Hand washing horrors – we need to do better

Not many nurses would have been surprised to read the findings of this article in the Sydney Morning Herald. Many of us have spent our careers reminding our medical colleagues to perform hand hygiene and usually copping flack for our trouble! I cringe when I reflect on my early training days (over 40 years ago) when the consultant surgeon would do his post op rounds, taking down dressings without a thought to hand hygiene being performed in between patients. Neither myself, as a lowly student, nor my more senior colleagues would consider reminding ‘Sir’ of this oversight! None of us had the courage to speak up for our patients, such was the culture and hierarchical structures of the time.  We are perhaps seeing the consequences of this culture, poor practices and lack of courage to advocate for our patients all these years later with the rise of the ‘super bugs’ and resultant mortality and morbidity. Reading the article, it was encouraging to see that hand hygiene rates are improving, but still a long way to go. All health professionals must take responsibility not only for their own hand hygiene, but in monitoring and encouraging good hand hygiene practices of others. It takes courage to speak up and remind others of correct procedures, but it can be done in a way that is respectful and should not be taken personally. I feel sure if it was a loved one suffering from an infection, we would be quick to act.

 

It is not only in hospitals that poor hand hygiene practices could be improved. I have on several occasions questioned food handlers in delis and fast food outlets who take my money with the same gloved hand they have just used to handle my food order. Last year I  reported a local café to the council for consistently not providing hand towels in the toilets used, not only by customers, but by the café staff! I gave the manager fair warning that I would be reporting him, but to no avail. Needless to say I go elsewhere for my coffee now!

 

On a lighter note, I am both heartened and amused when I see people take out small bottles of alcohol rub and perform hand hygiene in cafes and restaurants – they must be nurses I say to myself! But maybe not, I am hoping the hand hygiene message is getting through to a wider audience.

Menna

Passing the baton to the next generation

2015-09-03 07.12.15The Christmas holidays have given me the opportunity to attack the pile of perioperative nursing journals and catch up with my reading (and accrue some CPD hours!). An article that caught my eye was in the Journal of Perioperative Nursing in Australia (ACORN), (vol 29, issue 4, Summer 2016) by Seri Wilson. Whilst the content was related to Wilson’s research into retirement intentions of baby boomers (BBs) at her hospital, I found some of the statistics presented thought provoking. Wilson cites Australian Institute of Health and Welfare (2014) demographic data stating that in 2014, 38.3% (4 out of 10) of the nursing workforce were aged 50 years of age or over. Whilst these are overall nursing workforce figures, they are probably reflected in many of our perioperative environments. Wilson was making the point that the BB generation, if they haven’t done so already, will soon be leaving the profession and posed the question of whether we are doing enough to hand over to the next generation of nurses.

Being a BB myself, I am well acquainted with others of my vintage who have either retired, are about to retire or are still in the workforce. Many BBs are unable to retire due to financial reasons and there are many who just love their work. Such people were gold dust for me when I was working as a Clinical Nurse Consultant, because I knew that they would support, teach and mentor the new graduate nurses who were embarking on their perioperative careers.

The worry is – what happens when such valuable BBs finally do retire? Will we have enough perioperative nurses to take their place and will we have done enough to pass on the baton of safe patient care to them? It is a point made in Wilson’s conclusion – the need to have an appropriate handover to the next generation.2015-03-13 15.07.07

During my career as a perioperative educator, my passion has been to promote the specialty as a career path for both RNs and ENs. Long gone are the days when all student nurses (like myself) gained clinical experience in the operating theatre, where the seeds of a career in perioperative nursing were sown for me and many of my contemporaries. The reduction in the number of undergraduate nurses being exposed to perioperative nursing means that the pool of future perioperative nurses is also reduced. Many operating theatres are crying out for nursing staff, both RNs and ENs and I know, from talking to colleagues in the tertiary sector, that there are many undergraduates interested in the specialty and a clinical placement in the operating theatre. Unfortunately such interest is often not translated into action with many operating theatres being reluctant to open their doors to potentially the next generation of perioperative nurses. Why? Well, I have heard many reasons – ‘students are too much trouble’; ’we are too busy to spare the time to teach’; ‘don’t have an educator’; ‘we only do lumps and bumps’ etc, etc.

Whilst there may be legitimacy in some of these comments, I feel that operating theatres who are short of staff are really missing the opportunity to ‘grow your own’. Yes, visiting undergraduates can add to an already busy workload, but going the extra mile by allowing a them to follow a patient through surgery or providing a short rotation to the operating theatre, can pay dividends for the future. It does not matter that minor or less complex surgery is performed, the undergraduate does not care, they are fascinated by anything and everything. Whilst a CNC at Randwick Campus Operating Suite (RCOS) I assisted in facilitating a twelve month program for new graduates, the majority of whom stayed on staff following completion. They have become valuable team members and many of them are now senior staff within the RCOS.

So at the start of 2017, I have a challenge for those of you seeking staff. Consider ways in which you can ‘grow your own’.

Here are some ideas to get you started:

  • contact your local university/TAFE and offer options for exposing the undergraduates/EN students to the operating theatre – a patient follow through, a tour, an opportunity to present information about perioperative nursing at the university/TAFE
  • organise an operating theatre open day to which not only undergraduate nurses can be invited, but new graduates and nurses from other departments in the hospital. A number of current perioperative nurses started their careers in other specialties before seeing the light!
  • work with your local NSW Operating Theatre Association (NSW OTA) Zone to consider a united approach to promote the specialty

Many of you will have already tried these and maybe other strategies. Let me know what worked for you and if you haven’t tried these strategies, give it a go. Whilst I am not longer active in the clinical area (though business partner Sally is), through our business we are maintaining our passion to promote perioperative nursing as a career. We will continue to provide education to nurses who seek to enter the perioperative specialty through our Fundamentals program which was the subject of my previous blog. We are keen to run more of these courses in the coming months. So if you know of any colleagues who would benefit from the program, please let us know – we can help them take that first step.

Getting new staff into the perioperative environment is only the first step, we then have to work to educate and support them whilst they settle into their new career. So it is pleasing to see the Nursing and Midwifery Office within NSW Health launch the Transition to Perioperative Practice program. This program, to begin early 2017 and developed by experienced perioperative nurse, Deb Burrows, supported by NSW OTA, will provide new staff embarking on their perioperative careers a structured program, giving them skills and knowledge to provide safe patient care. This will overcome the need for individual hospitals to develop their own education programs and will hopefully encourage operating theatres to take on novice perioperative nurses.

We are at a critical point in perioperative nursing with the BBs moving on and what is required is a steady, ongoing supply of nurses, RNs and ENs – the new generation of perioperative nurses to take their place. The BBs have laid a solid foundation of perioperative practice, it is up to you to build the next generation and ensure the baton is passed on.

Menna Davies

Perioperative project in the Pacific – collaboration in action


 

group work

group work

What a wonderful few days we have just had in Suva, Fiji presenting at the workshop on implementing the Pacific Perioperative Practice Bundle (PPPB). We have been working with our colleagues within the organisation, Strengthening Specialised Clinical Services in the Pacific (SSCSiP) developing six infection prevention standards which formed the bundle, together with audit tools for each standard. The workshop was aimed at assisting our Pacific perioperative nursing colleagues implement the bundle within their own workplaces.

SSCSiP’s project coordinator, Mabel Hazelman Taoi and her team did a wonderful job coordinating the workshop and all the travel and accommodation for the twenty participants – no mean feat when you see where they all came from. You will need to get the map out to locate all fourteen countries of the Pacific region represented – Cook Islands, Fiji, Kiribati, FS Micronesia, Marshall Islands, Nauru, Niue, Palau, Samoa, Solomon Islands, Tonga, Tokelau, Tuvalu and Vanuatu. Some of the participants had travelled for a couple of days with many connecting flights via places such as Honolulu and Auckland! Nothing like our 4 hours direct flight from Sydney!

book signing

book signing

webinar with Jed Duff in Sydney

webinar with Jed Duff in Sydney

We had two and half days with our colleagues working through key elements of the standards and strategies for implementation. Each participant received a copy of the 2nd edition of the perioperative text book, Perioperative Nursing: An Introduction. Our fingers were well and truly crossed that technology would work and with the assistance of ACORN’s Education Officer, Dr Paula Foran, we arranged a live webinar with Dr Jed Duff (ACORN President) back in Sydney. He gave a great presentation on putting knowledge into action with excellent practical information on implementing change. It is one thing to have a bundle of standards, it’s quite another to implement them and we spent a lot of time looking and enablers and barriers to implementing change in the workplace based on Jed’s presentation. Another key element to the bundle were the audit tools and for many of our colleagues this was new territory for them. We were able to practice undertaking audits using the tools by carrying out observations in the local operating theatre, around the hospital and by watching videos.

location, location!

location, location!

One additional topic discussed was the formation of a professional association to connect all the perioperative nurses within the Pacific, encouraging sharing of ideas and progress on implementation. We tapped into the experiences of Phyllis Davis who was instrumental in assisting the perioperative nurses of Papua New Guinea form of their association. Another live webinar with Sydney based Phyllis got the ball rolling and served to inspire the group to the next step.

During our workshop we learnt more about the environments that our colleagues work in and the challenges they face in implementing the standards. Some of them work in large units and some come from small facilities with only one operating theatre and minimal staff. It wasn’t all work and we had a lot of fun along the way, including a night out with the group at a local Chinese restaurant.

a night out with the group - note Vane's NSW OTA shirt!

a night out with the group – note Vane’s NSW OTA shirt!

Mabel receiving one of our gifts

Mabel receiving one of our gifts

Unfortunately we were not in Fiji to join in the celebrations for their victorious, gold medal winning 7s rugby team! That would have been an experience judging by the obvious excitement still bubbling amongst the local population. We left Suva exhausted after a full on couple of days, but feeling very satisfied that we had provided the group with lots of information, strategies and encouragement for the next step of their journey. A journey that will bring a consistency to the standards of perioperative nursing practice to their workplace and ultimately a safer environment for their patients.

lovely necklaces and a Fiji banner as gifts

lovely necklaces and a Fiji banner as gifts

We have already had lots of emails from the group who have already organised meetings with their hospital administration to report on the workshop and submit implementation plans. So lots of positive steps are happening already.

We hope to see a few of the group at the South Pacific Nurses Forum to be held in Honiara, Solomon Islands in early November where Sally and Mabel will present a paper on the PPPB Project.

Lister, Carbolic Acid & Alcohol– have we come full circle?

I recently received my annual Nurses’ League Journal from my training hospital, Kings College Hospital, London – the same one featured in one of my previous blogs on the TV show, ’24 hours in Emergency’. The League is essentially the ‘old girls’ association which we joined on completion of our training. The journal is full of news of us ‘old girls’, the reunions that have taken place and general news of the hospital’s activities. The journal usually features an aspect of the hospital’s history, a South London institution since the early 1800s. In this edition, the story of the eminent 19th century surgeon, Joseph Lister was featured. He is widely regarded as transforming surgery into a practice governed by science due to his pioneering work on antisepsis.

Joseph Lister

Joseph Lister

Why am I telling you all this? Well, at the time I was reading about Lister in the journal, I was also editing the chapter on asepsis and infection prevention for the forthcoming second edition of ‘Perioperative Nursing: An Introductory Text’, due for release in May 2016 at the ACORN Conference in Hobart. I was interested to read about Lister’s infection control practices in 1867 and how they contrast with our present day practice. He, like many of his contemporaries, were appalled and puzzled by the high rates of surgical site infections (SSI) which often led to post op death.
It was the work of French chemist of Louis Pasteur’s that influenced Lister’s thinking about what might cause infection. Pasteur had postulated that fermentation of wine and milk was due to bacteria found floating in the air and not just the air itself that caused infection, as had been traditional thinking. Armed with this light bulb moment, Lister’s next step was to experiment with a variety of antiseptic agents which he thought might kill the bacteria that infected surgical wounds. He settled on carbolic acid (phenol) after hearing about its success in cleaning up the city’s stinking sewers. He introduced it into his operating theatre at the Glasgow Royal Infirmary, Scotland, which must have been a most uncomfortable place to work as he sprayed carbolic acid over the operative field (and all the assistants) continuously during surgery and soaked dressings in the solution. His breakthrough moment came when treating a compound tibial fracture in an 11 year old boy, James Greenlees using dressings soaked in carbolic acid. After a few days there was no evidence of the usual infection that blighted such procedures and James made a full recovery.

Lister spraying carbolic acid during surgery

Lister spraying carbolic acid during surgery

Lister continued this type of wound dressing on other surgical patients and his post-operative infection rates dropped dramatically. If Lister had access to the internet, news of this dramatic breakthrough in infection prevention would have spread like wildfire and perhaps been accepted a little sooner, but it was two years before he published a number of articles about his work in the Lancet medical journal. Even then his results were viewed with a degree of scepticism, by many colleagues, particularly in London and it would be another 20 years of further experimentation before the medical profession accepted Lister’s theory and practical application of antisepsis.
Lister carried out much of his research at my old training hospital, King’s College, where he was appointed Chief of Surgery in 1877 and confronted many of his fiercest critics. The hospital had prohibited open surgery into joints due to the high risk of infection, but Lister believing in his antisepsis methods bucked the system (after all he was the boss!), forging ahead with his work, which eventually paid off, laying the foundations for our modern understanding of antisepsis and ultimately aseptic technique.

operating theatre at Kings College Hospital, London

operating theatre at Kings College Hospital, London

Even though we have come a long way since Lister in our understanding of antisepsis and infection prevention, SSIs are still of great concern in the 21st century. Hand washing continues to be a vital strategy in the fight to reduce the risk of infection and what struck me about surgery in Lister’s era, the late 19th century was the use of alcohol as a hand hygiene product. Three to five minutes pre-operative cleansing of the hands using 90% ethanol was common practice amongst surgeons of that era. The efficacy of alcohol to kill microorganisms on the skin has therefore been known for sometime and with the recent introduction of alcohol based surgical scrub solutions (ABSS) in many Australian operating theatres, it feels like we are back to the future!
Moving to ABSS will require a change of culture in our operating theatres – the ritual of the surgical scrub is one which many instrument nurses may be somewhat reluctant to give up – that five minutes or so at the sink was good thinking time when you could gather your thoughts and prepare yourself mentally for the procedure ahead. Replacing that with a 90 second rub with alcohol based product will not come easy to some! For the surgeons too, it is a big change, although having witnessed some surgeons undertake what passes for a surgical scrub by a momentary waving of hands under running water, an application of alcohol will at least kill a few bugs!

Alcohol based surgical scrub

Alcohol based surgical scrub

Many of you have perhaps already been involved in trialling the variety of ABSS products that medical companies are now clamouring the sell us. It’s big business for them! What’s important is to ensure that we make choices based on available evidence of the efficacy of the products and not the hard sell and promises of the company reps. There are many different products on the market –some containing differing percentages of alcohol and those that combine alcohol with other antimicrobial products eg chlorhexidine. Which one to choose? Don’t be afraid to ask the reps for research evidence to back up their claims, but it’s also important to do your own independent research – there is plenty out there and World Health Organisation has some good resources too.
It seems we have come a full circle in the 150 years since Lister first laid the foundations of infection prevention with the introduction of ABSS in the 21st century. It will become one more strategy we can use to reduce the risk of SSIs that continue to be a cause of morbidity and mortality in our hospitals.
Let us know if you are using ABSS in your workplace and how this new procedure is being received.
Bye for now
Menna