Impact of Policy on Practice - Case Study Example

Impact of Policy on Practice Introduction Infection control is an essential part of healthcare for both patients and staff. This assignment will discuss, whether the policies that surround the issue of infection control, have impacted on practice or not. The spread of (HCAIs) in general and of methicillin resistant staphylococcus aureus (MRSA) in particular, is acknowledged as a key issue in NHS hospitals. There is still much to be done to tackle these infections, and to restore the public's confidence in the ability of health services to deal with this issue, which has received such intense media attention (HPA 2005). Scenario This incident happened whilst this second year student was on placement at a hospital that is part of a primary health care trust (PHCT). A patient with a hospital acquired infection (HAI), in this case (MRSA), was brought down from a ward to a busy x-ray department, in the middle of the day, without the knowledge of the infection being given to either the porter or the department staff. Although the department would have phoned the ward when the referral form was sent, to enquire how the patient was going to come down i.e. bed or wheelchair, no mention was made by the ward staff to the radiographer about this patient's infection status. The knowledge was gained by the radiographer while chatting to the patient in the x-ray suite. The radiographer then phoned the ward, which confirmed it. The policy at the trust is that all patients with an infection (such as MRSA or clostridium difficile (vomiting and diarrhoea) CD are brought down, one at a time, to a specific room in the late afternoon, (post clinic etc), when two radiographers or, one radiographer and 1 student, will carry out the examinations as a team. One person will handle the patient with gloves and apron, while the other person will handle the equipment. Once all patients have been x-rayed, the room will not be used again until it has had a thorough clean. This ensures that the patient is not kept waiting in the department any longer than necessary, and that there is less chance of any cross infection. PEST analysis is defined by Mindtools (2006) as "A simple but important and widely-used tool that helps you understand the big picture of the Political, Economic, Socio-Cultural and Technological environment you are operating in". Political The issues related to NHS are a hot topic of discussion for anyone even remotely related to politics. Politicians of all parties try to focus on it, as they know that this is an important agenda to gain public confidence. Needless to say MRSA has always been an issue of lengthy speeches made by our politicians. According to bbc.co.uk "The number of deaths in which the super bug MRSA has been cited as a cause has doubled in four years, official statistics show." (Para.11) Unfortunately political parties, instead of unitedly fighting the menace fight amongst themselves in an attempt to solve the problems. There is an excellent example of this statement stated in bbc.co.uk "last year Health Secretary, John Reid ordered hospitals to slash rates of MRSA bloodstream infection by half by March 2008." (para.17) "But Conservative Party leader Michael Howard blamed the government's 'obsession with targets'. (para.18) In the incident narrated above, the ward staff showcased sheer carelessness and pathetic attitude towards his professional responsibility while overlooking the policy related to the x-ray of MRSA patients. Do the people who make policies try to check whether the policies are being followed at all Laurance has stated; "to tackle the menace, ministers promised a crackdown on poor hygiene with hospitals ranked in a league table of cleanliness. But it is too little, too late." (MRSA, politics and press section, para.11) In the cases like the one mentioned above, the well being of medical practitioners gets ignored too. Very few think about the people who are on the other side of the platform called 'health'. One policy related to the above mentioned incident is to follow the directions of health care practitioners when suffering from MRSA. But who will care for the well being of the people who work for others' well being. Are they themselves safe. According to Appendix 5 of the report of Select Committee in Science and Technology,"Provision should be made to recognise persistent carrying of resistant bacteria by nursing and medical staff as an industrial disease" (para.31) In the incident under discussion, the porter and the radiographer were at risk in their own organisation. Their own colleague did not inform them about the infection they might get. So whatever the policy, was it brought into practice. Unfortunately no. According to department of health (DH)"MRSA bacteraemia rates will be higher in Trusts that have more vulnerable patients and that undertake more invasive and high-risk specialist care." (Publications and statistic section, para.6) To this statement of DH, it should be added that MRSA bacteraemia rates would also be higher in Trusts where simple policies of safety are ignored by the staff. According to bmj.com "although the power of each political body differ, each has important freedom with respect to NHS policy. As a result in England the emphasis has been on national targets to improve performance" (para 2) The need of the hour is that each and every individual or group related to all the areas of political and health care spectrum should work together to improve the quality of health care facilities. We are constantly being told by the powerful set of people to follow the principles set by them but we need someone to specify how should we go about it in practise. Economic There is huge economic burden associated with highly infectious diseases like MRSA in hospitals. If the incidents like the one that is being discussed increases further, then costs will continue rising. The patients have to spend many days in hospitals and use medications even longer. Due to all this treatment costs accelerate. If negligence is not combated then unnecessary expenditures will pose a serious problem in the health sector. Williams has observed in Dracopoulou (1998) "economics is about scarcity. Quality Adjusted Life Years (QALYs) are about the benefits of healthcareSo health care management is endemic, and to appraise it we need to think carefully about objectives and who should do what to ensure that resources are managed so as to pursue those objectives as successfully as possible." (p.29) Health care practitioners should set their professional goals in such a way that they not only perform their primary duties of care giving in the best possible way but also avoid wastage of resources while performing their duties. Therefore "common sense tells us that in the face of scarcity we should use our limited resources in such a way that they do as much good as possible." (Williams in Dracopoulou, 1998, p.29) But in the incident being discussed here, instead of following the policies related to MRSA, The ward staff indirectly acted towards unnecessary misuse of resources by letting the infected patient go to the busy x-ray department, threatening other people's chances of infection. If infection had spread to even a few people, the burden of their treatment would have affected the economics of NHS. This is just one example that took place in one of the trusts, but if we focus on the larger picture we would realize how the callous attitude of people related to the health sector is eating up the scarce and valuable resources of NHS. The problem of our health care system is that it is finance dependant. People who are learning the nuances of the trade are bound to make mistakes. Even when it's not their fault, they are not able to muster the courage to bring to notice the shortcomings that they are seeing, to the management, as their main aim is to acquire as much training as they can in a short span of time. Since resources are scarce, the health care system gets cheap employees in the form of students on placement. This is good from the viewpoint of the students but sometimes incurs loss for the health care system. Patients without infection present during the busy hours in the x -ray department were unable to understand the error. Since they were being treated in a trust they did not have much option of asking about the safety measures being taken or not. Had it been a case in a private hospital; the fear of patients behaving as customers would have prevented the ward staff from doing this irresponsible act. Social The other patients present in the x-ray department were not able to see the error. So they were at ease unaware of the fact that one of the patients among them is suffering from MRSA. The person who was the witness of the incidence under discussion was a trainee. So he was not able to identify how much authority he has in such circumstances. But whatever authority this trainee had, at least he was able to identify the error before it was too late. The case under discussion suggests that in certain situations if one is not able to adequately perform the professional duties he should try to at least show the human side of his personality. But the ward staff lacked both the virtues. How could he play with the safety of so many people by not bringing policy into practice He had no feelings for the porter and the radiographer who were for the time being his own colleagues. Even if we set aside the issue of policy and practice for a moment we need to ponder upon what Kushner and Thomasma has stated: ethically justified responses cannot always be defined in terms of rules or principles. Dynamic situations exist that confront the ability of anyone's quick application of a rule or principle. For this reason, physicians need to fall back on basic human affects and responses such as compassion and consolation. (p.32) Though this trainee found this situation strange and against the policies, the ward staff did not have the same perception. One of the reasons can be that he might have seen people senior to him not practicing the set policies. So he must have got accustomed to the norm of not practising the policy. The flaw is not in one or two people but in the entire system. This incident raises questions on the trust too, as what was followed at lower level must be actually implemented at the higher level as well. "The process in which the unusual becomes accepted as normal is called " the process of socialization": A process that transforms the strange, the unusual, the disconcerting, and even the abhorrent into something normal, familiar, usual, reassuring." (Kushner and Thomasma, p.36) May be the incident was normal for the ward staff but was highly unsatisfying for this trainee. The entire training period did not only teach him the nuances of radiography but what is beyond the books and guidelines. Trainees in the health care system can learn from everyone he comes across like doctors and patients and everything incident he comes across like bad incidents and failures. Sometimes the negligence of a particular person goes unnoticed and other issues are blamed for the wrong deeds of others. For example according to SocietyGuardian.co.uk " Public services union Unison blames the decline in hospital cleaning staff numbers for the increase in infections." (Mrsa story section, para.8) This might be one of the causes of the spread of infection but other unnoticed angles should also be considered to understand the problem in totality. The brave thing would be to bring the malpractise to the notice of people in two situations." First, when an action of a colleague (including nurses, and other co-medical staff) is clearly violating the lawSecondly, when an act is apparently against established hospital policy. Those policies are usually in written form" (Kushner and Thomsasma, p.245) " Managing, not banishing risk" is the message from Hackitt that has been mentioned in the Association of Occupational Health Nurse Practitioners' website. (General News section, para.25) If we look at the situation from the viewpoint of the patient who was suffering from MRSA, The situation was handled in a satisfactory way. The conduct of the hospital staff that has taken the charge of the patient during tests or x-rays has a therapeutic power on the patient. " The patient's confidence may be undermined if the doctor does not act in a directive way that indicates he is in control of the situation." (Rogers and Braunack-Mayer, p.56) In this case though the trainee was deeply astonished by the negligence he did not let the patient know about his feelings and acted in a calm and composed way in front of him. To be able to maintain the dignity of the patient and dealing fairly with him even during unusual circumstances is one of the virtues of health care. The problem of this trainee was that his service was short term and despite trying to bring changes in the system it was not under his capacity. There was a fear of the regular staff not supporting him as Rogers and Braunack-Mayer has rightly observed "colleagues are often slow to act because they fear the consequences both for themselves and for the doctor whose conduct is in question." (p.176) They have further stated " GP's must remember that their primary concern in these situations is the best interests of patients rather than a secondary interest in the good name of the profession or in their own welfare." (p.176) Technological The ward staff should be blamed from the technological point of view too. Nowadays it has become mandatory for the hospitals to maintain technological records of all the patients. "Electronic medical records can improve the accessibility, accuracy and completeness of patient information." (Transberg and Rashbass, p.57) Every time a patient undergoes a test or x-ray the old records are seen. Then how did the ward staff ignore such a vital fact When this trainee phoned him, he at once affirmed about the patient's MRSA status. This indicates that it was not just a careless mistake. The excuse of technological records being erased mistakenly is also over ruled as data of patients in NHS are highly protected. Transberg and Rashbass has rightly observed that: The NHS is a particularly important branch of the public service. The lives of most people are affected, both directly and indirectly, by the efficiency and effectiveness of NHS organisations, the decisions they make, and the way in which their limited resources are used. Thus there is likely to be quiet a high level of interest in accessing NHS data with requests from individual patients, patient advocate groups and journalists. (p.151) One great way to find out what's really lacking in hospitals in this era of advanced technological development is asking the patients to narrate what they observe during their stay in hospitals. According to Stanwell-Smith, in seventh report of Select Committee in Science and Technology, appendix 3 "one good way to find out what is actually happening is to ask patients." (para.20) Technological advancements can become boon as bane. Warren has researched that: Scientists in the US have linked the spread of the hospital super bug MRSA to a sharp increase in the use of technology in hospitals. (News section, para.1) Researchers working in hospitals have found that the deadly bacteria clings to the keys of the computer keyboards used to update patient records and therefore can re-infect the hands of staff even after they had washed their hands. (News section, para.2) The fans represent a further health hazard because of their potential to blow that same dust around a ward. (News section, para.10) Conclusion : what if In the discussed incident, the positive action would have been that instead of sending the patient in the middle of the day, without the knowledge of the infection being given to either the porter or the department staff; the ward staff would have sent him in the time set aside for the MRSA patients. Although the department would have phoned the ward when the referral form was sent, to enquire how the patient was going to come down i.e. bed or wheelchair, the ward staff should have mentioned the vital piece of information not only to the porter but also the radiographers if at all there was an emergency. Even in the case of emergency, the hospital management should have been consulted. The management would have then decided upon the plan of action. Arrangement of some other room would have been made. The ward staff would not have taken such an important matter so lightly. If the ward staff would have contacted the management regarding this matter or if he would have waited for the late afternoon then there had been no chances of the porter, radiographer and other patients being infected by the disease. Not only this, the wasted time of the patient suffering from MRSA, while waiting, as the x-ray department was very busy could have been saved. In addition to these the frustration that the radiographer went through would also have been avoided. If the ward staff had behaved responsibly then the whole situation would have been different for the radiographer and the patient. Chamberlain has rightly written in the magazine people management that, "my message is 'Let's be more proactive about prevention' and it will benefit the workforce and the patient'." (para.8) The ideal thing would be that the trust in which this trainee was working should encourage its staff to go through the fact sheets related to infectious disease from time to time to behave appropriately. One such fact sheet as mentioned in OMNI " was produced by the US Centres for Disease Control and Prevention (CDC). This document outlines the importance of infection control measures and procedures that hospital and healthcare personnel should take when considering prevention include hand washing, gloving, masking, gowning, appropriate device control of MRSA in the healthcare setting. (crossinfection section, para.11) According to the The Lawyer.com "MRSA will never be eradicated. The key will be to ensure it is always under control." (lawzone section, para.21) To keep things always under control the ideal situation would be to bring the policies in practice. Health care people should try to always make small but significant incidents like this positive because we do not get a second chance always. Word Count: 3074 'References' Dracopoulou, S. (Ed.). (1998). Ethics and Values in Health Care Management. London : Routledge. Kushner, K.T., Thomsana.C.D. (Ed.). (2001). Ward Ethics: Dilemmas for medical students and doctors in Training. Cambridge : Cambridge University Press. Rogers, W., Braunack-Mayer, A. (2004). Practical Ethics For General Practice. New York : Oxford University Press. Tranberg, H., Rashbass, J. (2004). Medical Records:Use and Abuse. Oxon : Radcliffe Publishing House. Chamberlain, A. (2005). 'Disability risk' checks for nurses. People Management: The Magazine of the Chartered Institute of Personnel and Development, 01795 414864. Appendix 3: Seventh report (1997). The United Kingdom Parliament. Retrieved July 22, 2006 from http://www.parliament.the-stationary-office.co.uk/pa Appendix 5: Seventh report (1997). The United Kingdom Parliament. Retrieved July 22, 2006 from http://www.parliament.the-stationary-office.co.uk/pa BBC News. (2005). Retrieved July 21, 2006 from http:// news.bbc.co.uk/1/hi/health/4293765.stm bmj.com. (2005). Retrieved July 21, 2006 from http:// bmjjournals.com/cgi/contentfull/331/7522/946 Department of Health. (2006). Retrieved July 21, 2006 from http://www.dh.gov.uk/PublicationsAndStatistics Guardian Unlimited. (2005). Retrieved July 22, 2006 from http://society.guardian.co.uk/mrsa/story/ Hackitt, J. (2006). The Association of Occupational Health Nurse Practitioners.RetrievedJuly22,from http://www.aohnp.co.uk Laurance, J. (2005). Wellcome trust. Retrieved July 21, 2006 from http:// www.wellcome.ac.uk/doc_WTX026126.html OMNI. (2006). Retrieved July 22, 2006 from http://omni.ac.uk/browse/mesh/D003428.html The Lawyer.com. (2004). Retrieved July 22, 2006 from http://lawzone.thelawyer.com Warren, P. (2005). Future intelligence. Retrieved July 22, 2006 from http://www.futureintelligence.co.uk/ Read More