VOL: 100, ISSUE: 20, PAGE NO: 36
Jane Reid, MSc, BSc, PGCEA, RGN, DPNS, is head of programmes, adult nursing, Bournemouth University
Elizabeth Robb, BA, RGN, RM, ADM, PGCEA, is director of nursing and clinical governance; Denise Stone, RN, AdvDipHE, is staff nurse, medical unit; Pamela Bowen, RN, AdvDipHE, is staff nurse, high dependency unit; Roselinda Baker, RN, AdvDipHE, is staff nurse, A Sally Irving, RN, AdvDipHE, is staff nurse, nursing home; Michelle Waller, RN, AdvDipHE, is staff nurse, Community Hospital; all at East Somerset NHS Trust
As final-year nursing students at Bournemouth University we were undertaking practice placements at East Somerset NHS Trust. As part of our theoretical programme we were asked to undertake a group project based on a clinical topic relevant to the trust. The project involved exploring and scoping the potential for change, and disseminating our findings. The emphasis was upon practice improvement and overcoming the challenges inherent to achieving change. This article describes the project and the lessons learned by the group and the trust as a result of it.
Identifying the topic
To ensure the project was grounded in clinical practice, the trust was asked to identify a clinical issue that required review or change to enhance the quality of patient care/service delivery. The management of patients’ fluid balance had received attention in the trust due to some complaints and incident investigations, and the senior nursing team had expressed concern about practice in this area. We were therefore given this to investigate.
Extent of the problem
Initial networking with the critical care outreach team, risk managers and clinical governance team demonstrated that the standards and rigour of fluid balance recording and documentation could be improved. Discussions with staff suggested they were providing appropriate care but for a variety of reasons - time, lack of training, and staff shortages - documentation was sometimes incomplete.
Fluid balance monitoring is concerned with maintaining a record of patients’ fluid input and output, and is an important aspect of care, particularly with critically ill patients. Failure to maintain fluid balance can have serious consequences for the patient. We therefore sought to discover why this aspect of record-keeping was poor compared with other areas of documentation.
Nursing documentation has received considerable attention in recent years (Bjorvell et al, 2003; NHS Modernisation Agency, 2001). Essence of Care (NHSMA, 2001) emphasises that record-keeping is a fundamental aspect of care, and that the nursing record is the first source of information examined when complaints are received. In legal terms, if nursing care is not documented it is assumed not to have happened. With the current emphasis on clinical governance and risk management this was clearly of concern to the trust, as it could be interpreted as a lack of individualised care and leave the organisation vulnerable to litigation.
Before beginning the project we secured support and permissions from the director of nursing and key stakeholders, and made important alliances with the trust’s nursing forum. The forum’s members were at the time seeking to redesign the fluid balance chart and develop other strategies to improve compliance in this area of documentation. Working on the assumption that fluid balance charts may not be completed whatever their design unless nurses were motivated to do so, we sought to complement the aims of the forum by investigating the reasons staff were not completing documentation appropriately at present.
The National Patient Safety Agency (NPSA, 2002) endorses such an approach, suggesting that the factors contributing to serious incidents need to be understood by analysing the root causes. We had identified that it was not enough to simply acknowledge that there was a problem with fluid balance recording, nor was it enough just to try and solve the problem. Before this could be achieved, the priority was to establish why there was a problem in the first place.
Understanding why things happen seemed important, as we recognised from previous placements that inadequate care cannot always be attributed to individuals. In many cases it happens as a result of the management and organisation of the care that is being delivered.
Our studies had taught us that when things go wrong the correct response should be to learn from the situation, in order to reduce the risk for future patients. As we were familiar with the work of Langley et al (1996) in relation to securing improvement, we adopted this approach. Our study was therefore structured into four sections - plan, do, study, and act. This is known as the PDSA approach.
The planning stage involved investigating the variables in fluid balance monitoring. The group met together every week and worked as a collective, sharing ideas and developing a project plan by considering all the options. The main driver for the plan that was adopted was the desire to complement other developments within the trust.
The doing stage involved carrying out the investigation. This was achieved through a number of means:
- Observing 12 nursing handovers to assess the attention paid to fluid monitoring;
- Undertaking an audit of 10 wards to determine the equipment used by staff to measure fluids;
- Conducting a quiz in an attempt to determine nurses’ knowledge of the subject. However, this secured a poor response rate with only three staff answering correctly all of the 30 questions asked;
- Undertaking a staff survey. The survey involved sending a questionnaire to 220 nurses asking for information on how they record fluid balance data, when they record it and who records it. The survey secured a response rate of 100 (46 per cent) consisting of:
- 13 of the 20 ward sisters;
- 40 of the 100 staff nurses;
- 31 of the 80 health care assistants;
- 16 of the 20 housekeepers.
The study stage involved summarising what we had learnt and identified from the investigation. This revealed:
- Inadequate communication and organisation within the nursing team regarding patients’ fluid balance status. Most notably, because the information was exchanged at handover there was a failure to inform housekeepers - who played a significant role in distributing oral fluids - as they did not attend these meetings (Fig 1);
- A lack of understanding about where the responsibility lay for the education and training of ward staff in fluid balance monitoring (Fig 2);
- A lack of ownership and accountability for the completion of fluid balance charts (Figs 3-4);
- A lack of equipment to enable nurses to accurately record volume input and output, which resulted in the estimation of fluids.
In order to complement our project and enhance our confidence in presenting our findings to the senior nursing team we conducted a further investigation. This involved reviewing 42 fluid charts on four wards over a three-day period to assess the accuracy with which they had been completed by staff.
Although the investigation used a small sample, this element of the study revealed a disturbing trend: not one of the 42 charts was completed appropriately. For example, one patient’s chart had no fluid records on the first day, while for the other two days, total input was recorded to be 5500ml more than the total volume of output. Inappropriate comments were common on the charts, such as ‘wet pad’, ‘toilet?’ ‘I forgot to measure’, ‘estimated’, ‘sips’ and even ‘??????’.
The act stage of the PDSA cycle involved producing a report on our findings for the director of nursing and the senior nursing team, and making a formal presentation to an invited audience from the trust and neighbouring acute and primary care trusts. The audience comprised the director of nursing, matrons, senior sisters, deputy director of nursing from a neighbouring trust, members of the clinical governance department, and practice educators.
At the presentation we detailed the steps we had identified that were likely to secure an improvement in fluid balance recording.
Our survey revealed that less than half of respondents had received formal training. Only 11 of the 20 nurses (55 per cent) had received training, while just two of the 22 HCAs (nine per cent) had been trained (Fig 3). In addition, two of the 13 sisters (15 per cent) did not provide education and training in fluid balance monitoring.
While clinical support teams and dedicated clinical skills demonstrators were tackling this deficit within the trust, there were clear theory-practice deficits and omissions. Given the misunderstandings about training, we recommended that all staff be given mandatory training on fluid balance, with particular attention paid to housekeepers’ learning needs as they play a central role in providing drinks to patients.
Our practice educator has reported that this particular recommendation has been received positively and that the trust is exploring how mandatory education for fluid balance might be incorporated within local training programmes in a manner similar to that for cardiopulmonary resuscitation and manual handling.
The use of bed signs
We further recommended that whatever education is implemented in future to support staff, the trust should place eye-catching signs over patients’ beds to raise awareness of fluid balance in general and individual patients’ fluid restrictions specifically.
While this recommendation may appear to advocate ritualistic practice, the results of the survey indicate that housekeepers are alerted to patients’ needs by such visual indicators. A fundamental requirement of any risk management system is to work actively to reduce risk. We believe that the use of appropriate signs will raise awareness and minimise the risk of patients’ fluid balance needs being overlooked.
Patient involvement in recording fluids
Linked to this proposal we also recommended that the concept of patient empowerment be embraced and that they be encouraged to record their own fluid intake where possible, using a patient-friendly chart (Fig 5). Chung et al (2002) highlight the value of involving patients in charting, arguing that it reduces nurses’ workload and improves the accuracy of recording.
During the PDSA cycle, we also identified that the trust was aware of occasions when fluid balance-related incidents were not reported in line with the trust protocol for incident reporting.
The NPSA (2002) has reported that one in 20 patients suffer preventable harm, and we suggest that if the trust is to prevent harm from fluid mismanagement, incidents that do occur need to be fully understood so that appropriate action can be taken.
We recommend, therefore, that in circumstances where fluid balance is not recorded appropriately, an incident form is completed to highlight the seriousness of this anomaly in care.
Finally the nursing forum informed us that a new design for the fluid balance chart was to be adopted shortly. To reinforce the principles of accountability, we recommended that the chart include space for a signature. Assuming that a nurse would be unlikely to sign anything that is not completed appropriately, we believe this small inclusion would further contribute to our strategies to minimise risk.
The students’ learning experience
The project gave us an opportunity to examine our individual skills and to experience the challenges that all teams face when seeking to facilitate change and practice development. Soon to be qualified as registered nurses, we were challenged to review our own strengths and weaknesses, which resulted in enhanced self-awareness. Specific skills that we identified as being central to the experiential learning of the project included networking, delegation, communication, team working, team building, public speaking, and time management.
The project seemed to bring all the elements of our previous theoretical and practice-based learning into sharp focus and directed it at a single outcome, facilitating change. It encouraged us to make sense of government white papers, as well as understanding how the Essence of Care directives and clinical governance relate to clinical practice. We also gained valuable insight into the role that is played by senior management and the politics of organisations.
Challenging clinical practice
Most importantly, the project demonstrated that patient care is the business of us all, and that as students we had a legitimate right to question and challenge. We realised from the start - and it was emphasised by our tutor - that the project may not result in us securing all the answers to a complex problem but that our priority was to investigate and critique.
Change can only happen if challenges are made, and by doing this exercise we have developed confidence in our abilities as future change agents in the NHS.
The efficacy of nursing programmes is often questioned in the literature, with current curriculum described as too academic and leading to nurses lacking practical skills on qualifying. This debate can cause anxiety to newly qualified nurses about to begin their first post but we believe that we have been appropriately prepared to take our place in the workforce.
We are the future nurses and nurse leaders and we have the belief, confidence and respect of our practice colleagues that we can constructively and effectively critique practice and implement change.
The trust’s learning experience
East Somerset NHS Trust has an open and learning culture, and the approach to this project was to welcome the students’ contribution to investigation and to the potential to make change. Their approach embraced the current framework for clinical governance as outlined in An Organisation With A Memory (DoH, 2000).
A considerable amount of work was already being undertaken to look at fluid balance but the students were able to augment this work and ensure that a comprehensive study was conducted, giving practical recommendations for improvement. It was clear from the work and our discussion that findings within the trust were no different to what might be found elsewhere in the NHS.
Disseminating the lesson
Since the final presentation included external staff, it resulted in the students being asked to present their work at other trusts. Not only did this give them personal development opportunities but, also more importantly, it promoted learning more widely in the area, which could result in further patient care improvements.
The trust’s clinical support team was asked to take the recommendations forward, so members ran sessions in the skills centre and provided education to staff at ward level. And a trial of the students’ recommendations was started on one of the medical wards.
In initial audit was completed at the beginning of the trial, then ward staff were made aware of the new bed signs that were to be used and the charts for patient participation. Patients were asked about their views and were happy to complete their own fluid charts during the day. The amounts charted were then totalled by the night staff at the end of each day and added to their fluid balance chart.
The students’ recommendation that incident forms be completed for incomplete fluid charts was not considered as necessary at this time. It was felt that this may be viewed negatively and have an adverse effect on what the team was hoping to achieve. We wanted staff to realise the importance of completing accurate fluid balance without raising the issue of apportioning blame.
Significant improvements were observed when the pilot ward was re-audited in September following the three-month trial. The initiative is being rolled out across the trust with the support of the clinical support team.
The trust believes the project has benefited all concerned, particularly patients.
In addition, by supporting the project and encouraging the students’ enquiry the trust has recruited five excellent and highly motivated newly qualified nursing staff. They will be able to monitor the outcome of the work undertaken as a result of their study and the associated trust projects to see the improvements and change brought about as a result of their endeavours.
This article has been double-blind peer-reviewed.