The Evidence Based Practice Cpd Nursing Essay
The complaint letter suggests that the physiotherapy service in question is falling way below the mark outlined by the Scottish Government and subsequently many clinical governance issues have been raised, four of which have been identified for review.
The initial handling of the situation before the patient had even received an appointment was unacceptable. When the patient wished to complain, the admin staff informed the patient the physiotherapist was on annual leave for two weeks and he could phone back then. This was largely unhelpful and suggests poor practice as only one physiotherapist could handle the situation creating an unnecessary delay. Best practice would have been for the admin staff to deal with the complaint and to inform the patient of the NHS complaints guidelines allowing the patient to raise their concerns early on. The guidelines suggest that prompt investigation and resolution of the complaint will be at local level, aiming to satisfy the person making the complaint whilst being fair to staff and that the issue should be answered within three working days (NHS inform 2012). Had this procedure been followed, the issue could have been resolved quickly and efficiently, providing the patient a positive experience with the NHS. The patient however will feel as though he has been treated unfairly and is likely to view the NHS as unprofessional as well as developing negative perceptions of physiotherapy before even attending therefore impacting on the treatment. By not allowing the patient to complain it has evoked a negative experience leaving the patient waiting with uncertainty.
A major communication breakdown between the referring GP and the physiotherapy department resulted in the patient being placed on a 16 week waiting list for chronic conditions which is unacceptable. Secondly the patient had to phone to obtain this information two weeks after the initial referral which suggests poor correspondence between the physiotherapy department and the patient. This highlights a lack of communication and ineffective team work whereby staff members are not adhering to standards outlined in the Healthcare Quality Strategy (2010). This policy states that in order for high quality health care services to be obtained in Scotland, staff must be caring and compassionate and clear communication and collaboration between clinicians, patients and others is essential for success, none of which has been shown in this case. When the patient raised his concerns the waiting time was reduced to six weeks. In relation to this it was highlighted in an audit by the CSP (2012) that there is a lack of awareness amongst commissioners of the amount of time taken to refer patients to a physiotherapist, with 73% unable to provide details. A recent census of 6941 adult physiotherapy patients published by the Information Services Division Scotland (2012) found 56% of patients to be seen for a first appointment within 3 weeks. 3% were seen more than 18 weeks from the referral and the median waiting time for a physiotherapy appointment ranges between 2-5 weeks. There however does not appear to be any information related to waiting list times for urgent appointments for physiotherapy within the NHS suggesting as long as targets are being met, some patients who require urgent appointments may be overlooked and may not receive treatment in an immediate fashion. Overall a lack of communication has resulted in the patient having to wait longer for urgent treatment which could have jeopardised his health and resulted in irreversible damage. An increased wait also limits and alters the type of treatment prescribed by the clinician as the condition has progressed from an acute to chronic stage and treatment will likely be less effective with recovery impeded and this is one of the main concerns of the CSP (2013). This raises safety concerns for the patient and emphasizes he is not receiving the best quality of care.
The initial assessment was disjointed and the patient was left standing in his underpants behind curtains which barely closed suggesting there was a lack of care for the patient’s modesty leaving him feeling angry and embarrassed at times. Poor feedback was given to the patient whereby statements such as "a stiff lumbar spine was likely causing the leg pain" and "the pain was probably postural related". These statements are not definitive answers and may have lead the patient to question if the practitioner was knowledgeable and skilled enough to be delivering the treatment? Throughout the assessment the patient may have lost respect for the clinician and lost all confidence in the physiotherapy service offered. One of the priorities outlined in the Healthcare Quality Strategy (2010) is that staff members continue to show clinical excellence and it is stated by the National Quality Board (2013) that Individual health care professionals, their ethos, behaviours and actions, are the first line of defence in maintaining quality. The clinician in question has failed to meet not only government standards but the patient’s expectations with little remorse. As a frontline member of staff the clinician has also shown physiotherapy to be unprofessional and he could be subject to investigation not only from the NHS but from the CSP who state in their code of professional values that members should strive to achieve excellence, take responsibility for their actions, behave ethically and to understand how their actions can impact on the physiotherapy profession (CSP 2013).
Evidence Based Practice/CPD
The National Quality Board (2013) suggests clinical effectiveness is high quality care, delivered according to the best evidence as to what is clinically effective in improving an individual’s health outcomes. The patient suggests being given a booklet to read and some exercises to do which were the same as previously prescribed however he was unable to do so due to pain. This emphasizes a lack of insight from the clinician and begs the question if evidence based practice and guidelines were being followed? The NICE guidelines for Low Back Pain (2009) suggest that all patients whose pain persists for more than six weeks must be offered the menu of three types of evidence based treatment which is: physical activity and exercise; manual therapy and acupuncture. If the clinician had taken the patient’s pain and inability to exercise into account then surely another treatment avenue should have been explored? The clinician’s decision was narrow minded, leaving the patient in the same position where exercise was going to have no beneficial effect. There is a large amount of evidence to support the use of manual therapy and by adhering to continuing professional development (CPD) which is a quality assurance standard of the CSP (2013) and by keeping up to date with current literature the clinician would have been able to make an informed decision based on evidence and knowledge. In this case the clinician has failed to demonstrate why he has chosen just exercise therapy over other modalities suggesting a lack of clinical reasoning and evidence based practice, subsequently delivering poor quality treatment with no beneficial effect to the patient. The clinician has failed to meet standards set by the Government and the CSP and would be held accountable for his actions in a court of law. The clinician could also come under investigation from the NHS and CSP, potentially facing disciplinary action with the possibility of having his licence to practice revoked (CSP Rules of Professional Conduct 2002).
Please see appendix on page ? for a detailed proposal outlined to address the complaint.
CAN I HELP YOU? Learning from comments, concerns and complaints (2005) was a guidance document developed by the NHS outlining their complaints procedure. This document states that NHS Scotland is committed to delivering high quality, patient-focused healthcare and to using the views and experiences of the people who use its services as part of a process of continuous quality improvement. This is backed up by Partnership for Care: Scotland’s Health White Paper (2003) which states that a focus on patients must mean a willingness to learn from situations where things have gone wrong or a patient has not received the level of service or care he or she expected. They suggest that the design of the complaints procedure should aim to strengthen the response to complaints, increase the focus on handling complaints quickly and ensuring that there is a positive and constructive response to patients and the public and that failure to do so could lead to investigation by NHS Quality Improvement Scotland. By advertising the correct complaints procedure it allows the NHS to gather valuable information of patients’ experience and to learn from their mistakes. This then forms the basis for new procedures to improve the service and to avoid future complaints (Scotland’s Health White Paper: Partnership for care 2003).
18 Weeks: The Referral to Treatment Standard (2008) policy highlights that shorter waiting times can lead to earlier diagnosis and improved outcomes; reduce unnecessary worry and uncertainty for patients and that faster access to treatment will allow for a rapid return to work. Stretched to the Limit: an Audit of physiotherapy services in England, CSP (2012) found there was considerable variation uncovered around the amount of time patients were having to wait for referrals with NHS Portsmouth confirming that "new appointments take four weeks and urgent within the week" but NHS West Sussex reported some patients having to wait up to 27 weeks to receive treatment. The CSP is concerned about rising waiting times and the effect this has on patients with chronic conditions as there is increased risk the condition will worsen and recovery impeded. To avoid unnecessary communication breakdowns and increased waiting times it is hypothesised that patients should self-refer to physiotherapy via writing or telephone utilising the NHS24 service. In response to the Independent Budget Review, the CSP (2010) highlighted a few figures worth noting. Self-referral to physiotherapy services provides cost efficiencies of up to £2 million compared to GP referral. In the UK 12.25 million working days are lost due to musculoskeletal disorders and Low back pain is the most common musculoskeletal problem affecting an estimated 18 million people, with associated costs of £5bn each year to the economy due to working days lost. The Department of Health (2008) state that analysis from pilot sites indicate patient benefits of self-referral to be: high levels of user satisfaction and confidence, a more responsive and attractive service to patients with acute conditions offering them wider access, empowering patients to self-manage their conditions and lower levels of work absence. Service benefits include: no increase in demands for services, greater levels of attendance and completion of treatment, lower NHS costs and the scheme was well accepted and supported by physiotherapists and GPs. The self-referral scheme adheres to the Delivery Plan for AHPs (2012-2015) government policy in that Allied Health Professionals are strongly placed to support self-management and enablement as well as reducing unnecessary hospital referrals and admissions therefore reducing costs. The scheme is sustainable, viewed positively by all parties involved and will allow patients quicker access to treatment. This will avoid waste of resources, improve patient outcomes and allow for quicker returns to work decreasing the amount of sick day’s lost and subsequent costs to the government.
The National Quality Board (2013) emphasizes the NHS constitutions values that guide the behaviours of those who work in the NHS: Respect and dignity, commitment to quality of care, compassion, improving lives, working together for patients and everyone counts. NHS Professionals are required by law to comply with these procedures to ensure that patients are treated with a degree of respect and dignity and that the best quality of care is offered. The code of professional values outlined by the CSP (2013) also state that members should be compassionate and caring, show honesty and integrity, show respect for individual autonomy, strive for excellence and promote what is best for the individual. Delivering compassionate care is at the very heart of clinical values and it is the cornerstone of the mutual NHS which was first described in Better Health, Better Care (2007). It is also outlined in the Healthcare Quality Strategy (2010) that people in Scotland have told the NHS that they want staff to be caring and compassionate, showing clinical excellence and that they want to be seen not as receivers of services but as partners in care.
Evidence Based Practice/CPD
The NICE guidelines for low back pain (2009) state that treatment and care should take into account patients’ needs and preferences and that people with non-specific low back pain should have the opportunity to make informed decisions about their care and treatment in partnership with their healthcare professionals. Information and advice should be provided to promote self-management of low back pain and that patients should be offered one of three treatment options taking into account patient preference: an exercise program, a course of manual therapy or a course of acupuncture. The use of manual therapy is backed up by Aure et al. (2003) who carried out a randomized controlled trial comparing manual therapy and exercise therapy in patients with low back pain > than 8 weeks. The results highlighted significant improvements in both groups however manual therapy showed significantly greater improvements in all outcome measures especially return to work where immediately after the 2 month treatment period, 67% in the manual therapy group had returned to work compared with only 27% in the exercise group. This clearly demonstrates the benefits of manual therapy especially when a quick return to work is the desired outcome.
Evidence based practice should be developed through CPD and it is integral to ensure that the patient is receiving treatment which has been shown to work and to be clinically effective. The CSP policy statement on CPD (2007), states that members should continue to develop and enhance skills, knowledge and competence both professionally and personally to improve performance at work, with the purpose being to enhance the quality of the service that patients and clients receive whilst striving for professional excellence and ensuring safety to the public. It is also highlighted that adhering to CPD is obligatory through the rules of professional conduct (CSP 2007).
IMPLEMENTING POLICIES/CHANGES TO PROFESSIONAL PRACTICE
It is highlighted that training of staff, initially through induction, is key to making the NHS complaints procedure work effectively (CAN I HELP YOU? Learning from comments, concerns and complaints 2005). The downside is that training is extremely time consuming and expensive. The Kerr report (2005) states that we need to be realistic about staffing and that the NHS consumes a considerable amount of the Scottish executive budget, as such the NHS has a responsibility to search out best value and take decisions that get the best possible return for every public pound spent. A substantial amount of time and money would need to be invested to retrain frontline members of staff to equip them with the skills to handle initial complaints. One problem which may arise is that if more physiotherapists are handling complaints and paperwork then it may significantly reduce the amount of patient contact time in an already under staffed work force which could reduce the quality of care patients are receiving.
Self-referral to physiotherapy is not a new concept however it is still largely unbeknown to the general public and if not marketed appropriately the service could be underutilised. Having a clear marketing and communications plan is important and at a basic level the service could be marketed through leaflets and posters in GP surgeries. Promotion could also include online media, local media and engaging with local councils and community groups (Musculoskeletal Physiotherapy: patient self-referral, CSP 2012). Another issue is that with self-referral via NHS24 there could be inequity of service, with only those patients with access to a telephone and who are able to communicate clearly over the telephone being able to access the service (Foster et al. 2011). It will undoubtedly take time to adapt the service and it is estimated that implementation would take three months to one year with a three month "run" in period which is recommended by the CSP based on the findings of (Holdsworth 2007). Another barrier to implementation is the perception among physiotherapists that waiting lists and the demand for the service will increase, creating substantially more work for clinicians. It is hypothesised however that following the initial rise, the demand will fall to normal levels after three months (Musculoskeletal Physiotherapy: self-referral, CSP 2012). If implemented correctly the self-referral scheme via NHS24 would be beneficial to both patients and physiotherapists. It would alter professional practice in that patients would be assessed and treated quicker potentially increasing the variety of treatment options delivered and improving patient outcomes. This is backed up by the concerns of the CSP (2013). Physiotherapists would also be practicing autonomously increasing pressure and their responsibility to the patient for which they would be held accountable (Musculoskeletal Physiotherapy: self-referral, CSP 2012). Physiotherapists would be practicing at a higher level with more responsibility and it means that they would be working to the full extent of their education and experience (Kruger 2010).
Ensuring staff members are acting professionally and providing the highest quality of care will be audited by collecting patient data on their overall experience with the NHS. The issue with carrying out an audit is that they take a long time to collect data and the most frequently cited barrier to successful clinical audits is the failure of organisations to provide sufficient protected time for healthcare teams (NICE 2002). Adequate time is required to plan, select criteria to be reviewed and implement the audit. The failure to follow through audit towards improved practice has often been the result of design problems, lack of senior support and commitment. In both cases healthcare staff rapidly lose their enthusiasm when they are unable to see benefit for their patients from the considerable extra commitment needed to mount a worthwhile audit project (NICE 2002). An individual wanting to implement a clinical audit requires many skills, dedication to the cause and adequate time to achieve results.
In terms of professional practice carrying out a clinical audit allows for physiotherapy career progression. It demonstrates commitment in a particular area of interest and allows physiotherapists to network with more senior clinicians in that field of work (NHS 2013). By implementing this particular audit, it will uncover which areas of practice are falling below the mark outlined by the Healthcare Quality Strategy (2010) and the CSP code of professional values (2013). It will ensure that physiotherapists are acting professionally and delivering consistent high quality care as well as understanding their responsibility to not only the patient but to the NHS and CSP organisations.
Evidence Based Practice/CPD
Many potential barriers have been identified to achieving change in practice and Grol and Wensing (2004) suggest that Individual professionals need to be informed, motivated and perhaps trained to incorporate the latest evidence into their daily work. A previous study by Cabana et al. (1999) based on a review of 76 studies on barriers to guideline adherence, identified salient factors as lack of awareness, lack of familiarity, lack of agreement, lack of self-efficacy, lack of motivation, and perceived external barriers beyond the control of individuals. Using evidence based practice needs to become habitual and we must start by informing individuals and potentially providing incentives for them to do so. The actual role of healthcare professionals is also expected to cause resistance to change. Many quantitative and qualitative studies have shown that failure to implement evidence involves factors at different levels of the healthcare system including: characteristics of professionals and patients; team functioning; influence of colleagues; organisation of care processes; available time, staff and resources; policymaking and leadership (Grol and Wensing 2004). To implement evidence based practice, clinicians must view the idea positively and be motivated to adopt the change.
By learning to implement evidence based practice, clinicians will learn the skills to understand the principles of EBP, recognise it in action, implement evidence-based policies, and have a critical attitude to their own practice and to evidence (Dawes et al 2005). This in turn will allow clinicians to provide the best quality of care based on current, valid and reliable evidence. Clinicians are again working more autonomously and it needs to be exercised responsibly (Herber 2005). There is a responsibility for clinicians to give accurate diagnosis, prognosis and the best quality of treatment based on their current knowledge and evidence.