The Department of Health policies on infection, ‘Winning Ways’ (2003) and the Care Quality Commission aim to ensure better health and care for everyone in all care settings. National service frameworks target groups include older people and diabetics amongst various others. Working together to reduce Healthcare Associated Infection in England was introduce to highlight the importance of controlling infection and also explained the growth in infections contracted by patients in hospitals worldwide. The factors which have driven, and continue to drive healthcare associated infection are multiple and well known such as patients with. Some are therapeutic needs, including indwelling devices that breach normal defence mechanisms. The publication of ‘Winning Ways’ (DH 2003) identified actions necessary to improve infection control in all invasive devices, which were underpinned by Saving Lives (DH 2005). For instance health professionals who undertake catheterisation should be, competent with insertion and manipulation of the urinary catheter’s system (DH 2003), also points out that staff should have the knowledge of the anatomy and physiology of the urinary system. Funding should be attributed to better training in areas such as aseptic techniques. World Health Organization (WHO 2009) also points out the importance of Aseptic technique whilst carrying out this procedure and the use of innovative training initiatives designed to ensure skills are maintained helping to improved patient outcomes (Ribby 2006)
Johns (2004) suggests that the methods for managing quality in care need to be devolved to the point of delivery and is an essential aspect of everyday practice. This approach has been adopted through the implementation of clinical legislation such as (Health Act 2006). Prevention and control of HCAIs policy is an extremely important part of the NHS. Independent and voluntary sectors are equally important to healthcare providers. Such groups work with LAs to tackle social exclusion in deprived areas, using the NA process. It is particularly important to have a high awareness of the possibility of HCAIs in both patients and healthcare workers to ensure early and rapid diagnosis. This should result in effective treatment and containment of the infection. The Department of Health policies on infection, ‘Winning Ways’ (2003) and the Care Quality Commission aim to ensure better health and care for everyone in all care settings. National service frameworks target groups include older people and diabetics amongst various others. Working together to reduce Healthcare Associated Infection in England, was introduce to highlight the importance of controlling infection and also explained the growth in infections contracted by patients in hospitals worldwide. Some are therapeutic needs, including indwelling devices that breach normal defence mechanisms… The publication of ‘Winning Ways’ (DH 2003) identified actions necessary to improve infection control in all invasive devices, which were underpinned by Saving Lives (DH 2005). World Health Organization (WHO 2009) also points out the importance of Aseptic technique whilst carrying out this procedure, and the use of innovative training initiatives designed to ensure skills are maintained helping to improved patient outcomes (Ribby 2006)
The impact of Government initiatives, The White Paper, The new NHS: modern, dependable, and the subsequent policy. documents, A first class service: quality in the new NHS and Good practice in continence services marked the introduction of a range of mechanisms to improve quality, involving setting, delivering and monitoring the standard of care patients receive (DH,NHSE, 1998; DH, 1998; DH 2000). The essence of care (DH, 2001) contains benchmarking tools relating to continence and bladder and bowel care. Clinical risk management Specialist nurses should have a clear understanding of local policies that aim to minimise and manage the risks associated with adverse incidents. Specialist nurses should have access to relevant clinical guidelines that support appropriate decision-making and ensure good outcomes for the patient (RCN 2006). Effective action relies on an accumulating body of evidence that takes account of current clinical practices. This evidence based approach should be used to review and inform practice. All staff should demonstrate good infection control and hygiene practice. And again it is important to stress the possibility of prevention as opposed to cure. (Health Act 2006). This idea of evidence based approaches can also be crucial in determine the efficiency of a policy or determine whether procedures need altering. For instance discussion enables one to review the success of new policies and can flag up issues which were only revealed when a theoretical solution is put into practice. By asking the right questions nurses can provide useful insight as well as understanding the patient’s perspective. Whilst this, coupled with adherence to NHS policies would demonstrate fair and good practice there has been evidence of deviance and mal practice in all areas of healthcare regulations. A report from age concern revealed an epidemic of mal-treatment, force feeding and denial of medical treatment (1998). A survey by Age Concern (2000) found that one in 20 people aged over 65 had been refused treatment. Hodges (1997) argues that older people do not receive optimum treatment for their illness, as they are assessed with regard to their age rather than clinical need. Even hospital policies were deemed discriminatory, where 1/5 of heart units operated on age related admission. USA studies concluded that whilst carers emphasised incontinence management rather than continence promotion. Encouraging abdominal exercise techniques have proved somewhat effective. Even with policies staff will not always comply, however acts like the Corporate Manslaughter and corporate Homicide Acts (2007) may prevent this as they enforce criminal sanction for patient death caused by clinical negligence. They clarify where serious failures in clinical management result in criminal liability. However like ‘core policies’ it is argued that such measures only force staff to act under duress in fear of punishment rather than the genuine desire to provide quality services, which may amount to poor practice management.
sociological
People who suffer from incontinence problems or who require assistance to enable to pass urine can experience social isolation, embarrassment and may isolate themselves from their family and friends. It can also impact on their quality of life including sleep disturbance, mobility problems and discomfort (Holland et al 2003). The publication of the National Service Framework (NSF 2001) for older people highlights that whilst older people are the main users of health and social care services have not always adequately addressed their needs. This National Service Framework is the first ever comprehensive strategy to ensure fair, high quality, integrated health and social care services for older people. It is a 10 year programme of action linking services to support independence and promote good health, specialised services for key conditions, and culture change so that all older people and their carers are always treated with respect, dignity and fairness.
Older people and their carers should receive person centred care and services which respect them as individuals and which are arranged around their needs. Older people and their carers have not, however, always been treated with respect or with dignity nor have they always been enabled to make informed decisions through proper provision of information about care across care sectors. Organisational structures have acted to impede the provision of care co-ordinated around the needs of the older person. Proper assessment of the range and complexity of older people’s needs and prompt provision of care (including community equipment and continence services) can improve their ability to function independently, reduce the need for emergency hospital admission and decrease the need for premature admission to a residential care setting. But service and system failings have undermined older people’s confidence in other aspects of care and their ability to remain independent. On the other hand policies should encourage GPs to build strong trusting relationships with members of the community and in turn would encourage people to continue to visit doctors and maintain good patient-doctor relationships and protect doctors services by opposing plans to impose impersonal polyclinics at the expense of local GP’s.
The first two standards in the NSF for Older People (DoH 2001) anti-discriminatory practice and person-centred care are inter-linked as they concern putting the older person at the centre of his or her treatment and ensuring that services are needs-led and not service-led (DoH 2001). To promote person-centred continence care, there are three principles that should underpin nursing practice: Eliminating any discrimination in continence care, to ensure staff have adequate knowledge of continence care. Contribute to the provision of a seamless continence service by providing single assessment (patientcentred, interprofessional/interagency assessment of health and social care needs). Discrimination in health care can also occur at an individual level during the client-practitioner relationship and at a wider level of service provision by organisations. The NSF for Older People (DoH 2001) states that no patient should be declined medical diagnosis based on age. Care providers could be accused of institutionalised ageism, perhaps reflecting discrimination against older people in wider society. Nurses are part of society and it is likely that unless nurses are made aware of the impact of such attitudes, discrimination could affect personal nursing practice. It also outlines standards for each priority to be achieved across England within specified time frames. One standard relates to the provision of comprehensive integrated continence services. By monitoring these standards, the Department of Health hopes to ensure that everyone will receive the same standard of service, regardless of their age or place of residence. You might also have identified limitations in the environment as a factor influencing poor practice in your clinical setting and this is one of the most difficult factors to change. When nurses are aware of such limitations, small steps can be taken to promote older people’s dignity in the short term, while in the long term nurses can use policy to recommend environmental changes to managers in their organisations.
Urinary incontinence can restrict employment, educational and leisure opportunities, and lead to social embarrassment and isolation, affecting both physical and mental health. It is vital that people who are incontinent are given every opportunity to regain their continence. High quality comprehensive continence services are an essential part of health care. Before treatment and management options are offered, the Royal College of Nursing (RCN) encourages the consideration of all aspects of a client’s continence problem, their lifestyle and any care needs. This RCN document looks at the key roles of nurses examining their potential influence on continence services - whether in a hospital or the community setting and the impact of the Government’s new initiatives (RCN 2006). It is a common problem in most societies for to ones intimate problems private. However incontinence is a private matter which must be revealed and many suffers find difficulty in doing so. The problem here is that it inhibits hospital aims to tackle such issues at the earliest stage to prevent infection or critical illness. Policies may be used to address this issue by first identifying reasons for patient silence. The feminist argument that females are disadvantaged by the lack of female GPs- with whom they will feel most comfortable confiding in, may also apply to males in most societies. Not only do statistics suggest that men are less willing to discuss illnesses, but they may feel uncomfortable around carers, who are predominately women. The legal right to privacy should be fully incorporated in home visiting policies, giving patients a right to request GP or nurse with the same sex as themselves and to avoid cases like Rodney Ledward- A gynaecologist who violated a number of patients. Religious views- notably Jehovah Witnesses may also lead people to refrain for engaging in medi-care which involve surgery and utilisation of manmade implants such as catheters. Another reason for delayed consultation may be due to deprivation. Marxists draw upon social and economic deprivation- underclass upbringing may lead to a lesser awareness about medi-care and the heavy reliance on NHS as opposed to the interpersonal care generally offered by private hospitals. Therefore there should be increased publication about the illness to break down the embarrassing stigmas and to demonstrate the negative consequence of delayed consultations.
Economical.
For many years government initiatives and NHS policies have considered the central role of a nurse to be to deliver high quality appropriate care to patients, within a variety of care settings. Recently, however there has been a shift from aims to improve quantity of care to delivering quality care. This view point has been expressed in many western societies especially since the economic crisis, which is said to be particularly detrimental to public services. Government expenditure is focused on fulfilling the aims to improve medical services, but there is rarely consensus as to how it government spending should be reduced. This was demonstrated in the political campaign between Barack Obama, whose government-centred approach aimed to attribute funds to public medicare by introducing national health insurance schemes whilst John McCain proposed ….. Policy reforms in Britain have meant that a nurse’s role is now more dynamic and continually evolving, in all aspects of health care. It is associated with caring and helping the patient achieve or carry out activities of living that they are unable to do for themselves (Peate 2005). According to the National Audit Office (NAO) the cost of hospital acquired infection is high, estimated at £1 billion per year. Assessment of the cost of control programmes to reduce infection versus benefit shows major savings can be achieved. Incontinence affects large numbers of people in the UK yet it remains a hidden problem by comparison with other conditions, which may mean that patients consult doctors at the later more critical stages in their illness which are more difficult to treat, thus increasing the costs of government spending on long term patient care. In 2000, the (NAO) report indicated that revised urinary catheter management policies could lead to a decrease in the number of urinary tract infections. However, a later review carried out by the NAO found that 40% of the infection control teams who responded felt that urinary catheter guidelines had been adopted only by parts of their trusts, with a further 10% of trusts not having adopted guidelines at all. The extra financial cost of urinary infection has been estimated at £1,122 per patient. Hazelett et al (2006) points out that with the use of an an indwelling urinary catheter it is estimated to be the most significant risk factor for the development of a UTI. Gokula et al (2004) states that as many as 50% of patients are catheterised inappropriately. Plowman et al (1999) states that the extra financial cost of a UTI has been estimated to be £1,327 per patient and blocks a hospital bed for an extra six days, costing the NHS £124 million per year. Rising NHS budgets may allow better care and increased patient care plan choices such as through increased number of beds and in care facilities. This would take into consideration and somewhat relieve the additional pain and suffering that a patient with a UTI experiences (Fernandez and Griffiths 2006).
Further funds may be spent on improving incident reporting - a system that helps to increase the safety of patients, visitors and staff and, therefore, quality of care (Secker-Walker 2001).o It is an integral part of clinical governance, which 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 care will flourish’, More simply, clinical governance is the totality of all factors that make the NHS safer (Lilley 1999). Almost all NHS trusts have incident reporting systems, often detailed in an incident reporting policy it is estimated 850,000 incidents per annum in NHS hospitals, 38,000 complaints about family health services in financial year 1998/9, Estimated, annually, 2,500, incidents that are serious enough to require reporting to, the NHS Executive’s regional offices, Annually, 1,150 people in recent contact with the mental health services commit, suicide, Financial. NHS paid out £400 million in settlement of clinical negligence claims in financial year 1998/9, 850,000 Incidents per annum result in around £2 billion direct costs in additional, hospital days alone., (Derived from DoH 2000).This example shows how incident reporting permits lessons to be learned and good practice spread (DoH). The learning activities needed to be integrated and prioritised with other clinical governance activities, including directorate-specific and trust-wide clinical risk assessments with action plans. The common goal was for the learning to become embedded in a trust’s culture and practice, not just learning by individuals directly involved (DoH 2000). Another benefit of incident reporting is that it can help build public confidence in the NHS. Failure or delay in discussing an incident or near miss with the family involved encourages belief that there is something to hide, leading to families ‘doctor shopping’ and ignoring medical recommendations (Vincent 2001). This is exacerbated if a patient or family subsequently hears the relevant information from a third party, or reading healthcare records themselves. In each of these examples, an apology was immediately given (not being an admission of liability), families were informed of and involved in the incident investigation and kept up to date. They were given findings once these were available, including an honest explanation of the facts and proposed learning activities. All these activities build trust (DoH 2000, Lugon and Secker -Walker 2001), and involving families brings other perspectives to understanding an incident’s root cause(s) that might otherwise be missed. The final benefit drawn from these examples is that incident reporting can positively impact litigation and complaints brought against trusts. Central notification enables early identification of potential claims (DoH 2000, Vincent 2001). A standardised investigation approach, regularly linked to related complaints or claims, gives better documentary evidence of events, expedites settlement of claims, improves handling of complaints and may reduce solicitors’ costs and subscriptions to the Clinical Negligence Scheme for Trusts (CNST 2000) (Lugon and Secker-Walker 1999, Vincent 2001).
Technological Factors
In the second half of the twentieth century, the explosion in scientific knowledge, the escalating costs of health services and the changing needs of the healthcare consumer population were social trends which triggered reforms in the delivery of healthcare services. These trends give rise to complex issues that involve economic, political, social, cultural, educational and ethical considerations. Scientific discoveries in medicine, notably advanced medical technology, have influenced the delivery of health-care services and nursing practice. Advances in medical technology permit intense monitoring of and interventions into human biological processes on a scale hitherto unimagined. Life and death decisions may be made on the basis of nurses’ interpretations of information from high technology equipment. These advances have led to increasing specialization within nursing, in both hospital and community settings. Advances in computer technology, as part of the explosion in scientific knowledge, have automated and consolidated information and increased the speed and efficiency of information processing. Nurses in a variety of healthcare settings are using computers to enter, store and retrieve patient information, check nursing and medical orders, and request services for their patients from other sectors of the healthcare system as diverse as pharmaceutical and social services. Genetic engineering developments have brought in their wake very complex ethical problems and nurses have increasingly to be aware of the need to offer patients opportunities to talk through these issues in a supportive environment. Counselling skills are increasingly becoming part of the nurse’s repertoire Walsh and Crumbie (2007).
A second trend, the rising cost of restoration to health through acute care hospitalization, in competition with other public needs and wants and in the face of finite resources, has provoked a search for alternative healthcare delivery strategies and sites. Health promotion and health maintenance through public education and community-based programmes have become widespread. Nurses have played a significant role in providing these alternatives and have been given the lead role in the NHS Direct 24-hour telephone health advice service and NHS walk-in centres in the UK. In addition, increased attention has been given to threats to human health from personal lifestyles, pollution of the environment and poor socioeconomic circumstances.( Walsh 2006).
Information technology (IT), although used throughout the healthcare environment for some records, is not used to the full and handwritten records are common. The view that IT is not used to its maximum potential in health care is reiterated by Hays et al (1994): ‘In the healthcare system, inefficiencies in managing and processing information have been identified as a major problem and a significant component of inflated costs. An ongoing role of the infection control nurse is advising all healthcare workers and patients in good infection control practice.
Law (1993) identifies that keeping records of any clinical advice given is one of the tasks carried out by the infection control nurse. Many still use outdated handwritten notes for this documentation. Lists of patients with organisms which require the patient to receive special care each hospital admission are again often handwritten. Any results from a database must justify the probable extra work of inputting the data. However, as users become more familiar with these databases, they might prove quicker than handwritten notes. Databases such as Access provide the facility for adding, editing, viewing and printing reports for everyday data. Some data collection tools would also be useful for other aspects of the advisory role of infection control nurses.
With the increasing use of completely computerised medical records, nurses and doctors would benefit from having the facility of infection control policies ‘flagged up’ when entering in practice documentation on ward-based computers. Infection control nurses spend a considerable amount of their time teaching formally and informally. In the current trend of moving away from traditional teaching methods, McGuire (1995) advocates the use of CD-ROM as ‘using a database allows the researcher to view related studies collectively and so provide a sounder knowledge base than taking one study in isolation’. CD-ROMs are already widely available in UK medical libraries.
There are researches that are being carried out in finding better equipments and materials used in health care, catheter-associated urinary tract infection (CAUTI) research have been carried to find evidence for the best type of catheter that can be used on a patient, results have shown evidence supporting insertion of a silver alloy-coated catheter helps to reduce the risk of CAUTIs for up to 2 weeks in adult patients managed by short-term indwelling catheterization. Results have found evidence supporting the insertion of an antibiotic-impregnated catheter for reduction of CAUTI risk for up to 7 days. There was insufficient evidence to determine whether regular use of an antimicrobial catheter reduces the risk of CAUTIs in adults managed with long-term indwelling catheterization. There was insufficient evidence to determine whether selection of a latex catheter, hydrogel-coated latex catheter, silicone-coated latex catheter, or all- silicone catheter influences CAUTI risk. Expert opinion suggests that selection of a smaller French-sized catheter reduces CAUTI risk, but evidence is lacking. The implications for practice, insertion of an antimicrobial catheter, either silver alloy or antimicrobial coated, is recommended for patients with short-term indwelling catheterization. There is insufficient evidence to recommend their use in patients managed by long-term indwelling catheterization. Selection of smaller French sizes for short- or long-term catheterization is thought to improve comfort and reduce CAUTI risk, but further research is needed to substantiate these best practice recommendations. Parker and Callan (2009)
The Nursing and Midwifery Council (NMC) exists to safeguard the health and wellbeing of the public, also introducing guidelines for staff members, It mentions the importance of the duty of care of the patient by health professionals as it is important that the Mr Taylor was given the right care and treatment, he should be able to trust those who are responsible of his health and wellbeing, whilst being assessed and carrying out the procedure of inserting the catherter. Health professionals need to work together to protect and promote the health and wellbeing of those in their care, their families and carers, and the wider community, provide a high standard of practice and care at all times, to be open and honest, act with intergrity and uphold the reputation of their profession. As a heatlh professional, they are personally accountable for actions and omissions in your practice and must always be able to justify their decisions, always act lawfully, whether those laws relate to your professional practice or personal life. Failing to do this would bring their fitness to practise into question and may endanger the lifes of the patient and their own registration (NMC 2008)
Conclusion
Mr Taylor’s UTI may have been brought about from poor ansteptic technique whilst he was in hospital, or poor hygiene technique by himself or carers involved in helping him with personal care. Patients who have an indwelling urinary catheter are at high risk of developing UTI because of the invasiveness of this device. Staff who have been trained to catherterise patients should ensure that infection control measures such as adherence to good hand hygiene technique is applied, correct perineal cleansing, adequate urinary bag emptying and patient education on catheter care, are undertaken to prevent cross-infection or contamination Naish and Hallam (2007).
Government and local policies have been introduce to help provide guidelines to help prevent infections, .......................
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