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).
Clinical governance integrates various well-known quality initiatives into one framework, based on the philosophy of continuous quality improvement. Inherently this quality strategy acknowledges the fundamental role of culture and leadership, in addition to emphasising the role of staff learning, development and empowerment as aspects of developing quality services (Heard, 2000).
Practitioners can take several avenues to initiate the key integrated elements of clinical governance into their practice. One is to develop and implement local clinical practice guidelines. This paper reports on how a local evidence-based practice guideline for confirming placement of a nasogastric tube was disseminated and implemented to define and reinforce good practice.
The role of guidelines
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 quest for clinical effectiveness
- Implementing evidence-based practice
- Risk management.
These are all inherent in clinical governance. As well as providing a means against which the quality of service can be measured, clinical effectiveness implies that practice is based on the best available evidence (Adams, 1999a). The fundamental aim of evidence-based practice is to support practitioners in making decisions, while helping eradicate ineffective, inappropriate, costly and potentially dangerous practices (Hamer, 1999). Therefore, when evidence based, guidelines promote the delivery of safe and effective care and assist practitioners to make decisions (Swage, 2000)
Evidence for guidelines - Porter and Carter (2000) recommend quality nursing research as a source of evidence for evidence-based practice decisions. Although approaches to nursing research originate from widely differing theoretical and philosophical stances (Mulhall et al, 1998) so-called hierarchies of evidence and grades of recommendation place greater emphasis on data derived from a positivist approach to research. This methodology is not appropriate for all situations arising within nursing. Since the availability of research evidence to support nursing practice decisions is often limited, it seems appropriate that other valid and relevant sources of evidence are considered and employed (Box 1) (Dempsey and Dempsey, 2000; Le May, 1999; Marks-Maran, 1999).
Draft guideline for nasogastric tube placement
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.
Evidence behind the guidelines
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).
The evidence informing the guideline regarding reliable methods to predict feeding tube placement included robust nursing research adopting quantitative methodology. This approach was considered appropriate in relation to this issue. The methodology selected must be appropriate to the aim of the research, as well as being as robust as possible (Adams, 1999b). The quantitative approach to research adopts a deductive approach aimed at seeking generalisations (Dempsey and Dempsey, 2000). Therefore outcomes of research, if reliable and relevant, can be transferred to other settings.
Workplace dissemination and implementation
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, communication, lifelong learning
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.
The UKCC (2001) charges each nurse with the professional responsibility to adopt the culture of lifelong learning to develop professional knowledge and competence. To support the change in practice and meet the team’s learning needs a synopsis of the draft guidelines’ main principles were devised and a folder of evidence was prepared. Inadequacies of current practice were identified in the literature included. Essential to the delivery of quality care is adequate knowledge and skills; improvements and changes need to be supported by adequate education and training (Scottish Executive, 1999a).
Even when benefits for change appear to be obvious and the behaviour required is achievable, some people will always react negatively to change and resist it (Plummer, 2000). Leadership, communication and a culture of lifelong learning were essential to achieving change.
Enquiries were made about the equipment needed and the necessary supplies were ordered - availability of essential equipment was a crucial factor.
Other factors that may influence the plan for change were also considered The aim was to promote strengths and opportunities and to manage and/or eliminate weaknesses and threats. As Eccles and Grimshaw (2000) pointed out: ‘Evidence is not self-implementing.’ Although knowledge of a guideline is important, it is rarely enough to change practice on its own (NHS CRD, 1999). The process and approach to change involved being proactive rather than reactive. It meant developing knowledge and skills through education and effective communication.
Communicating for change
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.
Being given time to adjust and prepare for the change minimises resistance (Bernhard and Walsh, 1995). Frequent discussions were held over several weeks in advance of the change. The synopsis and folder of evidence prepared were useful and successful resources for managing resistance, along with effective communication. It was helpful - in fact essential - to listen to the views of the staff as individuals and as team members. and provide further explanation and guidance.
Allocating time to support, listen to and inform staff was important. Figure 1 usefully summarises the basic components essential for lasting change.
Recognising changed practice
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:
- The previous means of predicting nasogastric tube placement has been discarded
- The planned change has become fully accepted and embedded in current practice.
Change should not be considered static as, when new evidence evolves, practice may again need to change.
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:
- To provide a structured framework, the PESTEL management mnemonic can be used. This tool advocates examining the following factors when considering change:
This enables a vision of the broader issues that can influence change (Adams, 1999c)
A SWOT analysis, could be performed (Adams, 1999c), allowing for the consideration of:
Ashford et al (1999) have devised a framework for identifying behaviour change strategies allowing crucial issues to be addressed
Lewin’s theory of change management (Lewin, 1951; Swage, 2000; Le May, 1999; Bernhard and Walsh, 1995) is tried and tested and based on the premise that there are three key stages involved:
In each stage, driving or restraining forces to change are likely to exist; when driving forces exceed restraining forces, the move towards change is facilitated.
Need for formal evaluations
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.
It is proposed that audit would be a competent, cost-effective way to formally evaluate the implemented practice change and is also a means of measuring and monitoring ongoing practice. Concurrent audit that assesses past and present care given, combining the use of records and interviews, would be the most beneficial form of evaluation. According to Bernhard and Walsh (1995) it is more likely to be accurate, as well as being most useful to those involved directly with patient care. When evaluation is initiated timing of audits would be determined by the previous audit outcomes. One audit a year should be enough, although recurrent audits can take place more often if an area of discrepancy is identified.
Team participation in the audit process would be encouraged to foster local ownership. Essentially audit outcomes would be disseminated to the team. Rye (2001) strongly recommends that all results be shared with all staff.
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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