Development of Innovation in the Clinical Setting: Hydration in Nursing

Introduction

This assignment will identify an innovation idea within a clinical setting, exploring different aspects, including the model used, feedback from service users and carers and why this innovation idea may be of use. Innovation is the action or process of transformation. The healthcare industry is constantly growing and transforming. It is crucial that today’s medical professionals stay relevant and ahead of the best possible options in patient care. Nurses can question traditional approaches, reject routine ways of thinking and work inclusively with service-users and carers to find innovative solutions to help improve healthcare outcomes (Howkins and Thornton, 2002; Nursing and Midwifery Council, 2012).

The Royal College of Nursing state that nurses are motivated to engage in innovative practices primarily because they seek to improve patient experiences, health outcomes and nursing practice. (2015).

Within this assignment, we will explore the use of water jugs, and the consumption of them by patients, from various wards. The NHS (Hospital Hydration best practice toolkit 2015), state the key points of why keeping hydrated is essential in hospital and the ways in which nurses and other professionals can implement this. Dehydration is a common problem in hospital patients across hospitals, there is evidence that the link between higher consumption of water reduces various medical problems. The Care Quality Commission (CQC) stated that in 2011, they found nurses sometimes left patients so thirsty that the only way for doctors to ensure they had enough liquid was to add “drinking water” to hospital medication charts. This highlights the need importance of basic human rights which are not being met while patients are at their most vulnerable.

The Nursing and Midwifery code (2008)  state that every professional should respect a person’s right to privacy in all aspects of their care make sure that people are informed about how and why information is used and shared by those who will be providing care , respect that a person’s right to privacy and confidentiality continues after they have died. Share necessary information with other health and care professionals and agencies only when the interests of patient safety and public protection override the need for confidentiality , share with people, their families and their carer’s , as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand state the need to respect people’s confidentiality. Within this assignment individuals will be referred to anonymously and confidentiality will be considered throughout.

PSDA Model

NHS Improvement (2018) state that the plan, do, study, act (PDSA) model, tests an idea by trialling a change on a small scale and asses its impact, building upon the learning from previous cycles in a structured way before wholesale implementation. There are four steps in PDSA model, they are

1. Plan—Plan the test or observation, including a plan for collecting data
2. Do—Try out the test on a small scale
3. Study—Set aside time to analyse the data and study the results
4. Act—Refine the change, based on what was learned from the test

The PDSA model has no limits of the size of the clientele it is trying to reach or the size, it can deliver too. The model is straight forward and simple in its approach to implementing quality improvement changes using a scientific method.

In nursing, models are often designed by theory authors to depict the beliefs in their theory (Lancaster and Lancaster 1981). They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice, for example, through specific methods of assessment. Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing practice (Lancaster and Lancaster 1981). Burke (2013) state that models are important as they help link theory and practice. It can be helpful to use a framework that focuses and determines the most important aspects of the innovation/change /development that require attention.

Providing context and rationale to my proposed innovation, has come from reading an extensive range of literature, data and policies which are already in place. While hydration for this innovation is focused on patients, The Royal College of Nursing (RCN)  used the  3Rs (rest, rehydrate and refuel) campaign to make staff consider the consequences of not looking after themselves when on shift, highlighting the “safety critical decisions” they have to take, as well as the affects that dehydration can have on concentration and cognitive function. It has been heavily documented in the media that nurses are understaffed and along with long hours, that they don’t have the time or can always fulfil their role to the best of their ability. Hospital Staff Nurses’ Shift Length Associated with Safety and Quality of Care study (2013), stated that nurses 12hour shifts regularly where longer and the breaks were cut short due to staff shortages. This highlights the cause for concern, and how dehydration effects not only patients but also nurses and other professionals.

There are various models and frameworks which can be used, all with different advantages and disadvantages, Kotter’s (2012) 8 step process for leading change, has eight single steps:

Create urgency- helps to initiate motivation

Form a Powerful Coalition- convince change is necessary within the workforce/organisation

Create a vision for change- ensuring people/organisation understand why you’re asking them to do something

Create a strategy- to achieve the vision

Communicate the vision- how you communicate the vision

Remove obstacles- remove barriers

Create short term wins- create short term goals

Build on change- continually look for improvements

Anchor the Changes in Corporate Culture- ensure that the change is seen across the organisation.

While this model is detailed and creates a sense of urgency, so results happen quickly, the negatives are the fact that barriers may arise at step seven (build on change) as there may be no more areas for improvements. Also, there are no references in Kotter’s (2012) work which helps to support and evidence the authors work.

The ADKAR change model was first published by Prosci in 1998 it is based on two ideas:

1. It is people who change, not organisations.
2. Successful change occurs when individual change matches the stages of organisational change.

For successful change to occur at the individual level people need to move through each of these stages: Awareness of the need for change, desire to make the change happen, Knowledge about how to change, ability to implement new skills and behaviours and reinforcement to retain the change once it has been made. The positives are that the model brings a checklist to easily highlight the stages which are completed and where more work may be needed. For this model the negatives are based around where the roles of leadership and management cross over, implementing new ideas at management level may be done in a way in which leadership level has not considered. In large organisations, where staff on the front line are the main people introducing change, problems can arise from higher up the hierarchy when communication and ideas are not clear.

PDSA is known for its simplicity and quickness in adjusting if needed, it can be adapted and changed to ensure results are produced quickly, and even if this result is not what are excepted, changes and improvements can be made.

Aims and Outcomes

The aim of the innovation is to make it more accessible and easier for patients to be in control of how much they are drinking while in hospital and to make it easier for health professionals to know the amount they are drinking. By having the timings on a jug, it will not only remind patients of when and how much they should be drinking it will also promote independence and keep them hydrated.

NHS supply chain (2015) stated that a previous innovation project around water jugs had be completed, which focused on the design of water jugs, ‘ the old style were heavy when full of water, they made it difficult for the very young, or the elderly to use. The lids were not securely attached and often fell off, spilling water. They were also difficult to clean, not going through thermal dishwashers. When cleaned they would crack and cloud making the jugs look unattractive and the water unappetising for patients. This project implemented new water jugs but still the issues around the amount of water a patient should be drinking has not been considered. This is especially important in the care of the most vulnerable, Nuffield Department of population health medical sciences division (2019) stated that, ‘thanks to advances in medical care and public health, we’re lucky to be living longer lives. Currently there are 10 million people in the UK who are over 65 years old and three million over the age of 80, and these figures are set to double over the next 20 years.  The main age range of hospital patients are the elderly, and this is ever growing, dehydration with the elderly is a huge problem due to poor self-care, lack of awareness and the general decline in patient’s health when they are unwell. This growing elderly population is one of the biggest challenges facing the NHS today. Older people are being admitted to hospital in ever greater numbers, putting increasing pressure on an already stretched service facing ever tighter budgets.

For all stakeholders involved in an innovation project, it is essential that good communication is at the centre, satisfying stakeholders needs and interests is paramount in making the project successful. For the project to be successful the stakeholders need to be involved in the project their influence and power can affect the project in a positive and negative way. For patients and families, the advantages of the innovation, would hopefully be based around the consumption of water and the patient being in control of their water intake and being more aware of how much they are drinking, thus reducing further problems due to dehydration. For nurses, ensuring each patient is aware of the amount of water they should be drinking in a certain amount of time, should help the patients be more in control of their own wellbeing, where appropriate. Advantages for managers the idea that if dehydration amongst patients could be solved, and the patients being more in control and aware of how much they should be drinking, patients time spent in hospital should be greatly reduced.

Literature Review

The importance of models and theories help to widen knowledge and explore different concepts, they help to assess plan and implement care by providing a framework within which to work. The Nursing and Midwifery council state that the confidence and ability to think critically, apply knowledge and skills, and provide expert, evidence-based, direct nursing care lies at the centre of all registered nursing practice. For this innovation assignment, the Plan, Do, Study, Act (PDSA) model will be used, this delivers a framework which develops ideas, tests them and implements change which primarily shows improvement.

Collins (1986) defines innovation as a new method/ or practice device, ‘Practice is regarded as a practising; habit or custom, repeated action for gaining skill, the resulting condition of being skilled, knowledge put into action and the exercise of a profession’. Within nursing it is essential that innovation is continually happening, as it assists professionals to broaden their knowledge, skills and to develop and find new ways of implementing them. Theories, frameworks, research all influence innovation, within the NHS innovation  is imperative to the constant changing of the organisation, it is also important, so new services, ideas and products can be introduced to the service, or applied in a way in which the NHS may not be doing so currently. Innovation also can significantly improve the quality of health and care wherever it is applied, thus having greater outcomes for service users.

Oates (2017), looked at the assessment of hydration in older people care within hospitals, who had pre-existing and acute health problems. There are no nursing assessments that are always used to identify patients who are at risk of poor fluid intake. Fluid balance documents are used across the whole of the NHS and can be useful when used correctly, but in a time when nurses and other health care professionals are stretched to their limits it isn’t always the most effective tool. The British journal of Nursing (2018), stated that dehydration is widely linked to increased risk of mortality in patients who are acutely unwell, and it also increases the risk of further illness. Despite being recognised nationwide as a cause for concern, 45% of hospital patients will become dehydrated upon admission, suggesting that more needs to be done to prevent dehydration. The use of bedside water devices allows patients to drink freely without assistance. Access to these can reduce a patient’s length of stay in hospital and minimise the risk of developing a urinary tract infection. However, further research is needed to fully assess the impact of having such devices at the bedside. NHS Choices’ page on Water and drinks says: Your body needs water or other fluids to work properly and to avoid dehydration. That’s why it’s important to drink enough fluids. In climates such as the UK’s, we should drink about 1.2 litres (six to eight glasses) of fluid every day to stop us getting dehydrated (NHS 2015). Patients that shouldn’t be consuming too much water for example, patients who are receiving haemodialysis, are limited the amount of water they can consume and would not be taken into consideration for this innovation project.

The fundamental aim of innovation and change in healthcare is to improve patient care (Department of Health, 2000). However, such transformations come from people – not technology or systems (Broome, 1998). Nurses are encouraged to develop effective leadership skills in order to change the usual structures, systems, roles and ways of working that exist within healthcare. In doing so, they must learn to maintain an energetic/changing balance between developing their own effective leadership attributes and developing their abilities for forming relationships and interactions with others within their team. When working in health care communication is happening constantly with patients, their families and other members of the health care team, ensuring that barriers to do with communication are minimised is essential, these include language, accent, body language, facial expressions and eye contact.

Teams are a fact of working life. The “health” of a team or teams has a bearing on patient safety. The size and structure of a team can influence how the team performs, as can the internal dynamics of the team members and how the group is led (Flin R et al 2009). Implementing an innovation project needs to ensure that the whole team/organisation are all aware of what the innovation consists of, what the aims and outcomes are and how the project is to be directed. Implementing the project should not take away from patients care but in fact improve patient’s care. Lecko, patient safety lead at NHS England stated that ‘good hydration is essential to maximise a patient’s chance of recovery. The appearance of water and how easy it is for a patient to help themselves, directly impacts on their hydration levels’. Water jugs with timings on, not only give nurses a helping hand in being aware and recording the water consumption of patients but also, gives those patients who are able to, to understand how much they should be drinking, and the timing prompts should aid this. Managing change within a team, can see problems develop rapidly, to ensure the risk of this is get to a minimum, all staff should be aware of the innovation project, have the opportunity to ask any questions, and be confident in explaining the project to patients.

Evidence-based practice (EBP) is at the core of healthcare delivery, with research appraisal and innovation going hand-in-hand to better address the needs of service-users and enable it to adapt to the ever-changing demands of public health (HEE, 2013). Every decision made by a nurse is based around evidence-based practice, this is because it improves patients’ outcomes, eliminates practices that have become outdated and not cost efficient, reduced cost and helps to ensure the best quality of care is provided.

These pieces of literature clearly show that there is a clear problem in tracking the intake of water of patients in hospital. Most of the researched has be based around elderly patients, but to ensure that results and data are accurate and take into consideration a wider range of patients it would be useful for it to be taken from a larger age range and across various difference wards.

Description and Critical Analysis

Plan

What are we testing? To use water jugs with timings on, with the aim to improve water consumption across patients of all abilities. Thus, making it easier for patients to monitor and be aware of how much water they need to be drinking, which can aid their recovery, reducing their hospital stay.

Who are we testing the change on?  We are going to initially test it across four different wards (Health Care of Older People, Medicine, Acute medicine and Oncology.

When are we testing?  Once confirmation from all wards has been received and all staff have been made aware of the innovation project. Testing the water jugs at one hospital in the local city.

PREDICTION

What do we expect to happen?  We expect to be able to receive feedback on whether the timings are useful or not, both from patients and staff.

DATA

What data do we need to collect?  Subjective findings from the patient and the nursing team (including health care assistants).

Who will collect the data?  Nurses, will be responsible to ensure the patients that are under their care, can feedback.    When will the data be collected? At the end of every week.

Where will the data be collected?  The project leader and Sister of the ward will make the decision at the start of the project.

What was actually tested?  A new type of water jug with timings on.

What happened?   Gaining consent from different wards, cost and implementing the project in a short amount of time was not visible.

Observations?  Cost was not considered, and no funding was available, timings couldn’t be just drawn onto the jugs, so it was unachievable.

Problems?  When observing wards and hydration, some patients were not asked if they wanted a drink, until they asked a nurse

Study

Initially I felt the project would be suitable for all wards and be useful to not only patients but staff too, fluid balance charts are not always easily used, as patients sometimes forget how much they’ve drank, or when they’ve drank. Cost is also an important factor, which was overlooked, at a time when the NHS is under great strain, the most cost-effective equipment is used, implementing new water jugs, would cost money and time. Using the water jugs on a small scale initially and also coming up with a timing measure which could just be stuck to the jug would have been more cost effective and could have been implemented easier.

Evaluation of the Innovation

Innovation assessment is concerned with determining how well the objectives of an innovation have been achieved (Miles, Cunningham, Cox et al., 2006). The effectiveness, efficiency and explanation of innovation successes / failures can be examined (Miles et al., 2006). Here, it is important to recognize that evaluating this project will require different evaluation methods to capture potential immediate, medium and long-term impacts (Miles et al, 2006).

Evaluation of the  innovation, could be done in various different ways, to gain good results an audit of patients and the amount of water they consumed while in hospital would be suitable, also having feedback for not only ward areas but also  for patients to see the link of good hydration in patients and the time spent in hospital.

The fact that nurses and other health professionals are busy, and their time is limited, giving patients control of the amount of water they drink, while guiding them on the amount they need to drink within a 24-hour window would greatly help those.

Future of the Innovation/ Implications for Practice

Communication is nursing, it is at the centre of all care, and as professionals we must ensure that our communication is always of a high standard. Nurses must have excellent personal and professional skills to be able to deliver the service and standards NMC (2015).

The innovation project could be of use in other settings for example, Care Homes, basing it around the health of older people, who may not be able to retain information of how much they have drank, this would be useful for staff, to encourage them to drink and for the patients to understand the amount they should be drinking.

The project didn’t produce any results, but the idea behind the innovation would be useful not only to patients but also nurses. The project would need more work around the planning stage and the cost implications would need to be looked at in detail.

Personal Reflection

Undertaking this project has highlighted areas in which I need to improve on but helped me widen my educational knowledge by reading literature which I wouldn’t have probably come across otherwise.  My knowledge was limited on the importance of innovation in healthcare and I now understand why it is important.

Undertaking this project, as well as engaging in teamwork within the action learning set, has been an enlightening educational and personal experience. From an educational perspective, I now understand the importance of innovation in healthcare; the need to think critically about the practice I experience and seek opportunities to improve the quality of service-user care (DOH, 2012). I have seen first-hand how effective adopting a model/framework has been in structuring my ideas to create change (Burke, 2013) and I now better appreciate the value in adopting differing styles of communication to deliver effective communication in the process (Heron, 1976). This project may not of produced the results I was intending to, but it has illustrated that time management plays a key role, completing practice placements, academic work and general day to day life, as been difficult at times. Moving forward through my degree, I need to be aware of time management and the implications it can have, I feel that I am pro active and confident in myself in my communication skills, but when working with people who I am not familiar with or have no rapport I do begin to doubt myself. I have gained knowledge and insights to nursing over the past two years and feel that building on my skills will help me in the future to ensure that I provide the best care, continuously build on my knowledge and become confident in the implementation of innovation projects which can help to improve and build on nurses everyday work. I also feel that reading is essential to understanding and learning why nursing is ever changing, this project has increased my knowledge and I have learnt that reading around projects can still produce useful information and can be used in all aspects of nursing.

Conclusion

Implementing an innovation takes, organisation, time and planning, this project has highlighted the fact that planning in detail is crucial, also how important innovation is to both registered nurses and student nurses. (Department of Health 2012) As the project never passed the infancy stage, it is difficult to be able illustrate a clear picture on the success of the project. The need for change in water jugs within hospitals is apparent, and has had publicity both in the media and within trusts across the U.K. As this is a widespread issue, I did not consider the scale of the project even across a small number of wards. When implementing an innovation this should be done when you are confident and have considered and tested all the possible ways of achieving change. In the future I will take more time in planning the innovation project, focusing on costs implications and also the relationships with other staff, as having good rapport with other people, makes communication easier thus staff being more interested and active in innovation projects. Also, the time a nurse has while on shift to already complete their basic work is limited, the royal college of nursing conducted a study Nursing on the Brink in 2018 and the results produced six recurring themes:

• patient care not carried out through lack of time
• not enough time to support families and carers
• too much time spent on non-nursing duties
• concern about the skill mix of nursing staff
• concerns about the mental and physical health of nursing staff
• concerns about staffing levels not being addressed.

Nurses time is so limited, and implementing innovation projects can be time consuming, while it is important for innovation to happen, nurses also need the time to be able to make it happen.

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