My Scope of Practice: Healthcare Logies Take on Pressure Ulcers

  Roz Elliott, Clinical Nurse Consultant, Intensive Care Unit, The Royal North Shore Hospital, Sydney, Australia, says her hospital has “the most sophisticated technology and some of the most amazing surgeons and anesthetists.” But she notes it is the nurses who must be thorough and aware of patient risks related to long-term immobility.

Skin breakdown, respiratory and urinary tract infections, and blood clots in patients’ legs and joints can be fatal if not addressed. Roz’s hard work, along with that of Project Officer Vicki Fox and other intensive care staff, recently was acknowledged by the New South Wales Department of Health. Roz and Vicki were presented the prestigious Baxter Quality Award in recognition of their education and training procedures in relation to pressure ulcer prevention. In addition, they received the Minister’s Innovation Award for reducing the rate of pressure ulcers in ICU patients. These healthcare “logies” (roughly translated, Australian for “Oscar winners”) couldn’t be prouder.

  The Department of Intensive Care at Royal North Shore Hospital is the only tertiary level ICU in the Northern Sydney Central Coast region and its referral areas. The facility covers a population of 1,130,000 people, 15% of whom are over the age of 65 years. The hospital comprises three clinical units (Neurosurgical, General, and Cardiothoracic surgical ICU). The Neurosurgical ICU is one of the few specialized neurosurgical units in Australia. All beds in the intensive care department have the capacity to provide multisystem support, including invasive cardiac and hemodynamic monitoring, administration of vasoactive medications, ventilation, and dialysis. Most patients require one-to-one nursing care that is led by a team (including Roz) of expert clinicians.

Education and Experience

  Roz made Australia her home in 1998. Previously, she studied nursing at St. Bartholomew’s Hospital and City University, London, England, and began her career in intensive care at London’s King’s College Hospital. In Australia, she started work at the Royal North Shore Hospital where she has held a variety of positions in the ICU. Currently, she is the Clinical Nurse Consultant. In 2005, she completed her Masters by Research at the University of Technology Sydney (UTS) – her studies involved the effect of a sedation guideline on ventilated patients.

  Among her duties, Roz is responsible for coordinating and facilitating educational inservices for all qualified nurses in the ICU, advising and providing instruction for the Graduate Certificate Critical Care Nursing course (University of Technology Sydney) and other clinical courses, introducing new products and equipment, and serving as a member of the hospital resuscitation and pressure ulcer prevention committees and nursing research interest group.

  Vicki was hospital-based trained in nursing at the Queen Elizabeth Hospital, Adelaide, and completed a High Dependency, Cardiac, Intensive Care certificate and a Bachelor of Nursing. She has worked in ICU for 12 years. During that time, she became the Clinical Research Coordinator and was involved projects that addressed acute lung injury, acute respiratory distress syndrome, acute pulmonary edema, and management of elective abdominal aortic aneurysm (AAA) patients. She achieved the position of Clinical Nurse Specialist.

  After moving to Sydney in 2003, Vicki participated in research projects involving ICU nurses and clinical decision-making. She then took on the role as Project Officer for the pressure area prevention initiative. Since completing this role, she has become a quality care reviewer. As Project Officer, she was responsible for developing and implementing a pressure ulcer prevention program that encompassed pressure ulcer identification and management (including resources), incidence and prevalence monitoring, and providing education across five facilities. As a quality care reviewer for the Royal North Shore Hospital QARNS program (a quality improvement incentive), Vicki identifies breaches in the standards of care through retrospective medical record review. Then, following a multidisciplinary review process, practice is changed to reduce the likelihood of a similar adverse event.

Facilitating Best Practice

  As part of the pressure ulcer reduction initiative, the ICU introduced monthly audits of patients by a team of clinical nurse experts, increased training for nurses, and increased the priority afforded to risk assessment using the Waterlow scale for each patient. Roz says emphasis is placed on “straightforward” techniques such as regularly repositioning the patient, using pressure-relieving equipment (mattresses and pillows), encouraging good communication among staff, and thoroughly inspecting all at-risk skin areas. As a result of the new program, the rate of pressure ulcers in the unit decreased significantly from 50% to 8%, well below the international benchmark of 20%, which earned the facility statewide recognition.

Common Goals

  When asked what Roz enjoys most about her job, she replies, “I like being a facilitator. I believe I am a conduit for information and evidence. My philosophy is based on Everett Rogers book, The Diffusion of Innovations. I believe people – more specifically, clinicians – want to do what’s best for the patient. To do so, they need the correct information to enable them to make the right decisions. I enjoy being a resource for that information. The downside? My job is never-ending. I wish I could devote 24 hours a day to achieving all the improvements I would like to see. Plus, I am a great believer in publicizing the good work nurses do – to co-workers, to the public, and to other healthcare professionals. Suzanne Gordon’s book, From Silence to Voice, also influences the way I address my responsibilities.” Vicki is proud of achieving the 42% reduction in pressure ulcer occurrence. She has seen her role as Project Officer evolve over time. “The pressure ulcer project initially was only to be implemented at one facility,” she says. “After its success, it became an area-wide, five facility program. My expanded responsibilities included adapting the program to suit each facility by closely liaising with key site champions and clinicians. To that end, I interacted with all levels of medical, nursing, hospital management, and allied health staff to achieve consensus. I became involved in each facility’s committees. These efforts afforded development of a standard template for all nursing care plans that linked risk assessment to appropriate interventions – this protocol is now integrated into elective and emergency admissions. I also have had a role in implementing policies/guidelines for practice at each site, ICD-10 international classification of diseases coding standards, a prevalence audit tool that includes education for yearly prevalence audits across the area, and resource (mattresses/cushion) use guidelines. I pushed for the facilities to purchase/hire more resources, demonstrating that prevention – which should begin at the time of admission – is cheaper than curing.”

  Roz and Vicki believe all patients deserve a Registered Nurse who has completed a university education. They agree that as nursing becomes more specialized, nurses must become more accountable. “Nurses should be able to answer for their actions,” Roz says. “It is no longer acceptable to do things because that’s the way you were taught or not know the rationale for treatments and interventions. Therefore, nurses must be able to access the best available evidence to care for patients.” Vicki adds, “Over the past 10 years, the focus on patient safety has increased, compelling us to acknowledge and learn from our mistakes.”

Looking Ahead

  Roz hopes to continue to assist her colleagues at the bedside in providing a high standard of care. She plans to pursue training in clinical supervision so she can extend her role as supporter and mentor. She also wants to apply the principles underpinning the successful pressure ulcer prevention program to other aspects of essential nursing care.

  Vicki will assume the role of Area Patient Safety Officer this month. In this role she will oversee the Safety Improvement Program (SIP) and assist with area-based patient safety priorities, including pressure ulcer prevention, falls prevention, and safe medication administration. She hopes to continue to “facilitate positive change.”

  Roz and Vicki have a great deal of respect for their colleagues. “Clinicians are people who have the best intentions,” Roz says. “When provided with evidence, they will provide care to the best of their abilities. Nobody knowingly intends to omit or be negligent. In becoming nurses, we set high ideals and strive to live up to them in our scope of practice.”

My Scope of Practice is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ. This article was not subject to the Ostomy Wound Management peer-review process.