VOL: 100, ISSUE: 32, PAGE NO: 63
Lynne Birchall, BSc (specialist practitioner), RGN, is trauma and orthopaedic practice development nurse, Southern Derbyshire Acute Hospitals NHS Trust;
Nicky Clark, BSc (specialist practitioner), RGN, is tissue viability nurse,Sheena Taylor, BA, RGN, is clinical standards facilitator, both at University Hospital Birmingham NHS TrustSince The Essence of Care (Department of Health, 2001) was launched there have been many publications about the document and the process of benchmarking. This paper will focus specifically on the implementation of the benchmark for pressure ulcers (Box 1).
Since The Essence of Care (Department of Health, 2001) was launched there have been many publications about the document and the process of benchmarking. This paper will focus specifically on the implementation of the benchmark for pressure ulcers (Box 1).
In June 2002, a clinical standards facilitator (CSF) was appointed to the University Hospital Birmingham NHS Trust to support the implementation of The Essence of Care (DoH, 2001). It was agreed that the pressure ulcer benchmark would be the first benchmark to be implemented across the trust. The tissue viability service (TVS) was well established and the members of the team had already formed a good working relationship with the CSF in her previous role. The TVS consisted of one clinical nurse specialist and two tissue viability nurses, in addition to the equipment nurse and equipment store assistants who provided a centralised service for pressure-relieving equipment (Birchall, 2001).
The TVS had established pressure ulcer and wound care guidelines and an audit strategy that included pressure ulcer prevalence and incidence.
Identifying key stakeholders
The tissue viability clinical nurse specialist and the CSF decided to lead the implementation of the pressure ulcer benchmark. Specialist nurses are expected to have leadership skills and the ability to influence best practice (Gournic, 1989) and tissue viability nurses should possess the qualities required to lead the implementation of the pressure ulcer benchmark (Morris, 2002).
It was decided that link nurses should be used to implement the pressure ulcer benchmark as this would provide a formal, focused approach to share good practice. The link nurse system had been developed in the trust over many years and the link nurses were able to access an established education programme and attend monthly link nurse meetings.
Morris (2002) used a range of senior staff in the benchmarking process, as she did not feel that link nurses within her workplace had the authority to influence any significant changes in practice.
However, Scanlon and Whitfield (2002) successfully used committed link nurses when they implemented the pressure ulcer benchmark in a community and mental health setting.
The TVS and the CSF had planning meetings to agree the actions required for implementation of the benchmark and to devise a suitable timescale. A pressure ulcer benchmarking working group was established to ensure links with relevant multidisciplinary team members. This included a dietitian, a nurse specialist for care of older trauma patients, a physiotherapist, an occupational therapist, a community liaison nurse, and an elderly care physician. All inpatient areas (58 clinical areas) were included in the project.
Chambers and Jolly (2002) identified the need to raise awareness and provide education on the process of benchmarking. We therefore set up half-day sessions and link nurses were expected to attend one. Up to 12 link nurses attended each session. This ensured that the forum could be personalised to the individual needs of the group. The session contents included an overview of The Essence of Care (DoH, 2001), discussion about the pressure ulcer benchmark and benchmarking process, and group work to familiarise link nurses with the scoring phase.
Adapting the benchmark
The benchmark working group decided that all nine of the benchmark factors would be covered at the same time (Box 1). We decided that the pressure ulcer benchmark tool provided by the DoH should be adapted to provide a user-friendly assessment tool. Stark et al (2002) endorse the adaptation of the document to suit the needs of the clinical area.
Lack of ownership is often cited as a cause of resistance to change and it is acknowledged that moving slowly and ensuring participation can overcome this problem (Curtis and White, 2002).
At the beginning of the project it was agreed that link nurses would be involved in developing the adapted tool to ensure that they had a feeling of ownership. This was achieved through the monthly meetings.
Closed questions (requiring a yes/no answer) were not used as it was felt that this might be restrictive and prevent the reporting of any innovative practices.
The pressure ulcer benchmark working group were positive about the adapted tool.
Chambers and Jolly (2002) state that The Essence of Care offers 'a framework with patients', clients' and their carers' experiences at the heart of the process - a qualitative approach to identifying, measuring, and reflecting on the quality of services provided'.
The benchmark working group set out to identify how patient involvement could be achieved.
A patient advocacy and liaison service had not been set up in the trust. However, we involved the Kidney Patients' Association, which includes patients who have received treatment for renal failure and their carers. Many of the patients have suffered prolonged illness followed by an inpatient stay to receive transplantation. It was felt this group would be able to provide an expert opinion from patients' perspective about tissue viability.
In addition, link nurses were encouraged to discuss the benchmarking factors with current inpatients when undertaking clinical-based assessments.
The assessment tool
The front page of the tool prompted the link nurse to consider some keys points when undertaking the assessment. These included local implementation of the trust policies and guidelines (including tissue viability, infection control, and moving and handling) and involvement in audit activities, including monitoring the incidence of pressure ulcers. In addition the link nurse was prompted to involve at least five patients and five members of staff.
The Essence of Care tool was adapted in format and content and a list of questions was developed for each factor. For example, questions to assess Factor 1 (assessment) were:
- Are all patients screened using the Waterlow score?
- Do you undertake a formal assessment for 100 per cent of patients identified as being at risk using the Waterlow score?
- When is the assessment carried out?
- How often is the assessment updated?
- Where is the assessment documented?
Each of the factors were presented on a new page of the assessment tool and although it appeared lengthy, it was easy to read and follow.
Implementing the assessment tool
In December 2002 the final assessment tool was circulated to link nurses for completion. Link nurses were asked to involve as many members of staff in the process as possible, including staff working in other disciplines, and if possible to consult patients.
They were asked to keep one copy in the clinical area and return another to the TVS within six weeks. The TVS set up further workshops when about 80 per cent of the forms had been returned.
These workshops allowed link nurses to compare their evidence for practice and subsequent scores. In some cases scores were adjusted as some link nurses had under- or overscored.
Examples of good practice were shared and it was agreed that template action plans would be devised to cover key actions for each factor to be implemented in all clinical areas.
After ongoing discussion with link nurses, ward managers and senior nurses, all 58 assessment tools were completed and returned.
The most common issue raised during the workshops was the lack of documented care plans for patients at risk of, or who had already sustained, pressure damage and the variety of methods of documenting assessments and evaluating care. One specific issue raised was the lack of documentation to support the repositioning of patients.
The areas of practice that scored highest were Factor 6 (pressure ulcer prevention - redistributing support surfaces) and Factor 7 (pressure ulcer prevention - availability of equipment). This was thought to be due to the availability of the centralised pressure-relieving equipment service.
Following completion of the initial assessment link nurses developed the template action plans. These were circulated in May 2003 for link nurses to modify according to the requirements of their clinical area. It was felt that template action plans would assist in the development of good practice, while still encouraging innovation by allowing individual areas to make their own modifications. Table 1 provides an example of a template action plan for Factor 3.
Updating the assessment tool
The initial assessment tool has been updated to reflect the new Essence of Care document (DoH, 2003) and there have been changes to make the tool more user-friendly and easier to interpret.
A 'not applicable' option has also been included as some aspects of the benchmarking were not relevant to areas such as theatres, which resulted in them having lower scores.
Although the multidisciplinary team was involved through the benchmarking working party, it has been suggested that the DoH benchmarking tool was primarily focused on nursing care (Hampton, 2001). A section to record which health professionals are involved in pressure ulcer care has now been incorporated into the new benchmarking tool.
Despite the lack of written nursing care plans, many patients did have a 'plan of care' that may have been devised by the TVS or therapists. Therefore the wording in the new tool has been changed to 'plan of care'.
The tool has also been adapted to incorporate specific patient requirements, including language, age, and special needs.
Building on the success of the project now depends on the link nurses engaging their colleagues in implementing action plans and maintaining enthusiasm.
Sessions on The Essence of Care and the benchmarking process have been incorporated into the existing tissue viability educational programme. The benchmarking tool has been included in the pressure ulcer prevention and treatment guidelines. It is hoped this will provide a useful method for assessing the effectiveness of guidelines and tissue viability care.
It took six months to develop and launch the tool, and a further four months before the template action plans were developed and implemented.
As expected, the commitment from link nurses varied; those who were very keen were involved throughout and attended all relevant workshops and link nurse meetings. However, some found the commitment difficult for varying reasons including workload pressures, and some had difficulty engaging other team members in the process. Chambers and Jolly (2002) identified these challenges when implementing the clinical benchmarks in their regional group. Unfortunately, a small number of link nurses gave up the link role due to the additional workload/commitment of benchmarking.
The trust hopes to undertake the benchmarking process with another local trust - the possibility of developing a repositioning chart is also being explored. The TVS needs to continue updating and reinforcing the use of tissue viability guidelines.
The assessment tool will be used as a template for the introduction of the other benchmarks.