An examination of nurses' practices when performing aseptic technique for wound dressings

ANTT® standardisation facilitates new efficiencies with a novel partially-sterile Standard-ANTT PIVC Pack

Introduction: The widespread adoption of the ANTT®Clinical Practice Framework as a single standard for aseptic technique, has highlighted that many clinical procedures do not require a sterile procedure pack to be performed safely and aseptically. This study explores the utilisation of a partially-sterile procedure pack that is specifically tailored to Standard-ANTT. Methods: A prospective project improvement evaluation, using a non-paired sample (pre: n=41; post: n =33) of emergency department staff in an NHS hospital. Staff were evaluated performing peripheral intravenous cannulations (PIVC) using Standard-ANTT and the B. Braun Standard-ANTT peripheral cannulation pack. Findings: Significant improvements were observed in practice following the implementation of the pack and training in Standard-ANTT, including: Key-Part protection significantly improved (pre: n=28, 68.2%; post: n=33, 100%), and reduction in the Key-Site being touched after disinfection (pre: n=17; 41.4%; post n=5; 15.1%). Conclusions: In conjunction with appropriate education and training, this study provides proof of concept that due to the widespread use of the ANTT Clinical Practice Framework as a single standard aseptic technique, procedure packs that are specifically tailored to Standard-ANTT, can help to promote best practice and improve efficiencies.

DEFINITIONS

Partially-sterile procedure pack - all items required to be sterile remain in their individual blister wrapper. The final assembled pack itself is not then subjected to a further round of sterilisation as it is not needed. Sterile procedure pack - often contains a mixture of non-sterile and sterile items that have been stripped from their individual blister wrapper requiring the sterilisation of the final assembled pack.

How widely has ANTT been adopted in NHS hospitals and community care organisations in England and Scotland?

Background:

To the detriment of patient safety, the important clinical competency of aseptic technique has been notoriously variable in practice, and described ambiguously in the literature, internationally. From a UK perspective, attempts have been made to improve patient safety by reducing variability and improving education and practice through standardisation. The Welsh Government mandated Aseptic Non Touch Technique (ANTT®) as a specific national standard in 2015. All healthcare organisations in England are required by the Health and Social Care Act 2008 to have a single standard aseptic technique, demonstrable by the clinical governance indicators of education, training, competency assessment and compliance audit. In Scotland, an education-based initiative was launched by NHS Education for Scotland in 2012. To review the impact of these and other initiatives on the current status of aseptic technique, all NHS trusts in England and NHS health boards in Scotland were assessed under the Freedom of Information procedure.

Findings:

93% of NHS trusts in England use a single standard for aseptic technique. In 88% of these trusts the single standard was stipulated as being ANTT. In Scotland, 62% of NHS acute and community care hospitals within health boards use a single standard. In 56% of these, the single standard was ANTT. When including those that use ANTT in combination with other techniques ANTT usage is 73%.

Conclusion:

These data demonstrate significant progress in standardising aseptic technique education, assessment and governance, and confirms ANTT as the de facto aseptic technique used in NHS trusts in England and health boards in Scotland.

Challenges faced by nurses in complying with aseptic non-touch technique principles during wound care: a review

BACKGROUND

Surgical and wound site infections (SWSIs) are the second most frequent type of healthcare-associated Infection. One way of preventing SWSIs is by adhering to the principles of asepsis. However, many nurses struggle to apply the principles of aseptic non-touch technique (ANTT) during wound management.

AIM

To identify the barriers and enablers that influence nurses' adherence to the principles of ANTT during wound care.

METHOD

A literature search using a systematic approach was carried out. Four databases were searched to identify relevant studies published between January 1993 and December 2018. Titles and abstracts were reviewed. Studies that met the inclusion criteria were reviewed for quality. The extracted data were then synthesised.

FINDINGS

A total of seven studies fulfilled the requirements for inclusion. Three themes emerged and were found to be the most dominant factors influencing adherence to the principles of ANTT: material and resources, nurse education, and nurses' behaviour.

CONCLUSION

Nurses' compliance with aseptic practice is directly influenced by environmental and psychological factors. Ensuring compliance to ANTT may require an integrated approach involving local, national and worldwide organisations, in collaboration with higher education institutions that teach nurses and similar healthcare professionals.

Wound care practices across two acute care settings: A comparative study

AIMS AND OBJECTIVES

Describe and compare current surgical wound care practices across two hospitals in two health services districts, Australia.

BACKGROUND

Surgical site infections (SSI) are a complication of surgery and occur in up to 9.5% of surgical procedures, yet they are preventable. Despite the existence of clinical guidelines for SSI prevention, there remains high variation in wound care practice.

DESIGN

Prospective comparative design using structured observations and chart audit.

METHODS

A specifically developed audit tool was used to collect data on observed wound care practices, documentation of wound assessment and practice, and patients' clinical characteristics from patients' electronic medical records. Structured observations of a consecutive sample of surgical patients receiving wound care with a convenience sample of nurses were undertaken. The manuscript adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement.

RESULTS

In total, 154 nurses undertaking acute wound care and 257 surgical patients who received wound care were observed. Across hospitals, hand hygiene adherence after dressing change was lowest (Hospital A: 8/113, 7%; Hospital B: 16/144, 11%; χ² : 8.93, p = .347). Most wound dressing practices were similar across sites, except hand hygiene prior to dressing change (Hospital A: 107/113, 95%; Hospital B: 131/144, 91%; (χ² : 7.736, p = .021) and use of clean gloves using nontouch technique (Hospital A: 88/113, 78%; Hospital B: 90/144, 63%; χ² : 8.313, p = .016). The most commonly documented wound characteristic was wound type (Hospital A: 43/113, 38%; Hospital B: 70/144, 49%). What nurses documented differed significantly across sites (p < .05).

CONCLUSIONS

Clinical variations in wound care practice are likely influenced by clinical context.

RELEVANCE TO CLINICAL PRACTICE

Using an evidence-based approach to surgical wound management will help reduce patients' risk of wound-related complications.

Integrating qualitative and quantitative research methods

There are a growing number of authors arguing the case for integrating qualitative and quantitative research methods within research projects. A study was carried out to identify the amount of published work integrating qualitative and quantitative research methods and to assess the quality of the outcomes of studies purporting to use both methods. Electronic searches of the health literature and critical appraisal of a random sample of papers retrieved was undertaken as well as a hand search of five journals. Over one-quarter (130, or 27%) of the papers from the electronic searches were theoretical discussions about the merits of mixing research methods, 22% (110) were papers purporting to have used mixed methodologies. Critical appraisal of the sample papers showed the qualitative and quantitative elements varied. Where the results of the different parts of the study were integrated, the outcomes from the research were more convincing than they might otherwise have been. Other papers had little discussion about the balance or integration of the different types of results. Hand searching revealed very few mixed method papers. Further work is required to refine and develop ways to mix methods to generate the evidence required to support practice.

Performing an aseptic technique in a community setting: fact or fiction?

BACKGROUND

Maintaining the principles of asepsis when performing wound care and other invasive procedures is one of the fundamental approaches of preventing healthcare-acquired infection. Such an approach has been advocated for community practitioners.

LITERATURE

The performance of an aseptic technique is an under-researched area. The few studies that have been conducted have identified how strict adherence to the technique is difficult and contamination of hands/gloves is common and that community nurses often have a fatalistic view about whether asepsis is possible in a community setting.

AIM

The overall aim of this research project was to examine how experienced practitioners have adapted the aseptic technique within a community setting and to what extent the changed procedure still adhered to the principles of asepsis.

METHODS

This study used a mixture of non-participant observation and individual semi-structured interviews to examine adherence to the principles of the aseptic technique among the district nurses. Data were collected from one Trust in England with a total of 10 district nurses taking part and 30 aseptic procedures been observed.

RESULTS

The results show that almost all of the staff understood the principles of asepsis and had adapted the standard procedure for use in a patient's home. Common challenges included wound cleaning using a single nurse procedure, the contents of the pack and the home environment. The research also identified misconceptions about clean versus aseptic procedures and a lack of training for staff.

CONCLUSIONS

This study highlights the challenges of maintaining the principles of asepsis in a home environment and the fact that district nurses are often relied upon to find creative solutions to such challenges. The study also highlights issues around the implementation of evidence-based practice and the need for clearer guidance about how evidence should be used alongside existing procedures.

District nurses' and aseptic technique: where did it all go wrong?

Concerns have been raised about whether it is possible to perform aseptic procedures within a community setting. Hallett (2000) has described how community nurses often have a fatalistic view about whether such procedures can really be performed at home. At the same time there has been an increase in the number of patients being cared for at home who need interventions which must adhere to the principles of asepsis. While it has been acknowledged for some time that community nurses must be resourceful and adapt the procedure, the view that community nurses cannot really perform aseptic procedures is a fairly new phenomenon. This article explores the reasons why concerns about the performance of aseptic procedures in the community may have arisen and what steps can be taken to address these concerns to ensure that care at home is both safe and effective.

Aseptic technique: evidence-based approach for patient safety

The fact that there is a relationship between the standards of aseptic technique performance and the rise in hospital infection rates has been suggested by the Department of Heath's (DoH's, 2004) 'Winning Ways' document. This literature review considers how the aseptic technique is performed in the UK, and examines the nature of ritualistic and evidence-based practice underpinning this skill-based procedure. The findings have identified an emerging glove culture and continuing poor hand-hygiene practices. The alternative 'clean technique' is also adopted widely in clinical practice which confuses the aseptic theory-practice gap. While it is hard to pinpoint an actual time or event that causes infection, it is unlikely nurses will ever become involved in litigation as a result of a poorly performed aseptic technique. However, the review concludes that nurses should not become too complacent. It briefly considers how performance of the aseptic technique can be improved, through creative educational strategy, applied risk assessment and clinical audits of nurses' practices.

Nurses' inappropriate use of gloves in caring for patients

Asepsis still remains an important part of infection control and sterile gloves are still required in acute wound care and surgical procedures. Some tissue viability practitioners have for many years used unsterile gloves for chronic wound care and this provides a cost-effective method of protection for both the patient and the nurse. However, there are still those nurses who are bound in nursing rituals and find it difficult to discard a practice that has been shown to be costly and unnecessary. At the same time, there is a worrying practice of wearing gloves for all procedures without changing between each patient contact and this can be a dangerous method of introducing cross-infection and increasing the potential for latex allergies. Therefore, the use of gloves must be carefully thought through and the rationale for their use should be based on researched evidence. This article reviews the available evidence.

Community infection control: what is the evidence?

Evidence-based practice is the conscientious use of current best evidence in decision-making about care or the delivery of health services (National Institute for Public Health, 1996). Evidence-based health care is one aspect of the quality improvement activities of clinical governance as a main component of the programme of quality in the NHS (Hek, 2000). Practitioners working in clinical areas are therefore being required to deliver care that has been shown to be effective. (Playle, 2000).

From simplicity to complexity: developing a model of practical skill performance in nursing

The purpose of this article is to present and discuss a new model of practical skill performance in nursing. The model is conceptualized as having five components: substance and sequence; accuracy; fluency; integration; and caring conduct. The model challenges the truism of 'simple' nursing procedures. It is argued that performance of practical skills in nursing is characterized by complexity on many levels. Complexity lies within and between the components of the performance model and in the interaction between the nurse and the clinical context where practical nursing actions are performed. These complexities are described. Examples that illustrate the complex and reciprocal nature of these components are drawn from an empirical study of graduate nurses' development of practical skill in surgical hospital units. Implications of the model for education, practice and research are discussed.

Practical skill development in new nurses

This paper reports the results of an empirical study of new nurses' development of practical skill. Actual practice and clinical learning of new nurses has received minor attention in nursing research. This may build on the assumption that practical skill naturally improve as a result of working in the clinical setting. In the present study nurses were videotaped several times as they performed in the clinical setting, and interviewed after each filming. Analysis of skill development was rendered possible by comparing characteristics of performance over time. A model of practical skill performance was developed during the analysis. This model advances a broader understanding of practical skill by incorporating the following constructs: substance and sequence, accuracy, fluency, integration and caring comportment. The nurses' trajectories of practical skill development are presented on the basis of this model. Individual and common trends in practical skill development are discussed, and the idea of development of practical skill as a natural happening in the clinical setting is critiqued.