highlighted that historically working with older people was viewed as a “menial job”.

Her study set out to explore modern attitudes to caring for older people across Scotland and five other countries: the US, Slovenia, Germany, Sweden and Japan.

Nurses and healthcare assistants, including those that worked predominantly with older patients, were asked to complete a 20 question survey. In total 4,791 responses were analysed.

Dr Kydd said: “The results showed that although health care professionals and assistants in America reported a sense of professional esteem, the majority of the respondents in the five remaining countries did not.”

She said a “large number” of respondents stated that other people did not view those working with older people as specialists.

“It would appear that working with older people is still viewed as a job and not as a specialism,” she said. “Further studies are needed to explore methods necessary to improve the image of those who work with older people.”

The findings were presented on Tuesday at the Royal College of Nursing’s international research conference in London.

• Older people’s nursing ‘not widely perceived as a specialism’ (2012) Nursing Times. Published online 29 April 2012.

The National Institute for Health and Clinical Excellence has updated infection control guidance originally published in 2003.

The guidance reiterates that hands must be decontaminated immediately before and after every episode of direct contact with patients, after any exposure to body fluids and after contact with a patient’s surroundings that could potentially result in hands being contaminated.

The new version of the guidelines also advises that nurses should decontaminate hands with liquid soap and water, as opposed to handrub, in clinical situations where there is potential for the spread of alcohol-resistant organisms, such as C difficile or other organisms that cause diarrhoeal illness.

This also applies to circumstances when hands are visibly soiled or potentially contaminated with body fluids. In all other situations, NICE said handrub should preferably be used to decontaminate hands.

• NICE (2012) NICE updates infection control guidance for practice nurses. Nursing Times. Published online 16 April 2012.

The National Patient Safety Agency has repeated a warning on the risk of harm posed by flushing nasogastric tubes before confirmation of placement.

The rapid response report said nothing should be introduced down the tube before gastric placement has been confirmed; nurses must not flush the tube before gastric placement has been confirmed; and internal guide wires or stylets should not be lubricated before placement confirmation. 

The NPSA said it was aware of three incidents, two of which resulted in death, since the alert went out where staff had flushed tubes with water before initial placement was confirmed.

• NPSA (2012) NPSA issues nasogastric flushing warning. Nursing Times. Published online 14 April 2012.

Any substances given through an enteral feeding tube must be via an enteral syringe or designated enteral feeding set (NPSA, 2007). The use of IV syringes to measure and administer medications through enteral feeding tubes has, in the past, led to fatalities due to the inadvertent IV administration of drugs meant for enteral feeding tubes (Hicks et al, 2008; Nevan et al, 2000). Enteral syringes are currently purple in colour and clearly labelled “for oral/enteral use” to distinguish them from IV syringes.

Three-way taps and syringe tip adaptors should not be used in enteral feeding systems because connection design safeguards can be bypassed (NPSA, 2007). All oral/enteral syringes containing oral liquid medicines must be labelled with the name and strength of the medicine, the patient’s name, and the date and time it was prepared and the person who did it, unless preparation and administration is one uninterrupted process and the unlabelled syringe does not leave the hands of the person who has prepared it. Only one unlabelled syringe should be handled at any one time (NPSA, 2007).

• Wilson N, Best C (2011) Administration of medicines via an enteral feeding tube. Nursing Times; 107: 41, early online publication.

Currently we teach all people with diabetes to look after their feet, including showing them how the nails should be cut, to prevent problems. 

Due to the increasing numbers of people with diabetes, having diabetes alone is no longer a reason to receive free chiropody. Only those people with diabetes who are at risk, such as peripheral neuropathy or had previous foot ulceration have access to free podiatry. 
There is no reason why nurses should not cut toenails provided they have had the training and have the appropriate equipment, however, they should be careful with all patients not just those who have diabetes.

Debbie Hicks is nurse consultant, diabetes, Enfield Community Services, Barnet, Enfield and Haringey Mental Health Trust; chair, Forum for Injection Technique; and co-chair, TREND-UK

A Cochrane review published in 2011 looked at three trials, involving a total of 2113 participants.

No statistically significant difference in infection rates between the masked and unmasked group was identified.

The authors of the review suggest more research is needed.

Traditionally patients would have a trail removal of urinary catheters at 6am. This allows time during the day for the patient to pass urine or to receive appropriate treatment if they go on to develop urinary retention.

Some urology wards remove urinary catheters at midnight. This allows the bladder to fill while the patient is asleep so they pass urine when they wake up. If they have problems with urinary retention these can be identified and managed earlier in the day.

One suggested advantage of the trail removal at midnight is earlier discharge from hospital and improved bed management. However, there appears to be very little evidence to support either approach or the outcome for patients.

The recently published Dignity Code by the National Pensioners Convention, says that older people should be addressed formally, rather than by their first name.

Last week Delivering Dignity, a report from the Commission on Dignity in Care for Older People, also highlighted problems with the language used to describe patients. It criticised the use of terms such a bed blocker, or referring to patients by their conditions for example as “the stroke”.

Should nurses always address patients as Mr/Mrs/Miss/Ms unless invited to use their first name?

Cognitive behavioural therapy (CBT) is a safe and effective remedy for women suffering from the side effects of breast cancer treatment, according to research.

The issue is explored in CBT ‘can safely cut breast cancer side effects’. Nursing Times. 15 February 2012.

Patients often perceive that a clinician has spent more time at their bedside when they sit rather than stand, according to nurse researchers from the University of Kansas Hospital.

The issue is explored in: Bedside interaction ‘better when clinicians sit’. Nursing Times. Published online 15 February.

Most nurses believe that staffing levels have regularly dipped below safe levels over the last year and want mandatory ratios for the number of staff per patient introduced, according to a Nursing Times survey.

Asked whether staffing had regularly fallen below safe levels on their ward over the past 12 months, 72% of respondents said that it had.

The issue is explored in: Nurses warn of dangerous dips in safe staffing levels. Nursing Times. 15 February 2012.

Many hospitals are introducing a red tray system at mealtimes to identify patients who need help or their dietary intake monitored. It was recently introduced at Norfolk Community Health and Care NHS Trust where patients with a specific dietary requirement have their meals served on an orange tray, while water jugs with red lids are provided to patients that require their fluids to be monitored.

However in this week’s practice comment Neil Wilson, senior lecturer at Manchester Metropolitan University asks whether red tray systems are putting a sticking plaster over the greater problems of poor nursing direction and leadership.

Wilson said: “The introduction of a vast amount of initiatives - such as “nutritionally screening” all patients on admission, even if the initial nursing assessment identifies they are at minimal risk of being nutritionally deficient - have increased the documentation workload for nurses. Alongside this, “red tray systems” and “red water jugs” for those at risk of dehydration/malnutrition have only proved to put a sticking plaster over the problem of poor nursing direction, leadership and the lack of management support for nursing quality care”.

The NMC Standards for Medicines Management state: “As a general principle, by disguising medication in food or drink, the patient is being led to believe they are not receiving medication, when in fact they are. The NMC would not consider this to be good practice. The registrant would need to be sure what they are doing is in the best interest of the patient, and that they are accountable for this decision”.

• The code: Standards of conduct, performance and ethics for nurses and midwives

The issue is explored in the NMC “Advice on Covert administration of medicines: Disguising medicine in food and drink”

The Queen’s Nursing Institute has launched a new drive to encourage district nurses to make the best use of new communications technology such as telehealth systems. A report published by the institute said some district nursing teams had already made significant changes to their practice as a result of new technology but others lagged behind.

The report said: “The first, and possibly the biggest issue is the attitudes of professionals to the adoption of new technologies, and their readiness to embrace such changes to practice.”

It cited a Royal College of Nursing survey from 2010 in which 20% of 1,300 respondents thought an electronic patient record could be a “threat” to the nurse-patient relationship.

But the report said communications technology was becoming part of “mainstream” community nursing provision and was “no longer just a series of interesting pilot projects”.

QNI director Rosemary Cook said: “Technology is transforming the way that care is delivered, as well as the relationship between the patient and the professional.

“It doesn’t replace the nurse, or the need for a high level of both clinical skills and interpersonal skills in community nurses. Technology only works for patients when it is combined with expert, relationship-based care.”

A recent research study found nine out of 10 care home patients are regularly exposed to drug administration errors, with half deemed to be serious mistakes. Lack of time and interruptions were identified as a major cause rather than lack of training.

Drug rounds for 345 older patients were monitored in “real time” over three months using a new barcode medication administration system. The system identified when a potential mistake was about to be made, alerting the nurse or care assistant so that an error was averted.

Study author Deidre Wild, a senior resarch fellow at UWE, told Nursing Times both staff and managers needed to be more aware of the “high level of risk of medication error” that residents were routinely exposed to and “greater effort needs to be made to protect staff undertaking medication rounds from other work demands”.

Ms Wild added that the findings highlighted the potential for increasing patient safety by using technology such as that used in her study.

She said care staff in nursing homes might be able to use it to safely deliver more simple medications, so registered nurses had more time for higher level nursing activities. But she warned: “This should not be perceived as an opportunity to reduce valuable registered nursing time in favour of employing more care staff at less cost.”

A new study based on Office for National Statistics (ONS) data has found more people are spending their final hours at home. The rise in home deaths appears to be most pronounced among people with cancer. The trend before this was a decline in deaths at home which almost halved from 1974 to 2003. Home deaths increased for the first time since 1974 among people aged 85 and over but this age group was the least likely to die at home of any adult age group over the study period.

EXPERT COMMENT

Christmas is a particularly emotive and difficult time for patients to be in hospital and anything that can help in trying to make it a little easier is important.

However, Christmas decorations in clinical areas are a challenge for several reasons i.e. health and safety, fire hazard and infection prevention and control.

Although there is little available evidence either way from an infection prevention and control perspective they have the potential for harbouring dust.

Therefore, they can make cleaning difficult particularly in the event of norovirus outbreaks which are particularly challenging at this time of year. In this event staff would have to be prepared to take down and dispose of decorations as part of the outbreak cleaning protocol.

A common sense approach and discussions with Health and Safety/Fire Advisors/Infection Prevention and Control and staff in clinical areas staff should ensure that suitable decorations can be agreed and placed in appropriate locations.

For example, most trusts advice against using Christmas trees with soil, glass baubles, tinsel, cloth toys or anything that is a fire/health and safety risk or cannot be cleaned or disposed of in accordance with trust policy.

It is important to ensure decorations are suitable for use in mental health and paediatric wards from a health and safety perspective. In mental health and the elderly, decorations are good for orientating patients to time and place.

Julie Hughes is a Nurse Consultant Infection Control/Lecturer, 5 Boroughs Partnership NHS Foundation Trust/University of Chester.

EXPERT COMMENT

It is a NMC requirement to have a documented plan of care.

Nursing care plans are, generally, the accepted way to record a patients plan of care. When completed accurately and individualised they can be an effective document.

However, in practice they do not always provide a relevant, individualised and up-to-date plan of care for patients. We need to ask whether this is due to the document itself or the standard of documentation when completing the care plan.

Lisa Magill is Practice Development Nurse, Queen Elizabeth Hospital, Queen Elizabeth Medical Centre.

EXPERT COMMENT

No, we shouldn’t because it stigmatises the older person.

It sends the message that the older person has no right to remain in their bed and that the individual is at fault.

Often the reason a person remains in a hospital bed when ‘medically fit’ is because of deficiencies in discharge planning or in care services.

It seems unjust that these deficiencies can affect perceptions of an older person’s value and entitlement to NHS services.

Linda is Consultant nurse, Ealing Hospital Trust.

EXPERT COMMENT

Peter Carter, chief executive and general secretary of the RCN has suggested that visiting times should be extended and made more flexible.

What do you think?

EXPERT COMMENT

AEDs are straightforward to use.

One study of their use at the three Chicago Airports showed that the best results were achieved when the machine was operated by someone who had no prior training.

Safe operation of an AED require people to use their common sense and follow the instructions.

Although procedures should be in place to ensure that nurses receive AED training, in the event of no prior training, nurses should be encouraged to use the AED if necessary.

Phil Jevon is Resuscitation Officer/Clinical Skills Lead, Manor Hospital, Walsall.

EXPERT COMMENT

“It is impossible to get flu from having the flu jab.

This is because the vaccine doesn’t contain any live viruses.

A very small number of people experience side effects that are similar to those of the flu, such as aching muscles, but this is simply your immune system responding to what it thinks is an attack from flu.”

NHS Employers’ ‘Mythbusters’ page

EXPERT COMMENT

Recording batch numbers for IV fluids is an outdated procedure. The burden of risk of giving an IV fluid is no greater than any other IV medicine where batch numbers are not recorded.

Martin Shepherd is head of medicines management, Chesterfield Royal Hospital NHS Foundation Trust.

EXPERT COMMENT

The routine use of physical cooling methods such as tepid sponging and fanning are controversial. If the body’s natural defence mechanism to combat infection is to increase body temperature, why try to reduce it? Physical cooling methods may actually increase body temperature: they can stimulate a compensatory response by resulting in heat-generating activities such as shivering, which can compromise unstable patients by depleting their metabolic reserve.

There is no evidence to support the routine use of tepid sponging in temperate climates such as the UK and it does not produce a sustained drop in temperature. It can cause vasoconstriction, which can result in a further rise in patients’ temperature. If it is performed too quickly, it can cause them to shiver, which will increase metabolic rate and subsequently core body temperature. It is also time-consuming.

However, some authors recommend that physical cooling methods should be used if patients have potentially life threatening hyperpyrexia, heat stroke or malignant hyperthermia.

There is no doubt that a cool fan (not directly on patients) or cool flannel on the face can be very welcome when feeling hot. Reducing the amount of clothing and bedding can also help.

Phil Jevon is resuscitation officer and clinical skills lead at Manor Hospital, Walsall, West Midlands.

EXPERT COMMENT

The simple answer is there is no evidence to suggest massage helps prevent pressure ulcers. In fact, there is limited evidence to suggest it actually causes harm, and several national guideline groups advise against it.

Key points are:

• There is no evidence to suggest massage helps to prevent pressure ulcers
• The potential for interpreting what constitutes a massage could mean there is no standard approach
• Massage on patients at risk of developing pressure ulcers who have inflamed skin could exacerbate existing damage

Heidi Guy is a tissue viability clinical nurse specialist, East and North Hertfordshire Trust, and an honorary fellow, University of Hertfordshire.

EXPERT COMMENT

There is conflicting evidence regarding the adequate quantities of fluid required for health, let alone for the management of constipation. Inadequate fluid intake is a risk factor for constipation. Older people drink less in an attempt to avoid nocturnal urinary incontinence and are at greater risk of dehydration due to an impaired thirst mechanism, especially those with severe cognitive impairment. Dehydration causes dry hard faeces resulting in a slow bowel transit time.  Consequently encouraging patients to increase their fluid consumption is widely recommended in the treatment for constipation based on the assumption that additional fluid leads to an increase in bowel transit time by bulking up faecal matter. Yet there is no clinical evidence that increasing fluids can successfully treat constipationunless dehydration is diagnosed.  However, there is a need to increase fluid intake in excessively hot weather, following alcohol consumption and if pyrexia is present.

Gaye Kyle is the chair of the ACA education committee

EXPERT COMMENT

Several studies show that healthcare workers clothing can become contaminated with potentially pathogenic microorganisms e.g. Staphylococcus aureus.

Aprons are also included as part of healthcare workers personal protective equipment regulations. (Personal Protective Equipment at Work Regulations, 1992).

Therefore, plastic aprons are part of universally accepted evidence based standards, guidance and regulations for infection prevention and control. They recommend that single use disposable aprons, or gowns, must be worn based on risk assessment when there is a risk that healthcare workers clothing may become exposed to blood, body fluids, secretions and excretions.

Such guidance also recommends that aprons must be changed and removed carefully between care provided for each patient to prevent transmission of microorganisms and when cleaning different areas e.g. bedrooms, bays, toilets, kitchens and clinical areas.

Many policies also advice different colour coded aprons to help ensure that they have been changed between patients and procedures e.g. different colours for patient care, isolation, food service, bathroom and kitchen areas. Some studies have indicated that plastic may acquire static electric charge which can attract airborne bacteria. Although there are various opinions regarding this it also helps support the need to change aprons between patients.

Julie Hughes is a Nurse Consultant Infection Control/Lecturer, 5 Boroughs Partnership NHS Foundation Trust/University of Chester.

EXPERT COMMENT

Measurement of respiratory rate should be undertaken meticulously, following local protocols and EWS guidelines. It is necessary to count the number of respirations in a minute. If patients realise their breathing is being watched, the rate may actually increase. To avoid this, healthcare professionals can pretend to check the radial pulse while, at the same time, counting the respiratory rate.

Indications include:

• Critical illness: it is an important component of the ABCDE approach;
• Ascertaining a baseline respiratory rate for comparison;
• Monitoring changes in oxygenation or in respiratory rate.
• Evaluating response to treatment, for example, following administration of a beta-2 agonist in the treatment of asthma.
• Jevon P (2010) How to ensure patient observations lead to prompt identification of tachypnoea. Nursing Times;106: 2, 2010.

Author Phil Jevon is resuscitation officer and clinical skills lead, Manor Hospital, Walsall.

EXPERT COMMENT

Rectal suppositories are conveniently shaped medicated solid preparations for insertion into the rectum.  They can vary in weight and usually consist of solid vegetable oil that dissolves at body temperature. Suppositories are manufactured in a torpedo shape with a pointed end (apex) and a blunt end. The blunt end is often concave forming a useful indention for the tip of a finger to push against.

The rectal route of drug medication is relatively painless and particularly useful for patients who are fasting or nil-by-mouth before or after surgery and for patients who are unable to tolerate oral medication

due to nausea and or vomiting. Suppositories also provide a useful route for medication in children who have needle phobia. Suppositories may be used for both local and systemic effect.

Historically suppositories were inserted pointed end first until the publication of a small study by Abd-El-Maeboud et al (1991) who recommended that suppositories were inserted blunt end first. The research suggests that suppository retention is more easily achieved if suppositories are inserted blunt end first because the squeezing action of the anal sphincter against the apex pushes (sucks) the suppository into the rectum. The research was pivotal in informing clinical practice culminating in  clinical text books advocating a blunt end in first for suppository insertion.

However, if a suppository for local effect is inserted blunt end first using the anal sphincter to assist with insertion there is no guarantee that the suppository will be in contact with the bowel wall. Suppositories need body heat in order to dissolve and become effective. This could subject the patient to an ineffective, undignified and invasive procedure. 

On the other hand, patients administering their own suppository may find blunt end more acceptable as there no need to insert the finger into the anal canal to push it in. This lends weight to inserting the blunt end first - especially if the suppository is for a systemic effect, as rectal absorption is more effective lower in the rectum as veins draining from this part of the rectum join the internal iliac veins. This means medication returns directly to the inferior cava, bypassing the portal circulation.

Gaye Kyle is the chair of the ACA education committee

EXPERT COMMENT

It is important that nebuliser chambers are clean and dry before use. Medication is delivered directly to the lungs and could, if contaminated, be a source of infection. To ensure appropriate hygiene nebulisers are either single use, denoted by the symbol, and disposed of after each administration, or single-patient use, enabling nebulisers to be washed and dried in between treatments. It is important that single-use devices are not re-used as the durability of the product often diminishes after one use, resulting in poor performance (and therefore potentially poor drug delivery).

Cost consideration is an issue: single-use nebulisers, although often cheaper per item, can be more costly per inpatient episode. In A&E it may be cheaper to use single-use equipment, whereas in ward areas single-patient nebulisers may be a more cost-effective choice. Nursing staff time can be an additional resource consideration if regular washing is needed. However, if patients are expected to continue nebulised therapy after discharge their stay in hospital can be an ideal opportunity to teach them correct use, and delegating responsibility for cleaning to them supports self-management and independence.

Carol Kelly is a senior lecturer at Edge Hill University, Lancashire.

EXPERT COMMENT

“Nurses can and should assess the basic swallowing of their patients. Nurses should provide an environment suitable for a patient to consume fluid, this means ensuring they are upright, preferably in a seated position, with good upper balance. A patient should be tried with a small amount of water, and observations for coughing, gurgling, wet voice should be undertaken. If a nurse suspects a patient is having difficulty safely swallowing, many trust’s will provide a further nursing assessment, which has been supported by the SLT, this will enable you to carry out a further assessments. Referrals should only be made to a SLT once there is a validated concern relating to these initial assessments, for the specialist support.” 

Neil Wilson is a senior lecturer and admissions tutor in pre-registration adult nursing at Manchester Metropolitan University.

Expert comment

My initial short answer would be no, what a ridiculous idea! For those of us privileged to be involved with the everyday miracle that is childbirth, whether that is in a hospital or home setting, the idea that in normal circumstances the mum and babe need to be somehow protected from the father or partner is nonsense. I would suggest he or she needs to be clean, and it’s always helpful if they are sober and not loaded with something infectious, but generally in my experience the need for full scrubs is negligible!

However, there may be circumstances when scrubs are required, e.g. where delivery is taking place in a hospital theatre environment, where scrubs are part of the routine infection control procedure, or where the mother’s immune system is at risk where all involved with the delivery may need to “scrub up”.

In these examples, scrubs would be a specific requirement for a particular situation. To suggest that as a general rule fathers should wear full scrubs during child birth suggests perhaps too much exposure to American television, with little thought as to how it may be enforced!

Having had to diplomatically suggest to a father that underwear at the least was the accepted mode of dress for him in the birthing pool, I could anticipate there may be problems getting him into full scrubs!!

B Knight, midwife

Expert comment

The use of nasal cannulas is common for patients with chronic obstructive pulmonary disease (COPD). This is often patient choice, as cannulas allow them to eat, drink and speak, and are often more comfortable than masks when they are receiving oxygen for long periods of time. Cannulas can also feel less claustrophobic, which is an important consideration for a patient experiencing breathlessness.

A note of caution however. Nasal cannulas may not be suitable in acute exacerbations of COPD. Oxygen administration is described as controlled or uncontrolled. Nasal cannula, simple face masks and non-rebreathe masks are uncontrolled, while fixed high-flow concentration masks such as Venturi deliver controlled oxygen.

The amount of oxygen a patient receives from an uncontrolled device depends on variables including depth and rate of breathing, which can alter during acute episodes and produce unexpectedly high concentrations of inspired oxygen. This issue is important, especially for patients with chronic hypercapnia, and can lead to serious or even fatal consequences. These patients require controlled oxygen therapy during an acute phase. This allows oxygen of a known concentration to be delivered and titrated according to the patient’s oxygen saturation (target saturation 88-92%) irrespective of breathing pattern, without the risk of hyperoxia and worsening hypercapnia (BTS, 2008). Nasal cannulas can be substituted once the patient has stabilised.

Carol Kelly is a senior lecturer at Edge Hill University, Lancashire.

EXPERT COMMENT

One of my abiding memories is of a nurse sending a patient with a post-operative pilonidal sinus excision wound for a shower and then irrigating the wound with a sachet of sterile normal saline before applying a dressing. There have been many reviews of wound cleansing which demonstrate a variety of solutions, fluid volumes and delivery techniques such as syringes of differing gauges with or without a needle.

A Cochrane update (2010) reinforced its original conclusion that using tap water (straight from the tap, boiled and cooled, or distilled) in adult acute wounds does not result in more wound infection than normal saline. They also remind us that there is little “strong evidence” that cleanings per se reduces infection or affects healing rates.

Studies have focused on chronic, acute and traumatic wounds. In the community people with leg ulcers routinely have their legs washed in a lined container with many benefits to patients’ comfort, skin care and general well being.  Unanswered questions include cleansing for immune-compromised patients (but they are more likely to be on antibiotics which complicates studies) and comparing showering with administration of fluids via a syringe or other delivery device. A DoH letter circulated in 2010 expressed concern about the cleanliness of taps and sinks which may warrant further investigation in bathing facilities

The major question is whether the wound needs to be cleansed at all; if the surrounding skin is managed the wound may well be best left moist and warm as long as there is not an excess of chronic wound exudate or debris in the wound bed.

Ritualistic practice arises from a lack of engagement with the literature, lack of time for practice based discussions and adherence to a procedure that is not thought through logically. Many patients could shower and if the facilities were appropriate there is scope for a great reduction in costs.  

Expert comment

Recording patient observations is an important part of nursing routine and an essential skill to be able to detect changes in the patient’s condition. A “one-off” or isolated observation is of little use unless compared to recent trends in clinical status. If a nurse is concerned about a patient enough to be motivated to carry out four hourly observations then that patient should be woken to have those observations recorded. However, nurses should also feel empowered and confident enough to be able to adapt their routine to reflect a patient’s progression towards recovery.   

Sleep is an important component of patient recovery and one of the most essential activities of daily living. Sleep deprivation is associated with delirium, which in turn has a negative effect on patient rehabilitation. This leads to increased length of stay in hospital, which corresponds with increased cost and, most importantly, is unpleasant for the patient.  Nurses should be able to carry out an “end of bed” observation without waking a sleeping patient. That is, be able to assess whether the patient has a patent airway, observe respiratory pattern and count the respiratory rate and be able to detect whether the patient is well perfused and, therefore, whether the patient has a adequate cardiac output. Nurses should also trust their instinct and if they feel the patient is deteriorating the question they should ask themselves should be whether four hourly observation is enough or should the patient be monitored more regularly or even continuously. At this point medical or critical care intervention should be sought.   

David Jones, Charge Nurse, Critical Care.

Expert comment

Self-administration of medicines schemes allow patients to continue to take their own medicines while in hospital. This maintains their independence and routines and allows health professionals to monitor how they take their medicine and offer advice and support.

However, in acute hospital wards, factors such as short length of stay and dependency of patients means opportunities for assessing patients to self-medicate are limited. As a result, patients who could benefit are overlooked.

In some trusts, models of care are being tried that assume all patients can self-administer their medicines rather than automatically assuming they cannot. It will be interesting to see the results of these “opt out” schemes.

Martin Shepherd, head of medicines management, Chesterfield Royal Hospital NHS Foundation Trust

Expert comment:

“Although there is a limited evidence base around the ‘Bare below the elbows’ directive I feel it is a common sense approach for both patients and staff. For example although making the link between transmission of potentially pathogenic organisms from jewellery, long sleeves etc may be difficult, jewellery can be a potential health and safety risk to both patients and staff. Stoned rings or watches can tear personal protective clothing such as gloves and can also scratch a patient during a care procedure. Long sleeves can also become contaminated with bodily fluids. In addition both make effective hand decontamination difficult where there is an evidence base about associated risks.”

Julie Hughes is a nurse consultant in infection control at 5 Boroughs Partnership NHS Foundation Trust - a specialist provider of mental health and learning disabilities services. She is also a Lecturer at the University of Chester.

Behind the Rituals

Is there another nursing ritual you’d like us to discuss here? Email your idea to nursingtimescomments@emap.com