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It is highly believed within the health care industry that Healthcare Associated Infections (HCAI) are a grave worry and concern for the public of the United Kingdom (Nunkoo and Pickles 2008). When it is considered that Clostridium Difficile, commonly referred to as C-diff, is a HCAI it is made apparent that the public are greatly aware of this problem due to the fact that a high percentage of people are aware of this infection (Bosanquet 2009). The Healthcare Commission (2005) have also noted their concerns over this problem both the actual problem clinical areas have at the moment and also the potential problems that C-diff actually poses within hospitals a concern that the Department of Health (2009) also holds.
These problems are also acknowledged by numerous additional sources who suggest that infection control in itself is required to be heightened in awareness and practice (Jenkinson et al 2006) making it a significant factor within primary care, a statement which is reiterated by the Nursing and Midwifery Council (2006).
Due to the significance of this issue the author has chosen to reflect on an incident that she encountered whilst on placement within an acute hospital ward regarding this matter. The author has chosen to reflect on this particular incident she encountered using Johns reflection model (1990) with the intention of accessing, making sense of and learning through a specific experience (John's 1994).
The situation chosen for reflection has been classified by the author as being a critical incident. This claim is due to the fact that the experience resulted in thought provocation. Smith and Jack (2005) agree with this when they claim that a critical incident is an experience that results in individuals thinking about what has happened or indeed what is happening, resulting in the provoking of thought within an individual, just as happened in the authors' experience.
Whilst on placement within an acute hospital I encountered a situation that provoked thoughts and feelings within me alongside a desire to further research the subject. I was on a morning shift and was asked by another staff member to help them with a lady patient in a side room that was being barrier nursed due to her being positive for c-diff. Before entering the room to assist the staff member I washed my hands and put on my apron and gloves and then continued to help the staff nurse with the patient. When the task had been completed I proceeded to take the cardboard liner out of the commode and checked with the staff nurse that I was to leave my protective clothing on whilst leaving the room to go to the sluice and dispose of the patients waste and the cardboard liner. The staff nurse told me that hospital policy stated that I would be right in doing exactly that and therefore I proceeded to do so before removing my protective clothing and washing my hands.
For this reflective assignment the author has chosen to use John's (1990) model of reflection due to the belief that she holds that this will ensure that she is to delve through her rationale for actions and the feelings provoked.
With regards to this particular incident the author intends to reflect-on-action so that the experience of the situation can be turned into knowledge therefore providing the oppurtunity of being able to learn from what occurred. Jasper (2003) suggests that this is credible due to the fact that reflecting-on-action as opposed to in-action changes the experience of the individual into knowledge.
What is c-diff? what does it do?
How often does it occur? In 2007 The Health Protection Agency (2007a) reported that there were over fifty thousand noted cases of c diff that presented within individuals over the age of 65. What is it now??????? What does office of national statistics say?????? HPA claim reduction????????? Who does and who doesn't????????
All hospitals are legally bound to ensure that legislation is followed by all staff something that is stated by numerous differing government led organisations including the Health and Safety Executive (2003) who reiterate the statement made by the Health and Safety at Work Act (1974) that states???????? HOW MANY HOSPITAL TRUST DO THIS? STATISTICS?????
The documents "Winning Ways" (DH 2003a) and the Matron's Charter (2004) outlined important areas in the control of infection and acted as a catalyst for local action. According to Shuttleworth (2007) local targets have been set to reduce C diff by twenty five per cent by introducing initiatives to improve knowledge, practical skills in infection prevention and control such as guidelines recently updated (Pratt et al 2007) and DH's and National Health Service (NHS) Modernisation Agency's "Saving Lives: A Delivery Programme to Reduce Healthcare Associated Infection (2005). The government (DH 2007b) provided tools and resources to embed robust infection prevention endorsed by the HCC (DH 2007c) by publishing "Essential steps to safe, clean care" that mirrors Saving Lives but is specific to primary care. These are based on standard principles of infection control such as isolating patients and implementing barrier precautions that must be applied routinely to prevent HCAI transmission (Gould 2009).
Defining the role of the nurse is a difficult task however the role the nurse has within infection control measures is that they are responsible for ensuring that policies and procedures are always followed. It is agreed by Health Protection Agency (2007) AND The Royal College of Nursing (2008) that one of these roles of the nurse is to ensure that individual patients that are confirmed to have c-diff are placed in a side room where they have access to their own toileting fascilities. WHY IS THIS?????. As stated this is the nurses role however this is not always possible to fulfill due to the fact that side rooms are not always available and the actual layout of wards within hospitals often limit the possibilities of individual toilet fascilities HOW DO I KNOW THIS????/.
WHEN THIS IS NOT POSS WHAT ARE THE RISKS? HOW FAR CAN SPORES TRAVEL?
WHO SAYS WHAT ABOUT THIS SITUATION????
Johnson and Gelding (2004) claim that even after thoroughly cleaning patient areas C-diff spores can still be found a claim that suggests that after a patient is moved out of a sideroom if they had c-diff confirmed whilst they were being nursed in the room even after cleaning the contamination risk is still apparent. WHAT DOES HCC SAY ABOUT THIS? AND ANYONE ELSE? EXPAND THIS.
How does cdiff spread? Hands, environment? Air? Hall and Horsley (2007) suggest that c-diff spores can be spread to patients from the environment however it is individuals who visit the hospital not following the requested hand hygiene that is blamed by Banfield and Kerr (2005). WHICH IS IT OR IS IT BOTH???? WHO SAYS????? SOME PEOPLE CLAIM THAT THERE ARE NO SPORES IN THE ENVIRONMENT AT ALL BUT WHO ???????
After washing hands they must be completely dried using a paper towel that is then disposed of (Johnson and Gerding 2004) however this is not agreed by Yamaoto et al (2005) who claim that drying washed hands using warm air may well be a more successful way of limiting bacteria that may be on the hands. WHAT DO NICE SAY AND RCN AND DOFH????
Arguably hand washing can be classified as being one of the important and utmost effective methods of reducing HCAI (Pittet et al 2000). The World Health Organization (2004) holds this to be at the forefront of its 'Global Patient Safety Challenge' something that Gould et al (2007) supports. Hand washing is advised to be done at specific times within situations in a healthcare setting one of which is before and after contact with any patient (Department of Health 2008). The National Institute for Clinical Excellence (2003) support this statement along with numerous additional governing bodies. The Department of Health (2008) continue that when hands are washed they should be done so with soap and water. The rationale behind this method was recommended in 2001 by the Infection Control Nurses Association due to the fact that soap and water supporting the correct technique helps the skin oil layer to be removed which is the one that retains c diff spores. In addition to this it is suggested that the hands are dried once again by a specific and rigorous technique which uses a paper towel that is deemed to be disposable (Johnson and Gerding 2004). This claim is not supported by everybody, Yamaoto et al (2005) believe that drying hands with a paper towel is less effective than leaving them to dry by air, suggesting that this technique would minimize the amount of becteria present on the hands. Alcohol gels are nowadays commonly used therefore rendering soap and water as replaced in many situations and environments. Using alcohol gel prior to and post patient contact is a recommendation that NICE (2003) supported with the exception of when hands can be seen to be soiled to the naked eye.
NICE (2003) recommend using an alcohol-based hand-rub before and after patient contact, unless hands are visibly soiled of which case then implement liquid soap and water and an effective hand-washing technique. EPIC 2 (DH2007e) support this claim though believe alcohol is not effective against C diff microorganisms and suggests the nurse must consider the need to remove transient and/or resident hand flora. Non-compliance of this suggestion EPIC 2 (DH 2007e) believe presents a direct clinical threat to patients. Wilson (2006), Pellowe et al (2007) believes hand hygiene technique and the principles of infection control are too complex for staff to comply or perhaps too complicated for healthcare professionals to in-cooperate into everyday routine (Yamaoto 2005 et al). Jenkins (2004) recognizes staff hand hygiene is poor and is part of the nurses' role (Supported by DH Chief Medical Officer 2002).
IS IT LOW STAFFING LEVELS OR WRONGLY PLACED EQUIPMENT OR INDIVIDUAL NURSES ATTITUDES THAT AFFECTS HAND WASHING ?????? IT IS PART OF THE NURSES ROLE??? Jenkins (2004) suggests that hand hygiene of health care staff is not at a high level despite it being part of the nurses' role within the hospitalâ€¦.WHO SAYS IT IS NURSE ROLE?????
The following of stringent infection control policies and regulations often are not carried out which is something that can be due to numerous different factors. Different organisations and individuals put the blame for any lapses in infection control procedures down to different things including the belief that it is the mixture of skills and qualifications that are employed on a ward (Pellowe et al 2007). Additional factors believed to be responsible include the attitudes held by individual staff and the social norms of the actual ward environment (Pellowe et al 2007) however this is not the main influencing factor believed by all. Hugonnet et al (2007) suggest that they are in agreement with the idea of the ward environment playing an important part as they claim that the positioning of equipment for example sinks and cleaning products is something that can increase or decrease infection control guidelines being followed. This in itself is not something that is agreed by the HCC (2006) who state that the spread of infection within hospital settings is heightened due to shortage of staff on wards. However, the author believes that if shortage of staff was to blame then poor infection control would be evident on all wards that have this denominator which is not the case.
DISPOSABLE GLOVES, APRON????????
It seems that numerous organisations agree that to reduce the risk of cross contamination and infection itself protective clothing should be worn. The government themselves state that disposable aprons and gloves should be worn by all staff when caring for individuals whom are not only confirmed to be infected yet also when they are suspected to be (Department of Health 2007a). This is reiterated by the Royal College of Nursing (2008) who also suggest that this is important in reducing infection.
There is some contradiction in beliefs regarding the use of plastic disposable aprons after hand washing with Hateley (2003) suggesting that this prevents any microorganism to clothing transmission, this is reiterated by numerous people including Wilson et al (2007) and HCC (2006). This is not agreed by Babb et al (1983) when they claimed that microorganisms are not completely prevented by the use of these specific aprons however a reduction was believed to occur.
Gould (2009) take this one stage further in the suggestion that upon exposure to any excreta aprons should be worn before stringent disposal immediately after exposure, a statement that is supported by NICE (2003). Although there is agreeance between NICE (2003) and Gould (2009) there is no specific specification that denotes when gloves should be changed, be it before leaving the particular isolated environment or after. It is stated that wearing protective clothing of any sorts is not necessary upon the entry into an isolated environment (Gould 2009) however this same author claims that when in practice protective clothing should be worn at all times due to the chance of patients requesting assistance. This somewhat contradicts the first claim that protective clothing is not required when entering high risk areas yet is actually required in general practice upon the pretense that help could be asked for.
It can be seen from this that the evidence and recommendations with regards to protective clothing are somewhat confusing at times. Derbyshire County Barrier Precautions Policy (2007) further add to this confusion when they stipulate that before leaving any infected area gloves should be removed suggesting that they should actually be worn in the first place. This policy then continues with a suggestion that any members of staff with any materials needing maceration should indeed change their gloves at just before the point of actually handling the door to the sluice, alongside this they claim that protective clothing should indeed be worn throughout the whole of the task until completion. If Gould (2009) is to be followed then no protective clothing would have been worn in the first place in the isolated area.
This confusion only enhances with the addition of clinical waste disposal, something that by admittance by is found to be confusing to members of the healthcare team (Gould 2009). Following the recommendations of Gould (2009) any items for the macerator should be taken directly into the sluice whilst protective clothing is still being worn resulting in immediate disposal in the macerator. The protective gloves and apron is then said to be required to be discarded into correct refuse prior to washing hands. Gould (2009) continues to state that in an ideal world any patients that may be infected with c diff should have one of either their own individual en suite toileting facilities or their own individual commode. The later of these two statements has enhancement from the Department of Health (2008) who state specifically that this commode should not leave the patients room.
So clearly from these authors and organisations it can be clearly seen that the evidence and suggestions are indeed confusing.
The Royal College of Nursing (2008) claim that when wearing gloves a warm and moist environment is created which in turn leads to the possibility of microorganisms growing in vast numbers. Hateley (2003) reiterates this claim alongside Pratt et al (2007) who suggest that upon glove removal soap and water be used to wash hands as mentioned earlier in this text.
When I was tasked with disposing of the infected waste I wanted to ensure that I did so using evidence based practice so as to minimize, if not completely eradicate, any risk of cross contamination whilst taking the waste from one area to another where the macerator was based.
I was aware of the potential risk of contaminating the environment along the corridors of the ward and did not want to do this and put other patients and staff at risk therefore I needed to question my practice.
The contents of the bed pan could have spilled on the floor or the paper towels which would have resulted in spores being released into the surrounding environment. I did consider using my elbow to open the door handle in the patient's room and the one leading to the sluice yet came to the realization that this could have resulted in spillage onto either myself or the surrounding environment.
O' Callaghan (2005) stated that any challenge that nursing practice may receive could possibly add to any changes to policies and or practice regarding infection control procedures and barrier nursing. If Mohanna and Chambers (2001) is to be believed then risk management can be deemed to be an integral factor within clinical governance. Throughout this experience I did hold an awareness of the principles of barrier nursing. This led me to challenge this specific ward's policies on the best practice for taking the bed pan from the patients' room to the sluice.
When I walked down the corridor with only paper towels covering the bed pan I was aware of the possibility that I may well have been spreading c diff spores. This could have had huge implications for all within the surrounding environment. Upon opening the door handles I was more than aware that my gloves had a high risk of being contaminated yet there was nothing I could do to eliminate this. My feelings at the time, are as they still are, ones of hypocrisy. I felt slightly shamed at the fact that I lacked the knowledge to stand and challenge the policy in a greater depth.
One of the first influencing factors of this situation was the recognition that the ward, its patients and staff were intitled to the very best of care. The NMC code of conduct (2008) state that all nursing staff have a duty of care. Within this very code it is stipulated that nursing staff hold a role that means they are expected to prevent patients from infection and protect them at all times. It also stipulates that nurses have a professional duty which includes providing evidence based practice and care that is up to date.
The whole scenario was obviously one that would cause the patient to lose their dignity thereofr eI was more than aware of the need to dispose of the excreta immediately and safely. This dignity was what I was trying to protect when covering the bed pan with the paper towels, something that has been agreed as ethically right and correct practice by Timby (1996) alongside the Department of Health (2003b). Not only is this noted as being best practice within the circumstances yet also practice that would provide a reduction within the chance of spillage, therefore I was showing risk management skills.
COULD I HAVE DEALT WITH THE SITUATION BETTER?
In hindsight I feel that the confusion I encountered at the time of the incident could have been avoided had I had made myself aware of the ward's policies on infection control and barrier nursing at the beginning of my placement.
Other than this I think that I handled the situation well by questioning what I was being asked to do, however I wish I had held the knowledge that I have gained through this reflection prior to the experience. If I had then maybe I could have foreseen the situation arising and possibly found a solution to a potential problem instead of being confused by an actual problem. In addition to this one thing that I realize I did not do yet could well have done is to have used alcohol gel after washing my hands. This could have reduced the risk of cross contamination further (RCN 2008) which could have resulted in easing my concerns slightly.
Numerous issues still remain with regards to infection control and infection prevention however this experience resulted in my awareness of the subject matter being raised. Prior to this experience I encountered I was unaware of factors that potentially predispose individuals to infection. Disease is not always caused by c diff when it is present in the bowel, it is only when bowel flora is changed from being deemed to be normal that disease occurs. This alteration of normal bowel flora can potentially be caused by specific antibiotics, a claim that has had wide spread support throughout the past twenty plus years (Lyerly et al 1988, McFarland et al 1989, Association of Medical Microbiologists 1998, DH 2007a ).
Despite my actions being that of best practice within the specific trust's policy I appreciate that isolating any patient into an individual room of their own so as to decrease the risk of cross contamination. However it has to be considered that c diff spores are never truly eradicated completely from the environment.
In compliance with evidence based practice guidelines (2009) I ensured that I washed my hands correctly prior to going into the patients' room and also wore protective clothing. I placed two disposable paper towels over the bed pan liner due to my awareness that to get to the macerator I would have to walk down the corridor of the ward. I believe that covers for these cardboard liners should always be supplied and used. However upon searching for such a product I could not find any such thing. This is still not an idealistic solution as the risk of spillage would still remain therefore in an ideal world, as suggested earlier, all patients should have their own toileting facilities. So as to resolve the confusion of opening door handles with gloves that pose the risk of contamination it could be suggested that doors within ward environments be handle free. This would limit the contamination risk however the handle on the macerator would also need to be redesigned so as to enable that too to be touch free, from hands at least. This suggestion is something that the Department of Health (2008) could be argued to support due to the fact that they claimed to be researching touch free designs for specific equipment.
Hand washing and protective clothing can be deemed to be a priority within the spread of c diff yet from the research and literature reviewed within this assignment it is clear that some confusion is apparent, probably steming from the noted contradictions.
This experience of a critical incident enthused reflection as explored by the use of Carpers (1978) methods and ways of knowing, namely personal, ethical, aesthetic and empirical. The thorough acknowledgement of these patterns is claimed to expand not only the bredth of understanding yet also the expansion of personal thinking beyond specific approaches (Ashburner 1996).
Upon placing paper towels over the bed pan the patient's dignity and privacy was maintained, alongside professionalism being shown. Factors that are not only thoughtful yet also a part of the NMC's 'code' (2008).
Throughout the experience I was led by the theoretical knowledge that I had gained throughout the journey of my life. Moral decision making is said to be solely focused upon what should actually be done within a specific scenario or situation (Davis 1995). Prior to my reflection upon this practice I was not fully aware of the rational for my actions and the theory that underpinned it however I acted as I did through, as stated above, my knowledge and moral decision making.
Using the reflection model of John's (1990) guided me through an exploration of numerous and varied differing knowledge sources that led my individual actions. My whole level of understanding and awareness of infection control within healthcare settings has been raised which in turn will heighten my confidence within the subject matter for the future.
This assignment has noted differing cultures within ward settings and policies that lead to contradictions and often confusion. Despite this numerous attributes that I personally hold have been credited and become aware to myself; including critical thinking and problem solving which has allowed me to explore a thought process that led to alternatives to current practice being explored.
One of arguably the most important realizations I have gained from this reflection upon practice is that healthcare workers within any setting all play a part within infection control. It has been suggested that hand hygiene, namely hand washing, prior to dealing with any patient and again afterwards is at the heart of infection control (Storr et al 2005). Alongside this and the previously mentioned infection control procedures I believe that the policies and their appliance within day to day practice is indeed the key. Despite all my fore mentioned research into this subject I am left wondering and concerned that even if all staff members follow their specific policies, due to confusion within the literature a risk of cross contamination, resulting in the spread of c diff, will still be present.