Management of Change in Nursing - Essay Example

?Essay Management of Change in Nursing Candi number: Module Personal Cohort: Word Count: 4163 Introduction This assignment aims to promote change in clinical practice by introducing an education package that will encourage nurses to ascertain the benefits of different coated urinary catheters in reducing the risks of infections. This proposal is based on findings as established in the literature review conducted on the topic. In order to accomplish the goals of this study, evidence-based research shall be evaluated and its relation to the actual clinical practice shall be considered. The rationale for this study, as well as the summary of the literature findings shall also be set forth. The change proposal shall then be laid out and the steps in the implementation process shall also be explained based on the change management framework developed by Lewin. Based on the Nursing and Midwifery Council (NMC, 2008), a nurse is obligated to deliver the best and the highest standard of care at all times. More specifically, they are called on to deliver care, according to the best available evidence and best practice; and they must also ensure that the advice they are giving to their patient, in terms of healthcare products and services, is based on evidence (NMC, 2008). There are numerous evidences which are often made available to nurses for use in their practice. For which reason, it is important for nurses to be knowledgeable and skilled in the critical evaluation of evidence and ensure that the evidence they would choose to support and apply in their practice would be the best (Spector, 2007, p. 1). For the purpose of this essay, the definition of evidence-based practice by Sackett, Straus, Richardson, Rosenberg, and Haynes shall be adapted. They define the practice as “the integration of best research evidence with clinical expertise and patient values” (Sackett, Straus, Richardson, Rosenberg, and Haynes, 2000, p. 71). This definition emphasises the importance of incorporating the best available evidence with clinical evaluation, and highlights the important role of the patient in his care. It also helps provide support for the implementation of an education package in implementing change. Evidence-based practice therefore considers the role of the patient in the planning and conceptualisation of their care (Pipe, Wellik, Buchda, Hansen, and Martin, 2005). The nurses have to include and consider patient preferences in relation to the best evidence available and apply such to the planning process. Critics like Mullen and Streiner, however, are not supportive of EBP, contending that it prevents the application of the most effective treatment for the patient. They point out that EBP does not “fit the realities of individualised, contextualized practice, especially nonmedical practice wherein problems are less well defined (Mullen and Streiner, 2004, p. 133). They also emphasised that there are often many limitations in the methods of research in the systematic reviews and meta-analysis. Moreover, concern has been expressed on how evidence-based research can be conceptualised when competing elements like public opinion and resource limitations affect policy-making (Mullen and Streiner, 2004, p. 133). On the other hand, health practitioners are quick to point out that EBP is about being guided by the best available evidence. This means that absent available randomised controlled trials without design flaws, trials which have limitations can be used instead (Mullen and Streiner, 2004, p. 133). In effect, health practitioners and users of health services must be cautious about the risks and benefits when the evidence for decisions are made apparent, even if this would mean that there is not much evidence supporting the different choices (Mullen and Streiner, 2004, p. 133). Proponents of EBP also point out that even as the realities of practice may be far removed from the behaviour and practical aspects of the clinical practice, there is merit in considering the decision-making process in EBP. However, it is also important to note that EBP does not exclude the complex decision-making process, nor does it exclude the values and preferences of the patients (Mullen and Streiner, 2004, p. 133). In the end, in order to ensure efficiency of each intervention, the applicability of such intervention depends on acceptability, comfort, and receptiveness of the patient. Fitzpatrick (2007) emphasises that in the current healthcare setting, evidence is being constantly updated. With new research and technologies being introduced into the practice, old practices and opinions are often subjected to evaluation and assessment. In effect, evidence is constantly evolving. Nurses must therefore keep up with such changes and perspectives in their service delivery (Fitzpatrick, 2007). They must submit to the implementation of educational packages in their ward or unit. They must also consider the adoption of a process of EBP which can be subjected to scrutiny by peers and by the general public. Through openness and transparency, the clinical decisions can be justified and a nurses’ accountability exemplified (NMC, 2004). The Royal College of Nursing (2007) is of the belief that EBP helps lead to quality health services and the constant improvement of such services is important in clinical governance. In effect, clinical governance is defined by the Department of Health (1998) as “a system through which the 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”. It also includes different elements like client participation, effectiveness and safety of treatment in order to provide the best possible service for the patient (Welsh Assembly Government, 2008). The WAG (Welsh Assembly Government) sets forth standards in order to empower health practitioners in the implementation of clinical governance in their workplace. Such clinical governance often heavily relies on the existing culture in the workplace. Such governance then acts as a change agent in empowering individuals to apply evidence-based change in the workplace (Scally and Donaldson, 1998, p. 61). Change in the workplace is therefore dependent on a variety of elements, all of which centre on specific qualities of the workforce, the practice, and the patients themselves. In this case, setting up an educational package in the unit can help implement much needed changes in the ward or unit. Rationale and summary of the literature review A review of literature was carried out in order to establish how to prevent and reduce the risk of urinary tract infections with indwelling catheters. This review was conceptualised due to observations made in the clinical practice with different methods of infection prevention for catheterised patients being applied. This review now sets forth different aspects or themes in its analysis: causes of catheter-associated urinary tract infection (CAUTI); prevention of CAUTI through catheterisation; antibiotic-associated means of preventing CAUTI; and prevention of CAUTI among patients under prolonged catheterisation. Johnson, (2001) discusses that indwelling catheters can also cause nosocomial infections in the acute and the long-term care setting. Catheters are instrumental in providing bacteria and other microorganisms a pathway to the sterile urinary tract, consequently, increasing the risk for bacteriuria and funguria on the catheterised patient. For patients under short-term catheter use, they develop UTI at a rate of 10% to 25% and at almost a 100% rate for those under chronic catheter use (Johnson, 2001). For patients under short-term catheter use, fever is rarely an occurrence; however, the incidence of bacteremia still registers with a 1-3% incidence, often causing prolonged hospital confinement and higher hospital costs (Johnson, 2001). The CAUTI also often gives resistant organisms a reservoir for possible spread. This emphasizes that the inappropriate and unrecognised catheter use is prevalent, but also avoidable. Systemic antibiotics are sometimes not advisable to prevent and treat asymptomatic CAUTI; and metal cleansings and bladder irrigation can sometimes be ineffective in preventing UTI. The role of antimicrobial in preventing CAUTI has yet to be defined (Johnson, 2001). Catheter removal often eventually resolves fungal CAUTI; in chronic care settings, fever in catheterised patients is often caused by CAUTI, but eventually resolves without antibiotics (Johnson, 2001). For the most part, some practitioners recommend the avoidance of catheter use in the prevention of CAUTIs. However, in the actual setting, this is easier said than done. There are certain procedures which often require catheterisation, and without proper precautions on the part of the health professionals, CAUTIs would remain an issue in the clinical practice. It is therefore important to set forth remedies in the prevention and management of CAUTIs. The importance of applying measures for the prevention of CAUTIs have been pointed out in the study by Tenke, et.al., (2008, p. S68), wherein the study revealed that they conducted an extensive literature review on the development and prevention of CAUTI. Their review revealed that the urinary tract is the most likely source of nosocomial infection, especially when the bladder is catheterised. Most CAUTIs are also derived from the patient’s own bacteria, and the presence of the catheter often predisposes a patient to UTI. Moreover, the most relevant risk factor seen in the development of CAUTI is the duration of the catheterization (Tenke, et.al., 2008, p. S68). The longer the catheterisation, the most likely the patient would acquire CAUTI. The researchers emphasised that reducing the duration of catheterisation should be made priority in order to prevent CAUTI. And while the catheter is in place, effort must be made to prevent infection, including the administration of antimicrobial treatment and the regular conduct of routine urine culture to assess for infection among asymptomatic catheterized patients (Tenke, et.al., 2008, p. S68). Some studies have pointed out that with antibiotic precautions taken in order to prevent infection during catheterisation, it is possible to reduce incidents of CAUTI. The study by Park, Cho, Choi, and Jeung, (2003, p. 951) sets forth that the use of norfloxacin-releasing catheters facilitated in the release of antibacterial for up to 30 days in the urinary tract. This antibiotic helped to inhibit the growth of Escherichia coli, Klebsiella pneumonia, and Proteus vulgaris. The authors pointed out that adapting this method of catheterisation is very much helpful for patients undergoing long-term catheterisation (Park, Cho, Choi, and Jeung, 2003, p. 951). Practitioners also believe that removing unnecessary urinary catheters is one of the simplest means by which CAUTI can be prevented. In a paper by Wei-Chun, Shue-Ren, Shoa-Lin, Kunin, and Ming-Ho, (2004, p. 974) the authors set out to determine the efficacy of nurse-generated daily reminders to physicians to remove unnecessary urinary catheters 5 days after insertion. During the course of their research, they were able to establish that with more limited durations in urinary catheterization, patients also manifested with lower rates of CAUTI (Wei-Chun, et.al., 2004, p. 974). The nurse’s role in the process of preventing CAUTI is as important as the physician’s role in prescribing antibacterial medication for the catheterised patient. With the sufficient amount of vigilance, it is possible for the patient to experience less incidents of CAUTI, to incur lesser hours of hospital care, and decreased cost in health care. Practitioners also advocate for the use of silver alloy hydrogel-coated urinary catheter in order to prevent CAUTIs. Various studies yielded favourable results for the use of such silver alloy hydrogel-coated catheters. One of these studies was carried out by Rupp, Fitzgerald, Marion, Helget, Anderson, and Fey, (2004, p. 445) where the authors sought to assess the cost effectiveness of the coated catheter and the emergence of bacteria in relation to these coated catheters. The study revealed that the use of silver alloy, hydrogel-coated urinary catheters was linked with a decrease in nosocomial UTI and with lower cost in terms of health care. All in all, this study, along with other similar studies yielded favourable outcomes for patients. These studies indicate how nurses can benefit from the implementation of an education package which can teach them how to reduce infection among their catheterised patients; instead of using the traditional catheters, they can use these coated catheters to reduce the rate and the incidence of bacterial growth. Process for implementing change Change can take up many forms and conceptions. In the most basic pretext, change is about making a shift from one to another (Webster, 2011). It is often an inevitable process and occurrence which all individuals, organizations, and technological systems undergo. In the healthcare setting, change is a welcome and important process because the health process and health interventions must be constantly updated to fit the changing needs of the patients. “The improved awareness of the need for change in healthcare has as yet not fully led to a powerful introduction of tools that help to improve (the efficiency of) healthcare (Weerangsinghe, 2009, p. 98). The changes which have been implemented in healthcare throughout the years attest to the positive and favourable outcome of changes carried out in the healthcare practice. The NHS has reached a favourable place in the current delivery of healthcare because of these changes which were implemented throughout the years. In the process, the NHS has become at par with the global or international healthcare standards (WAG, 2005). An important part of the change process is the change agent. A change agent is one who “intentionally initiates and creates change” (Daniels, 2004, p. 1472). Changed agents continuously come up with ways to implement improvements and they often use creative and innovative solutions. In most cases, critical thinking is applied in order implement change and to evaluate its impact on the individuals affected by such change. In this case, a change agent can be a nurse who is introducing an educational package for the implementation of a new and more effective intervention. In the delivery of nursing care, the assistance and the active participation of the specially-skilled nurses is often crucial to the implementation of change. In this case, the expertise of the hospice and/or palliative care nurse is essential in order to implement the change in the catheterisation of patients, especially those in the long-term care setting. Moreover, the implementation of the educational package can help implement the much needed change. Proposed change: This assignment proposes to educate nurses’ through an educational package on the different kinds of urinary coated catheter they can implement on the catheterised patient. The object of this change is to reduce urinary catheter associated infections. This objective is kept simple, measurable, achievable, realistic, and time-bound (SMART) (Gopee & Galloway, 2009, p. 55). This will show rates of measurable infections and effectiveness, which becomes possible by comparing the rates over a period of time. Change management theories There are various change management theories. One such theory is the Prochaska and DiClemente’s change theory. This theory sets forth a general process of change and is usually less specific (Kritsonis, 2004, p. 3). These theorists explain that people go through different stages of change: precontemplation, contemplation, preparation, action, and maintenance. Getting through these stages is cyclical, not linear because most people tent to regress on their efforts to change when they are able to successfully gain their initial goals (Hicks, n.d., p. 1). Most people have the chance to leave any stage of the change process if they decide not to change. Another theory is the theory of reasoned action. This theory emphasizes that “individual performance of a given behaviour is primarily determined by a person’s intention to perform that behaviour” (Grizzell, 2007). This theory involves the concept of perceived control over opportunities, resources, and skills essential in the performance of a desired behaviour. A third theory is the change theory by Lewin. Lewin introduced his change theory by conceptualizing the three-step change model. Lewin was a social scientist who saw behaviour as a “dynamic balance of forces working in opposing directions” (Kritsonis, 2004, p. 2). He further explained that driving forces implemented change because they stirred employees in the favourable direction. On the other hand, the restraining forces interfered with change because they pointed employees in the opposite direction. These driving and restraining forces must therefore be evaluated and Lewin’s model can help shift the balance towards the planned change (Kritsonis, 2004, p. 2). This theory was chosen over the two other theories because the Lewin’s change process is more applicable to the change programme to be implemented. Most practitioners have gotten used to the traditional way of using the catheter and the shift from the old to the new coated catheter way is bound to go through an ‘unfreezing’ stage. This aspect of the change process is not available in the two other stages discussed above. But Lewin provides details for this ‘unfreezing’ to take place; hence, his change theory was chosen for this study. Lewin’s three-step model follows the steps below: a. Unfreeze the existing situation or status quo Lewin (1951) explains that the initial step in changing behaviour is to unfreeze the situation or the status quo. The status quo is considered to be the current situation in any organization. Unfreezing such status quo involves the process of getting past the difficulties of individual resistance and group conformity (Kritsonis, 2004, p. 3). In implementing the chosen change programme, Freeman (1999, p. 381) suggests that the change agent first influence the younger staff to accept the change, and then to promote them. In long-term care facilities, it would be prudent to re-educate the older staff and integrate them into the change process. The process of unfreezing the status quo also involves the process of reconsidering the current existing hospital policies on catheterisation and suggesting amendments to these policies. By resisting the existing policies in the organization, it is possible to set forth new ones. The educational package can then ease the transition into these new policies. It would serve as a bridge between the old familiar policies and the new unfamiliar ones. The unfreezing process will also involve setting forth schedules for the staff to attend the sessions as part of the educational package. Their resistance to change their schedules and attend the sessions would be expected, however, by making the attendance to the sessions mandatory, the implementation of the package would be easier and faster. Some of the staff members would not be receptive to attending the sessions which would end up changing their patterns of behaviour, but letting them know that the change is inevitable would ease the acceptance process. b. Movement The second step in Lewin’s theory of change management is movement. In this stage, it is important to “move the target system to a new level of equilibrium” (Kritsonis, 2004, p. 3). This stage can be assisted by three actions: convincing the staff to assent to the fact that being in the status quo would not benefit them and persuading them to evaluate the issue from a fresh perspective; working together to search for new and relevant knowledge; and connecting the perspectives of the group to well-respected leaders who also support the change programme (Kritsonis, 2004, p. 2). Once a state of openness is achieved in the organization, it is now time to take the system into a new level. In implementing the educational package, the movement here would involve setting up days of lecture and training with the nurses. It also includes the process of arranging for a room or a hall for the education and training process to be carried out. I would also need to prepare leaflets and handout lectures for the staff. These materials will detail the new methods and new processes of catheterising patients. There is bound to be some resistance from the staff members in the implementation of these processes, however, a certain amount of resistance is also essential in ensuring that unnecessary and illogical threats to the status quo are prevented (Deutsch, Coleman, and Marcus, 2006, p. 439). The staff members are not expected to welcome the change in their nursing management because it would entail shifts in their usual way of carrying out their tasks. On a more specific note, it would require additional training on their part on the application of the hydrogel catheters and the coated catheters. However, as the status quo has been unfrozen, the movement and implementation of the new catheterisation program would have to be accepted by the staff members. In the second stage of the change process, the change agent “identifies, plans, and implements appropriate strategies, ensuring that driving forces exceed restraining forces” (Marquis and Huston, 2008, p. 169). This stage is likely to require a significant amount of planning. It may be difficult to overcome resistance of staff members; however, by giving the staff members time to adjust, it may be possible to gain favourable outcomes. The change agent involved in implementing the new catheterisation program would have to carefully plan the change process through the issuance of new instructions to the staff. The change agent would also need to coordinate with the hospital and with other health care officials on the arrangement of rooms and in coordinating meeting time with staff members. c. Refreezing The last step in Lewin’s change model is refreezing. This step has to be carried out after the change has been implemented so as to ensure that it would be sustained or that it would persist over time (Kritsonis, 2004, p. 2). For the most part, if this step is not implemented, the employees may revert to their old behaviour. This stage therefore involves the integration of the new processes and values in the community traditions. This stage aims to stabilize the new procedure by gaining a balance between the driving and the restraining forces (Kritsonis, 2004, p. 2). In order to implement this step, it may be necessary to reinforce new patterns and to institutionalize them with the use of formal mechanisms such as policies and procedures (Robbins, 2009, p. 564). In applying this step to this change process, notices from the supervisors have to be coordinated and sent out to nursing staff in order to ensure that all staff members participate in the educational program and that they carry out the new procedures for catheterisation. It has to cover a wider landscape in order to ensure that it will be institutionalised as a formal and necessary part of the change process. In order to successfully implement this process, different health care institutions must also plan the implementation of the educational pack in its jurisdiction. After which, the new processes of catheterisation must be written down as part of the hospital policy. Eventually, the new process would be something they would naturally integrate in their health care processes until such time when they would get used to it. In the end, the possibility of them reverting to their old behaviour would be decreased. Evaluation In order to evaluate or measure how the efficacy of the educational pack, a questionnaire shall be handed out to the different members of the staff participating in the pack. This questionnaire shall evaluate the lessons learned by the staff from the educational pack. It shall also evaluate how well they have understood the different elements of the new catheterisation process. The questionnaire shall also quiz them on their understanding of the rationale behind the application of the education pack and the use of coated catheters. If the education pack is a poor material, the staff nurses’ intention to revise their behaviour may not be manifested in their answers; therefore, there is a need to reassess the education package and possibly implement a new pack. If the behaviour of staff nurses does not change despite a strong motivation to accept change, different factors such as inadequate training can be considered. The effect of the new method of catheterisation among the patients can also be assessed. Each catheterised patient is usually under constant care and supervision of a health care professional. Baseline values in relation to the incidence of infection can be measured immediately after the educational package and the new catheterisation process is implemented. One month after such package is implemented, the incidence and severity of the infection can be measured again. Every month for six months, the patient’s incidence of infection shall be measured. Pearson, et.al., (2007) points out that the assessment must present the amount of the success gained from the change implemented. In effect, in order to measure infection incidence, the following elements can be evaluated: number of days readmitted to the hospital due to CAUTI and amount of antibiotic use attributed to CAUTI. These evaluation measures help measure the effectiveness of the education package and the subsequent implementation of the new coated catheterisation measure. Conclusion This essay evaluated evidence-based practice and how it impacts on clinical governance. Clinical governance is about supporting the standard of nursing services. It also helps initiate changes in the pursuit of quality of care. Change is an important part of the nursing profession and its implementation calls for good management. This essay exemplified the need for change to be supported by theories and models of change. Incidents of catheter-associated urinary tract infection can be adequately controlled when proper precautions are taken by the health professionals involved in the patient’s care. It is expected that reducing incidents of CAUTI would call for continuous changes in the catheterisation process. However, with the proper implementation of change processes and programmes, better patient outcomes may be reached. Works Cited Clinical governance (2007) Royal College of Nursing, viewed 12 February 2011 from http://www.rcn.org.uk/development/practice/clinical_governance Daniels, R. (2004) Bottom of FormTop of FormBottom of FormNursing fundamentals: caring & clinical decision making, California: Cengage Learning Definition of Change (2011) Merriam-Webster 2011, viewed 10 February 2011 from http://www.merriam-webster.com/dictionary/change Deutsch, M., Coleman, P., & Marcus, E. (2006) The handbook of conflict resolution: theory and practice, London: John Wiley & Sons Fitzpatrick, J. (2007) Finding the research for evidence-based practice - PART ONE - The development of EBP, Nursing Times, volume 103, number 17, pp. 32-33, viewed 12 February 2011 from http://www.nursingtimes.net/nursing-practice-clinical-research/finding-the-research-for-evidence-based-practice-part-one-the-development-of-ebp/292457.article Five basic principles, and how to apply them (1999) Team Technology, viewed 10 February 2011 from http://www.teamtechnology.co.uk/changemanagement.html Freeman, R. (1999) Correctional organization and management: public policy challenges, behavior, and structure, London: Elsevier Health Sciences Gopee, N. and Galloway, J. (2009). Leadership and management in healthcare. London: SAGE Publications Ltd. Grizzell, J. (2007) Behavior Change Theories and Models, Cal Poly Pomona, viewed 12 February 2011 from http://www.csupomona.edu/~jvgrizzell/best_practices/bctheory.html Hicks, Vicki, (n.d) Change Theories, University of Kansas Medical Center, http://www.kumc.edu/instruction/conted/online/substance/ module3/mod3comp1.html Johnson, J. (2001), Catheter-associated UTI. Interscience Conference on Antimicrobial Agents and Chemotherapy, viewed 12 February 2011 from http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102270348.html Kritsonis, A. (2004) Comparison of Change Theories, International Journal of Scholarly Academic Intellectual Diversity, volume 8, number 1, pp. 1-7 Marquis, B. & Huston, C. (2008) Leadership Roles and Management Functions in Nursing: Theory and Application, London: Lippincott Williams and Wilkins Mullen, E., and Streiner, D. (2004) The Evidence For and Against Evidence-Based Practice, Brief Treatment and Crisis Intervention, volume 4, number 2, pp. 111-121 Scally, G and Donaldson, L (1998) Clinical governance and the drive for quality improvement in the new NHS in England, British Medical Journal, volume 317, number 7150, pp. 61-65. Park, J., Cho, Y., Choi, J., & Jeong, S. (2003) Norfloxacin-releasing urethral catheter for long-term catheterization, Journal of Biomaterials Science, Polymer Edition, volume 14, number 9, pp. 951-962(12). Pearson , A., Field, J. & Jordan, Z. (2007), Evidence-based clinical practice in nursing and health care: assimilating research, experience and expertise, Oxford: Blackwell Publishing Pipe, T., Wellik, K., Buchda, V., Hansen, C., & Martyn, D. (2005) Implementing Evidence-Based Nursing Practice: Evidence-Based Nursing Practice, Medscape, viewed 12 February 2011 from http://www.medscape.com/viewarticle/514532_2 Robbins, S. (2009) Organisational behaviour: global and Southern African perspectives, London: Pearson Rupp. M., Fitzgerald, T., Marion, N., Helget, V., & Puumala, S. (2004) Effect of silver-coated urinary catheters: Efficacy, cost-effectiveness, and antimicrobial resistance, American Journal of Infection Control, volume 32, number 8, pp. 445-450 Sackett D, Straus S, Richardson S, Rosenberg W, Haynes RB. (2000) Evidence-based medicine: how to practice and teach EBM. 2d ed. London, U.K.: Churchill Livingstone. Scally, G and Donaldson, L (1998) Clinical governance and the drive for quality improvement in the new NHS in England, British Medical Journal, volume 317, number 7150, pp. 61-65. Secretary of State for Health (1998) A first class service. London: Department of Health Spector, N. (2007) Evidence-Based Health Care in Nursing Regulation, National Council of State Boards of Nursing, viewed 12 February 2011 from https://www.ncsbn.org/Evidence_based_HC_Nsg_Regulation_updated_5_07_with_name.pdf Tenke, P., Kovacs, B., Bjerklund, T., Matsumoto, T., Tambyah, P, & Naber, K. (2008) European and Asian guidelines on management and prevention of catheter-associated urinary tract infections, International Journal of Antimicrobial Agents, pp. S68–S78, viewed 11 February 2011 from http://www.escmid.org/fileadmin/src/media/PDFs/4ESCMID_Library/2Medical_Guidelines/other_guidelines/Euro_Asian_UTI_Guidelines_ISC.pdf The code: Standards of conduct, performance and ethics for nurses and midwives (2010) Nursing and Midwifery Council, viewed 12 February 2011 from http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/ Weerasinghe, D. (2009) Electronic healthcare: first international conference, London: Springer Publications Wei-Chun Huang, Shue-Ren, Wann, Shoa-Lin, L., & Kunin, C. (2004) Catheter?Associated Urinary Tract Infections in Intensive Care Units Can Be Reduced by Prompting Physicians to Remove Unnecessary Catheters, Infection Control and Hospital Epidemiology, volume 25, number 11, pp. 974-978 Welsh Assembly Government (2008) Clinical governance in Wales, Cardiff: WAG Welsh Assembly Government (2005) Designed for life: Creating world class health and social care for Wales in the 21st century, Cardiff: WAG Read More