The Essence of Emergency Care Practice - Article Example

Essence of Emergency Care. The objective of this assignment is to identify a critical incident from practice and use current literature to suggest possible recommendations for future practice. The purpose is also to highlight the factors that may support or inhibit the process. The particular incident selected in practice concerns uniforms that become contaminated with bodily fluids -- such as blood, vomit, urine or faeces – and the subsequent necessity of having sufficient alternate uniforms. The Department of Health 2007 Uniform & Work wear document states that good practice is to change immediately if uniforms become visibly soiled or contaminated, as it may cause a risk of infection. No member of the staff wants another person’s bodily fluid within close contact of their own skin, as this is invasive to personal hygiene. Any blood contamination could pose a risk of transmission of bacteria (Leonas 1993 cited in Eberhardt et al 2004). Past research on uniforms has shown that nurse’s uniforms can grow pathogens (Waters 2005).While no evidence is currently available linking the transmission of bacteria to patients (Wilson et al 2007 cited in Royal College of Nursing 2009), the possibility of transmitting infection via uniforms still remains an important issue for employers. It has the potential of severely affecting the contaminated staffs working practice, and breaching the compliance to guidelines. The local trust policy of 2008 states that uniforms that are contaminated with blood or bodily fluids must be immediately changed -- especially before these uniforms have contact with another patient. The recommendations proposed for the clinical setting are the wearing and use of hospital scrubs (belong to the department only) instead of uniforms, as uniforms have been the topic of critical research for a number of years (Hignett & Crumpton 2000 & Royal college of Nursing 2009) The uniform that were designed previously have not evolved with the changing patterns of the modern health service industry and environment. Is the presently used uniform clinically appropriate? The purpose of this research assignment is to show that the use of scrubs is essential in the contemporary health service environment. A literature search was conducted using the key search terms: uniforms, scrubs, infection control, hospital textiles & clothing, hospital clothing policies & work wear. The database used in the search integrated Science direct, CINAHL, British Nursing Index & Wiley InterScience/Blackwell synergy. The NHS National Library for Health, online journals for nursing and infection control journals were also investigated. In completing a literature review, it was revealed that there are general questions and dialogues concerning scrubs, but limited professional research around the use of regular clothing. When considering references used in other articles, it was revealed that the evidence they based their findings on was from very early dates. Nevertheless, the current literature utilized was entirely from established government research. Considering the present media frenzy around infection control, the expectations of recent research should have been immense; surprisingly, this was not the case. Fundamentally, one can analyse the rationale behind requiring only certain areas such as ITU, theatres and maternity to be able to wear regular items of clothing, while other departments and wards have to don the standard hospital uniform. McDaid & Lightfoot (1993) as cited in Hignett & Crumpton (2000) reported nurses are still, in many cases, wearing antiquated uniforms of 60 years prior. A review of the standard uniforms requires them to conform to current standards and infection control recommendations; Hassan (2008) explains that new uniforms are essential in order to improve infection control and to enhance the corporate image. This statement is paramount to the current proposed recommendation. Hospitals are supposed to be a clean and safe environment, but the reality is that hospital life is dirty and filled with fluids and life threatening infectious diseases (Waters 2005). This environment is reflective of nurse’s uniforms. Callaghan (2005) discovered that nurse’s uniforms were contaminated even at the start of shifts. Perry et al cited in Twomey et al 2009 survey found 39% of health works uniforms tested were positive for VRE (vancomycin resistant enterococcus, MRSA (methicillin resistant staphylococcus aureus and c.diff (clostridium difficile). Swapping uniforms for theatre scrubs is one of the solutions that would aid in reducing the spread of infection. A study at Dundee University took swabs from scrub uniforms of nurses in three hospitals and found a contamination rate of just one in twenty seven (Gall 2005). The spread of MRSA has increased the use of scrubs (Neely & Maley 2000). In 2008, Parker-Pope found that if a worker entered a room where a patient has MRSA, the bacteria would end up on the workers clothes about 70% of the time, even if the person never actually touched the patient (Parker-Pope 2008).In an A & E department, a variety of illness’s are seen. For some patients infections may not yet be diagnosed (McCulloch 1998) -- some of which are MRSA cases -- so that after every discharge (whether at home or to at a ward) similar to MRSA the healthcare professional must change their uniform to prevent further contamination. Uniforms become heavily contaminated around the pockets and buttock areas (Callaghan 2005 & Gould 2008). Presently, hospital staffs have an inadequate number of uniforms. Gall (2005) researched that fewer than half of NHS hospitals provide nurses with a sufficient amount of uniforms. The Royal College of Nursing (2009) declared that there must be sufficient uniforms provided, as well as access to spare clothing if staff clothing becomes contaminated. There was a low contamination rate for scrubs worn by nurses in theatres and recovery (Waters 2005). Due to the inexpensive cost of scrubs compared to the standard hospital uniforms, the availability of scrubs should be doubled (Walker 2008). The scrubs would then be held on site and if the need to change arises it could be done without any complications .In current practice, when a clean set of scrubs is required to replace soiled uniforms, the departments that scrubs are actually worn in are reluctant to issue them. The staff then becomes hesitant to ask to borrow scrubs. This breaches the condition of the Royal College of Nursing (2009) that requires access to spare clothing if the staff clothing becomes contaminated. Callaghan (2005) stated that if nurses get a splash of urine on their uniforms they are unlikely to change, but since the fabric of scrubs is thinner and it becomes visible, they are encouraged to change. Scrubs were designed to be simple with minimal places for dirt to hide, easy to launder and cheap to replace if damaged or stained. (Walker 2008). Scrubs are cheaper to make than uniforms (Callaghan 2005), so that the ratio of nurse scrubs per nurse could be increased, allowing a larger volume in circulation. Historical evidence regarding the use of scrubs dates back to the 1800’s when they were made from cotton fabrics (Smith & Nichols 1991 cited in Eberhardt 2004). Today, standard uniforms are made of a mix of two fabrics, one of which has a higher percentage of polyester. Polyester reduces adequate air circulation and evaporation of perspiration. Superbugs, such as staphylococcus aureus can live in this type of material for up to 56 days (McCaughey 2009). Scrubs can be purchased from a mix blend or 100% cotton; the latter choice is recommended to the department in question, as there is a much lower chance of surviving on this type of material. Evidence based research conducted by Neely & Maley (2000) showed the survival rate of staphylococcus aureus is only 1 to 5 days on cotton. Huang & Leonas (1999) cited in Eberhardt (2004) suggested that health care worker uniforms could provide better protection if a textile finished with a water repellent or antibacterial finish was applied. Taking these recommendations and looking at this from a patient or family member’s perspective -- where there are strong views for the transition from the standard hospital uniform to hospital scrubs -- the way staff dress can send a diverse range of positive and negative messages. The professional image presented by the nursing staff is an important component in the way nursing is regarded by patients and the public. It promotes a role of professionalism, trustworthiness and is recognized by the general public (Loveday et al 2007).The Royal College of Nursing (2009) articulates that uniforms or clothing must be smart, safe and practical. The uniforms should project a professional image to encourage public trust and confidence. A vast number of people made comments that scrubs look untidy, Walker (2008) characterized scrubs as not as smart as uniforms. On the opposite side of the patient perspective is the staff who would be wearing and benefiting from the scrubs. Sutton (2009) comments that specialised clothing that professionals wear each day should be comfortable and practical for daily wear. Tobin (2006) remarked that nurses found manoeuvring patients was easier when wearing scrubs. Crumpton (2001) established that a nurse uniform weighs 210g/m2 where as scrub fabric weight is 190 -195g/m2 -- this increases comfort. For this reason, heat and perspiration would be diminished, subsequently reducing exhaustion; this would engender a higher rate of productivity, as staff would be in a better state of mind, and stress levels would be reduced, keeping the staff healthy while working. Having a work force that wears a different uniform to other departments of the hospital would give them a sense of pride and individuality. In addition to the staff wearing scrubs when they require new work attire through wear and tear, pregnancy or weight gain/loss, the staff members would not be directly or indirectly discriminated. The staff would also not need to wait for new uniforms, unlike present practice where the long wait manifests problems for the working environment. Further recommendations include having a different colour set of scrubs for each department. There are two reasons for this: the first reason is that the public will recognize the staff from the same area, and the second reason is that those scrubs would be returned to the correct place when laundered. The colour would then be subdivided from dark to light shades to denote nursing grades; this practice has already been implemented in another trust and had a positive and enthusiastic conclusion and reduced the cases of MRSA by a third. A study implemented by Loveday et al (2007) reported that responses strongly supported that any uniform worn by nurses needed to be identifiable and distinguishable from other groups of staff. It could be argued that the seniority of the nurses should be demonstrated by the way they conduct themselves in the clinical environment and not by the colour of the work attire. Scrubs are often worn in different colours in medical facilities to identify different types of personnel to patients and other medical professionals (Sutton 2009). The department’s title would be incorporated on the top to conform to The Royal College of Nursing (2009) whose general principles state this should contribute to identification for security purposes and project a professional image to encourage public trust and confidence. If the department changes to wearing scrubs they should be of good quality, as a neat and tidy appearance gives the impression that you take good care of yourself and are also likely to take good care of them (the patient)(Hill 2001) Wearing scrubs would require that the staff member change into personal clothing before leaving the hospital grounds due to their immediate recognition as coming from a high infection risk environment. In addition to the scrubs being made from a thinner material, comfort and warmth outside could pose a further factor. Staff changing out of scrubs before leaving work will also minimize the risk of attack/injury as people that are identified as health care professionals may be at an increased risk of attack. For this to be put into practice, adequate changing facilities need to be available to the staff, as this is another reason the staff leaves the hospital grounds still in uniform. At present, only 26% of trusts have adequate on site staff changing facilities (Nye et al 2005). Nye et al 2005 informed that inadequate provisions of uniforms and laundering facilities in hospitals results in many staff travelling to and from work in uniforms.However, there is no evidence of an infection from travelling in uniforms, but patient confidence in the NHS may be undermined (DoH 2007 & Royal College of Nursing 2009). McCulloch (1998) writes that nurses must be sure that they do not contribute to infection risks and must take every step to prevent infection wherever possible. Nurses have a professional and moral duty to safeguard patients (Nursing and Midwifery Council 2004).The general public’s perception is that uniforms pose an infection risk when worn inside and outside clinical settings (Loveday et al 2007). For the reason that was previously stated, scrubs are more cost effective and the availability of a clean uniform for the next day’s work would never come into question as there would be a greater reserve; this can be contrasted to present conditions where staff are only allocated 4 uniforms when in full time employment, as 30% of the staff do not wear a fresh uniform daily (Callaghan 1998). In January 2008, a hospital in the South West enforced their staff to wear scrubs to prevent the further spread of healthcare-associated infections and supplied access to a clean pair of tunic and trouser style scrubs at the start of each shift. Transitioning from hospital uniforms to scrubs in clinical practice would require a change that comprises a 3 theory phase. This is taken from the well known theorists Lewin (1951) cited in Yukl (2006). He was the best known of the early classical change theorists, and he identified several rules that should be followed in implementing change: change should be implemented for good reason, always be gradual, should be planned and not be sporadic or sudden, and all individuals who may be affected should be involved in planning for the change. The three phases are unfreezing, changing and refreezing. In the unfreezing phase, people come to realise that the old ways of doing things are no longer adequate; this can be a result of an obvious crisis, in current practice this is an ongoing problem. A consideration of cost benefits and a risk assessment would need to be addressed at this stage to make the recommendation of wearing scrubs viable. This would consist of an assessment undertaken to ensure that the clothing or uniform provided for the staff allows unrestricted movement at the shoulders, hips and waist. A risk assessment allows the investigation for adequate storage and attachment points for ID tags, pens & scissors on the proposed scrubs and to demonstrate that inappropriate choice of materials/fabrics may cause chafing, rashes and dermatitis. People may become discontented and confrontational. The change agent has to motivate the staff by getting them ready for change. In the changing/movement phase, people look at new ways of doing things/new perspective and select a promising approach. This phase could be addressed by holding a workshop inviting those staff members concerned to voice their opinions and a question and answer session could take place, this also could be an opportunity of presenting the proposed scrubs. In the refreezing phase, the new approach is implemented and it becomes established. For this stage to be effective the change agent must be supportive and reinforce the individual adaptive efforts to those affected by the change. Once implementation has been made it needs to be apparent that the change will be re- examined to confirm the change remains viable and workable also to tackle any problems which may have arisen along with re assessing the risk assessment topics. A strong resistance will be shown if the unfreezing phase has been missed and the person has moved directly to the change phase. There is a more positive approach clinically for changing from the standard hospital uniforms to hospital scrubs. Negatively the views concerned were around untidiness and not being smart but combating and reducing infection rate should be at the forefront of every hospitals driving force. The general public would learn to accept the change in time. The need to change is to prevent and combat the ever increasing struggles of managing infection control topics. In the long term the initial outlay for changing from uniforms to scrubs would run into thousands from the trusts budget ,however this is insignificant compared to the cost of the increased number of patients being diagnosed with, treated and the increased hospital stay due to hospital acquired infections which is adding billion’s a year to the nation health tab. There have been many NHS trusts which have made the move to wearing scrubs with a positive outcome. However, scrubs are seen as the way forward but they can give the wearer a false sense of security that they are “clean” when in fact are as easily contaminated as any other clothing so stringent changing and laundering needs to be continued. Scrubs are just a piece of clothing and not a super protective suit. The other areas which would need to be addressed before the introduction of scrubs is the legal framework The Health and Safety at Work Act 1974, The Control of Substances Hazardous to Health regulations 2002, Management of Health & Safety at Work Regulations 1999, Securing Health Together & Health Act 2006 Code of Practice (Department of Health Doc 2007) which altogether protect, promote and safeguard the patients, general public and medical profession. The summary of recommendations for the trusts department in question would be for the transition to hospital scrubs that are 100% cotton consisting of a water proof barrier, a unique colour for the department sub divided into shades for different grades bearing the trusts name and department, reinforced sections to house required tools and ID badge and for the department to develop adequate changing facilities. The only other factor/suggestion which needs to be taken into consideration, The RCN, Unison and the Royal College of Midwives cited in Walker 2008 made comments that the scrubs should have side fastening to avoid pulling contaminated scrubs over the face. Read More