Essence of Care - Nursing
Within the contents of this essay the author will focus on how the Essence of Care (Department of Health 2001 and 2003) document originated. The organisation structure of the chosen trust and the leadership and management skills required will be discussed, including the change management theory needed to implement the benchmark to practice, and how a local practice has implemented the benchmarks. The author's main focus will be on factor one (screening and assessment) and factor six (Pressure ulcer prevention-redistributing support surfaces) of the benchmarks for Pressure Ulcers identified in The Essence of Care (DH 2003).
Benchmarking is a process by which practice and care standards can be measured and has come about through Government guidance and policies (Stark et al 2002) and the public demand for better quality health care. The measurement of quality care was first mentioned by the present Government in the document A First class Service: Quality in the New National Health Service (NHS) (DH 1998). This document provides a framework for delivering quality care and identifies how the process of benchmarking fits into the quality framework. At a national level the standards are set within the National Institute for Clinical Excellence (NICE) guidelines and the National Service Framework (NSF's)
In 1999 the DH's document Making a Difference defined clinical benchmarking as a process by which best practice is identified and can continued to be improved upon through comparison and sharing (Scanlon and Whitfield 2002). This put clinical governance at the centre of its plans for quality improvement. Clinical Governance is defined as:
'A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical practice can flourish' (NHS Executive 1999)
Badham et al (2006) explain that, exploring the benefits of benchmarking was cited as one way in which the nursing, midwifery and health professionals could re-focus on the fundamental and essential aspects of care; making standards explicit; monitoring practice and seeking to improve quality. The concept of quality care was extended and further developed in the NHS Plan (DH2000), which states that: 'Quality will not just be restricted to the clinical aspects of care, but will include quality of life and the entire patient experience'. The NHS Plan (DH2000) reinforces the need to get the basics right and improve the patients experience. Following publication of Making a Difference (DH1999), patients, carers and professionals worked together to agree best practice and to identify a range of 'aspects of care' benchmarks, fundamental to the patients' interest.
This led to the launch of The Essence of Care (DH 2003) document in February 2001 (updated in 2003). The overall aim was to help improve the quality of essential aspects of care through benchmarking tools and to help practitioners take a patient focused and structured approach to the care they provide. The Essence of Care includes benchmarks covering nine aspects of care, which are interrelated, for example, food and nutrition will link with pressure ulcer, in that adequate nutrition to gain strength will help maintain mobility, which in turn prevents pressure areas developing (DH 2003).
To implement the changes required to practice within the essence of care guidelines there needs to be an understanding of the type of management structure, style and culture in an organisation. These variables can denote how a change process can be undertaken (Mullins 1999). The author suggests that the Trusts organisational structure is based on the bureaucratic structure of Weber (1952) because of its increasing size, complexity of departments and the associated demand for effective administration (Clark 1997).
Weber's Bureaucratic Model (Weber 1952) relied heavily on a means to an end rationality to create organisational effectiveness. The main principles of Weber's Bureaucratic Model of Organisational Effectiveness are rules and regulations, well defined job descriptions, competence and training, administration separate from production and hierarchy of authority. This type of organisational structure is commonly called line structures or line organisations and is frequently found in large organisations, including health care facilities. One of the problems with line staff structures is the adherence to chain of command communication, which can restrict upward communication, although good leadership will encourage upward ...
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Weber's Bureaucratic Model (Weber 1952) relied heavily on a means to an end rationality to create organisational effectiveness. The main principles of Weber's Bureaucratic Model of Organisational Effectiveness are rules and regulations, well defined job descriptions, competence and training, administration separate from production and hierarchy of authority. This type of organisational structure is commonly called line structures or line organisations and is frequently found in large organisations, including health care facilities. One of the problems with line staff structures is the adherence to chain of command communication, which can restrict upward communication, although good leadership will encourage upward communication to compensate for this (Marquis and Huston 2006).
Having researched further on organisational structures, the author firmly believes that this is the way the trust is organised; although Weber's work did not take into account the changes in society and in the way large organisations are structured and managed in the twenty first century. Current research supports the thesis that an organisation structure should be in a manner that increases the autonomy and the empowerment of nurses as this will lead to more effective patient care (Millar et al 2001). Mullins (1999) states that effective organisation is based on structure and delegation through different layers of the hierarchy. The management style of the trust is of the classical style, with attention given to the division of work with clear definition of duties and responsibilities.
In an organisation, to implement change management they would need to follow a change theory. There are many theorists who have developed processes of change, but Lewin's (1951) theory is perhaps the one that is most recognised. Karl Lewin (1951) addresses three phases of change: unfreezing, moving and refreezing, which are based on two concepts identified as driving and restraining forces, also called a force field analysis framework for looking at problem solving and change. (Anderson 2001, Lancaster J 1999). Lewin proposes that when implementing any change there are a number of factors that help to achieve change, this would be the driving concept, for example the aim to improve patient care. Conversely, a restraining factor could be unwillingness to change or poor staff morale (Cork 2005)
Other theorists include Lippett (1973) who identified seven stages in the change process and Rogers (1962) who expanded on Lewin's three phases of change with five phases by emphasizing both the background of the people participating and the environment in which the change takes place. The five stages in Rogers change cycle are awareness, interest, evaluation, trial and adoption (Lancaster 1999). The author prefers Lewin's theory because it is not complicated with only three phases, it makes sense and it is user friendly. The author found lippett's theory too long, although the stages are consistent with the steps in the nursing process. Roger's theory was similar to the stages in Lewin's but the unfreezing stage was broken down into three smaller stages as Roger's believed the process of adopting change was more complex that the three steps discussed by Lewin's (Lancaster 1999).
Pressure ulcers, as defined by Department of Health (2003) 'are identified as damage to an individuals skin due to the effects of pressure together with or independently from a number of other factors for example, shearing, friction and moisture'. To achieve quality care in relation to pressure ulcer prevention, the author's chosen practice area has developed a robust and pragmatic approach to the identification and reduction in incidence of pressure ulcers.
The Trust have appointed a Tissue Viability Clinical Nurse Specialist (TVCNS) to co-ordinate the approach to be taken to address the issue of pressure ulcers, including the early identification of high risk patients, the prevention and management of pressure ulcers. The clinical guidelines developed are based on the pressure ulcer risk assessment and prevention guidelines produced by NICE (2001), and adapted for use by the Trust's wound care committee. The aim of the guidelines is to facilitate the staff to produce high standards of patient care in all matters relating to pressure ulcer prevention. Pressure area management is relevant to all areas of nursing disciples in the trust and benchmarking provides an opportunity to share best practice and identify areas that can be improved.
The changes needed to implement the pressure sore benchmarks are known as planned changes, which is the result of a well thought out and deliberate effort to make something happen, in contrast to accidental change or change by drift. Planned change is a deliberate application of knowledge and skills by a leader, usually the change agent, to bring about a change requires the leader to have the skills of problem solving, decision making and interpersonal and communication skills (Marquis and Huston 2006). For a change effort to be successful the change agent should be a person skilled in the theory and implementation of planned change to be able to deal appropriately with the very real human emotions, including resistance that planned change can bring about (Marquis and Huston 2006).
The benchmark for pressure ulcers had already been implemented in the trust at the time of writing. The TVCNS at the trust is the change agent for the implementation of any further changes and is the nurse lead for the comparison/focus group for pressure ulcers. The nurse lead will look back at the local and corporate action plans and utilise the latest format of the Essence of Care (DH2003) document. The nurse lead will also review the comparison/focus group membership ensuring that all key stakeholders, which include all relevant disciples and users, are represented. Stakeholders are those entities in an organisation's environment that play a role in the organisations health and performance, or that are affected by the organisation, such as, patients, carers, staff and management, suppliers and volunteers (Martin and Henderson 2001). It is important that the leader is aware of who their stakeholders are because these are the people who can influence the working of the environment (Martin and Henderson 2001).
The author has worked with the TVCNS and has had the opportunity to observe how she has implemented the changes needed to embrace to Essence of Care (DH2003) benchmark and to observe / judge the type of leader she is. The author would suggest that the TVCNS is a transformation leader in that she motivates followers to perform at their full potential by influencing changes in perceptions and by providing a sense of direction to the group (Ellis and Hartley 2000). The author felt no sense of resentment from the different members of the nursing team for the changes that were needed to continue to work within the benchmark guidelines and feels this could be because the change came from outside the organisation of the hospital...............ref more
Factor one, screening and assessment of the pressure ulcer benchmarks for best practice is for all patients identified as 'at risk' screening will progress to further assessment (DH 2003). This has been implemented using the admission document, which looks at the condition of the patient's skin, diet and mobility for the screening element. For the full assessment a risk assessment tool based upon the Waterlow (1985) risk assessment tool, (appendix one) and the grading classification for pressure ulcers, (appendix two) which is based upon the European Pressure Ulcer Advisory Panels (EPUAP) pressure ulcer treatment guidelines (1999) is used; together with a manual handling assessment.
The action plan formulated by the comparison/focus group have documented that re-evaluation of documentation should be every Sunday unless a patient is more at risk. The time frame will then be decided by the team leader. For critical care patients re-evaluation should be every twenty four hours. The action plan also aimed to ensure that all health care personnel will have training in screening and assessment. This is to be achieved by adding a section to the staff competencies and induction. Also liasion with the training department regarding adding any updated practices to the basic skills day will take place. This action was agreed by the comparison group to achieve an A on the benchmark grading scale.
Factor six, Pressure ulcer prevention-redistributing support surfaces of the benchmarks for best practice is that patients at risk of developing pressure ulcers are cared for on pressure redistributing support surfaces that meet individual needs, including comfort (DH 2003). The comparison group agreed that the following evidence would justify an A grade on the benchmark grading scale: Anyone deemed at risk from the assessment has a mattress request completed; outside companies are used if a mattress is not available; All the normal beds have pressure relieving mattresses; All mattresses are correctly cleaned and turned between patients; The central store arranges maintenance of the equipment.
The comparison group suggested the development of a flow diagram which indicates who needs an airflow mattress and what type. They also highlighted the need for the Trust to give all healthcare personnel information/training to rationalise use of specialist beds. The corporate action plan for February 2005 (Appendix three) highlights areas for reform and areas where the implementation has improved awareness and knowledge in providing quality, evidence based care to patients.
In adherence with clinical governance the outcome of the changes implemented are monitored by an explicit audit process. This measures both the incidence and prevalence of tissue damage across the Trust, both of which being important indicators of the quality of care provided. Currently a snapshot of pressure ulcers is conducted on a bi-annual basis and reported upon. It is intended that in order for the Trust to establish clearer and more definitive measurements of pressure ulcer occurrence a rolling audit will be carried out with an audit being completed each Sunday (Appendix four) by a designated practitioner.
An audit is defined as
According to the Touche Ross Report (1994) the estimated cost of preventing and treating of pressure ulcers in a six hundred bedded general hospital costs between £600.000 and £3 million a year. Therefore pressure ulcer prevention can improve patient outcomes whilst reducing health service resource use.
In conclusion the author fells that the Trust has implemented the benchmarks for pressure ulcer well
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LEADERSHIP AND PRACTICE DEVELOPMENT MODULE
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