Proper Training of Nurses Caring for Chest Tube Patients

PROPER TRAINING OF NURSES CARING FOR CHEST TUBE PATIENTS 21

ProperTraining of Nurses Caring for Chest Tube Patients

ProperTraining of Nurses Caring for Chest Tube Patients

Nurses,like otherhealthcarepractitioners,arerequiredto safeguard thesafetyof thepatientsall thetime.Thisisespeciallyin thecaseof chesttubepatients,whereresearchhas indicatedthatfewnursesandotherhealthcare practitioners knowtheappropriateprocedureto followin suchcases.Surveyspertainingto chestdraininsertionshavedemonstratedthatover-penetration of thetrocar andevenvisceralinjuriesutilizingArgyle-type chestdrainstakeplaceevenamong experiencedthoracic surgeonsandrespiratory physicians.Itmay alsobeacknowledgedthatthoracic injuriesare creditedwith 25% of thetotaltraumadeaths.In spiteof theseverityof theinjuries,lessthan ten percent of thebluntchestinjuriesandbetween 15% and30% of thepenetratingthoracic traumanecessitatethoracotomy. Asmuchas theultimateobjectiveof drainingthepleural cavitymay haveremainedthesame,theactualmethodpertainingto chesttubethoracostomy has significantly changedsince its inception.Of particularnoteis thefactthatchesttubeinsertion,givenits clinical utility,is categorizedas a mandatoryskillthat everyphysicianthat providescareforinjuredpatientshas to acquire.Itis unfortunatethatthispotentiallylife-saving procedurealsocausesconsiderablemorbidity. Generally,chesttubecomplicationsmay be classifiedas infective, positional orinsertional. In particular,about30 percent of thecaseshavereportedpain,impropertubepositioning, and vascular injury,inadvertentremovalof thetube,longerhospitalstays,postremovalcomplications,andpneumonia.Theseareconsideredas normalsince majorvisceralandvascular structuresare in closeproximityto not only the chest tubes and the differentinsertionlocations.Chesttuberemovalhas overtimebeenfacingchallengesmoresoin termsof caringforpatientswith chesttubes.Amajorityof nursesfinedthepracticeto be intimidatinghenceendup not adhering to theethicalconsiderationas faras their professionis concerned. Itis from thispointof dilemmain thissectionof healthpracticethata needto havean implementationofthe newmeasurein chesttuberemovalpractices.CurrentpracticeApparently,chesttubesare utilizedto treatconditionsthat interferewith thepleural space.Thebodycan ingest littlevolumesof liquidorairover thelongperiod.Biggervolumeslimittheexpansionof thelung, bringingabout respiratory problems.In greatcases,a strainpneumothorax may create.Thisconditionhappenswhenharmedtissueshapesa restrictedvalveorfoldthat allowairto enterthepleural spaceandkeepingitfrom gettingawaycharacteristically. Seenprincipallywith thoracic injuryandlinearrangement,thisconditionquicklyadvancesto respiratory inadequacy,cardiovascular breakdown,andeventuallypassingifunrecognized anduntreated. Itobligespromptlife-savingtreatmentby embeddinga needleto diminishweight(needlethoracentesis), trailedby chesttubeinsertion.Conventionally,large-bore Argyle-type drainswould be inserted.However,thelastone-decade has seena shiftfrom thisto inserting of a smallbore10-12 French gaugedrainsby theuseof theSeldinger technique.Thetechniquewasthoughtto resultin a reductionin thepatientinvasiveness anddiscomfort,with physiciansvouchingforitbecause of theapparentspeedandeaseof insertiongiventhesmallnessof thedrain(Maskell et al.,2010).Someof thecomplicationspertainingto smallborechesttubescould includehospital-acquired pleural infectionsby theuseof non-aseptic method,punctureof theintercostals artery,insufficient“stay”suturewhich resultsin thefalling out of thechesttube,blockage of thetubeunlike thecaseof thelargerboreArgyle drains,as wellorganperforationas a resultof theoverintroductionof dilator to thechestcavity.Thisunderlinesthefactthataccidentsorcomplicationshavea highlikelihoodofoccurringirrespective of theefficiencyof themethodthat isusedon a patient.Of course,themajorquestionrevolvesaround thefactorsthat could becreditedwith theseproblems.Scholarshaveacknowledgedthattheincidentsare largelycausedby thedeficiencyof experienceof theoperator,insufficientsupervisionlevels, inabilityto followtheinstructionsof themanufacturer,suboptimal imaging, poorpatientpositioning andselectionof suboptimal insertionsite,as wellas thedeficiencyof familiaritywith thepublishedguidelines pertainingto chestdraininsertion.Ofspecificnoteis thewaythatthispresentpracticeof testtubeinsertionpracticeneedsto bechangedbecauseof theartfulinconveniencesthat patientsmay encounteras an aftereffect of themidsection tubeincorporate diseaseandbloodclustersin thearmorleg.Thebloodcoagulationcan goto thequiet`slungs, bringingabout breathingissuesandmidsection torment,which can be life undermining. Thetubecan likewisejab through organsnear to thelungs. Themidsection tubecan likewisemovestrangelyas thepatientturnsormoves.Indeed,eventhedoctorsofferingsupervisionto theattendantscould at presentbe ambiguousornot knowledgeableabout thecorrectmethodofdealingwith midsection tubepatients,in which casetheycannot offerfittingdirectionon thesame.Thisrequiresan assessmentof theimpactsthatpreparationwould haveon theadequacyof attendantsin thefield,andadditionally confusionratesforpatientsthat havemidsection tubesembeddedinthem. Itgoeswithout sayingthatlegitimateinstruction,preparinganddirectionneedsto begivento theattendantsin orderto lesseningtheratesof inconveniences,in both thefleetingandthelonghaul.Essentially,with downto earthchangesputsetup, attendantswill figureout howto watchover midsection tubesnosweat.KeyStakeholders within theHealthcare Setting whoisa Component of thecurrentNursing PracticeLike in everyotherinstitution,there is boundto be variedstakeholders especiallyconsideringthatthehealthcare industryinvolvesnumerousrelationshipsbetween differentplayers.Itcan berecognizedthatthere isa varietyof stakeholders in thelevel of interestorstakethat distinctiveelementshavein aspecificchangeorundertaking.Asto theupgradeof thelevel of preparingforattendantscateringformidsection tubepatients,differedpartnersbecomean integralfactorinthenursinggroup(Maskell et al, 2010). Thenationalcommitteeof nursingwith administrativesheetsfrom thechesttuberelatedtreatment,drugstore,exercisebased recuperationandsolutionbethefundamentalpartnersin thispresentnursingpracticeof chesttube.Theyincludeoccupationaltherapists, pharmacy,medicineandphysicaltherapists.Rolesof theKey Stakeholders in Supporting theProposed Change in PracticeEachof thekeystakeholders will be undertakingparticularroleseachof which would beaimedat allowingforthe enhancedqualityof serviceswithin thehealthcare facility.Itis worthnotingthatthemainobjectiveof thekeystakeholders would be to guaranteethetopqualityserviceandsafetyofferedin thehealthcare unit.Inthecaseof theoccupationaltherapists, theymay be seenas theinitiators ortriggers of thechangeprocess.Theyare theonesto assesstheconditionof theprocessof chesttubing. Theycan tellthechancesof thesuccessorfailureof theprocess.Forinstance,thepatientsarethe testamentto theutilityof anymodeof treatmentthat isoffered,in which casetheydeterminetheneedto retain,maintain,andimproveoreve changeit.In thecaseof thepharmacists,theyare involvedin theproperavailability of themedicationsto thepatientbefore theprocess,in thecourseof theoperationandtheaftermathof theoperation.Lastly,medicalandphysicaltherapists comprisedof theAdvanced Public Registered Nurses andRegistered Nurses.TheAPRN weretheonesto performthechesttuberemovaluntil in 1993 whenRN wasalsolegallyallowedto performchesttubing butof coursewith somelimitationsdepending on thequalifications.Forinstance,mediastinal andpleural wereperformedby fewRegistered nurses

Informationwith similar entities on the most appropriate ways of solving thecurrent problems.

Citation

Evidence Strength (1-7) and Evidence Hierarchy

Wallace, S.M., Doy, L.E., Kedgley, EN &amp Ricketts, W.M (2010). Evidence-Based Emergency Oxygen Guidelines Are Not Being Followed In The Emergency Department. Thorax, Volume 65, Issue Suppl 4

Evidence strength: 1

Systematic review: This article is based on the impact that the publication of the first Emergency Oxygen Guidelines in 2008 has had on patient safety. As much as an audit carried out in 2009 demonstrated improvement in the utilization of target saturations within the inpatient setting, there are concerns that the uptake of the guidelines has been considerably less impressive within the emergency departments. In this case, a study was carried out examining three time periods including immediately before and after the publication of the guidelines and 18 months after the publication. In total, about 253 individual attendances were examined with the results demonstrating that there was frequent inappropriate utilization of the tubes in ED and that there was no improvement even after the publication of the guidelines. It was demonstrated that the most common basis for failure to follow guidelines was excess utilization of oxygen. A large number of patients also experienced their first inappropriate reception of excess oxygen, meaning that the adherence of guidelines is sib-optimal in the ambulance service. The main reason for the low adherence to instructions and guidelines may be the deficiency of awareness beyond the medical specialties. On the same note, the trust had no oxygen champion, in which case the appointment of one would go a long way in enhancing the situation as is the case for an education program.

2. Naicker, T.R &amp McLeod, D.T (2010). Chest drain insertion training is simulation training the answer? Thorax,

&nbspEvidence Strength 1

This study was carried out on CMT trainees who had undertaken the Chest-drain insertion using Porcine-Recine Model. The authors sought to underline the fact that as much as the trainees may have performed well, they required experience in the field so as to be competent in the profession. In essence, two groups composed of 12 and 18 trainees respectively were selected based on the trainer availability rather than their desire to participate. The results of the study demonstrated that averagely, the trainees within the mentored group undertook 10.5 procedures within the previous 6 months while those from the general pool had undertaken only 2.2 procedures. Perhaps one of the most disappointingly universal feedbacks was given by the participants from the general group as they stated that they quickly lost the skill and confidence that they had obtained as trainees. This was blamed on varied issues including the deficiency of opportunity to exercise their skill, the numerous cases of radiologists undertaking the routine tasks, and particularly the deficiency of supervision. In essence, as much as the simulation training could have imparted familiarization and confidence of the trainees with the chest-tube insertion, it was required that the individuals undergo another 5-7 supervised insertions on the patients so that they can do procedures without direct supervision. This underlines the necessity of close mentoring and supervision in mastering the skill.

3. Fremlin, G. Baker, R. Walters, G. Fletcher, T. (2011). Are nursing staff sufficiently educated and competent in managing patients with a chest drain? Thorax, Vol. 81

&nbspEvidence Strength 1

In this study, the authors acknowledged the importance of instructions from doctors and the right training of nursing staff in lowering the prevalence or averting the possibility of chest drains. The study aimed at determining the levels of knowledge that nurses had with regard to the management of chest drain, as well as the support and direction that doctors offer after drain insertion. It was noted that there was high potential for serious accidents. Further, as much as all nurses reported that they had managed the drain, only about 12% of them had formal training on the same even as a meager 34 felt confident to manage the drain. It is noteworthy that the nurses in the respiratory wards seemed to have limited knowledge pertaining to drain management, while a large proportion of them (78%) felt that the ward doctors had offered them inappropriate or poor instruction regarding the chest drain management. In essence, it was concluded that deficiency of evidence-based nursing care and inadequate training may have caused uncertainty and a deficit of knowledge on crucial aspects pertaining to the care of chest drain. In addition, the provision of poor instruction by doctors to nurses after chest tube insertion compromised patient care even more. It was determined that the post-insertion complications could be minimized through carefully designed, as well as implemented care programs.

4. Naicker, T.R &amp McLeod, D T. (2012). Chest Tube Insertion Training- What Is The Effective Way? American Thoracic Society Journals

&nbspIn this study, the authors underline the notion that as much as chest tube insertion is one of the main competencies pertaining to medical trainees at the ST2 level, there exists no formal training for the same. The study examined a simulation training in chest tube insertion through the use of a novel porcine rib model that was deemed valid for training on chest tube insertion. In essence, the study would examine whether the trainees that had undertaken simulation training can transfer the skills so obtained to the bedside or rather the real medical world.

In this study, all the trainees that participated underwent a one-day training on chest-tube insertion through the use of the porcine rib model. These trainees would then enhance their skills under supervision in the course of their academic year. In addition, 16 randomly selected doctors were paired with a mentor so as to determine the impact that individual mentoring had. Given that the training was not a requirement or mandatory, it was possible to create three categories. First, there was the group that received conventional training, while the second group had obtained simulation training and conventional training. The third group had obtained simulation training in addition to mentorship. The results of the study demonstrated high statistical variations between the three categories. As much as the simulation group was performing better compared to the conventional training group, it still lagged behind the group that had both simulation training and mentoring. By transitivity, the third group did much better than the first as well. This was a clear demonstration that the simulation training gave individuals a head start as far as chest tube insertion was concerned. However, the consolidation of the knowledge and transferring of the skills to the bedside necessitated that one undertakes mentoring as well.

5. Epstein, E., Jayathissa,S &amp Dee, S (2012). Chest tube drainage of pleural effusions—an audit of current practice and complications at Hutt Hospital. The New Zealand Medical Journal, Vol. 125, Issue. 1354

Evidence Strength 3

&nbspThe article was based on the need to compare the chest drain insertion practices for fluid with those in other institutions. It was determined that the complication rates were almost uniform. Indeed, it was noted that the small-bore tubes made up around 91 percent of chest tube insertions and formed 92 percent of the complications, with close to 55% of the chest drains that were placed for empyema necessitating cardiothoracic surgical intervention. Nevertheless, it was emphasized that procedural training for junior medical staff and the maximization of the safety of drain insertions using ultrasound guidance, coupled with clear guidelines and clinical governance pertaining to chest tube insertions are crucial in the minimization of harm that could come from this procedure.

Intensive Care Unit, Dewsbury District Hospital, Dewsbury

Choice making is a basic component of nursing work (Boblin-Cummings et al, 1999 Berggren and Severinsson, 2000 Bucknall, 2000) which vacillates as per experience, area and individual limits. Nursing judgements are said to depict the way of nursing learning and practice (Thompson, 1999 Buckingham and Adams, 2000a) and can influence others either positively or unfavorably (Gordon et al., 1994), with Buckingham and Adams (2000a) underlining the advantages to be picked up from comprehension the procedure, including enhanced clinical adequacy and self-information. It is said that all choices are made in one of two ways- -hypothetico-deductively or naturally (Dowie and Elstein, 1988 Thompson, 1999 Buckingham and Adams, 2000a)- -albeit diverse titles are utilized reciprocally for the same modes. Both of these modalities are analyzed. Hypothetico-deductive thinking involves presentation to data before and amid the patient experience. These information are assembled and used to create a theory or conceivable determination. The second position in choice making is established upon instinct and nearly connected with aptitude. The vicinity of midsection depletes after cardiothoracic surgery is known to bring about extreme torment, accordingly meddling with respiratory mechanics and the capacity to participate in physiotherapy activities (Owen and Gould, 1997 Fox et al., 1999 Charnock and Evans, 2001 Lazzara, 2002). This work accordingly intends to inspect the choice making methodologies in connection to the brief evacuation of midsection depletes by investigating the alternatives accessible and the aptitudes needed to use them adequately

E.Specific Best Practice based on the Summary

Itis understood that chest tube training comes as extremely fundamentalto the health of the country and that of the population at large.This is particularly considering the high prevalence of chestailments and injuries. It is required that the healthcare sectorcontinually grows so as to allow for the treatment of patients in asafer and more effective way in both the long-term and theshort-term. However, the fact that there has been deaths as a resultof complication of the chest tube whether with regard to position orinfections and other injuries by the tube underlines the need for achange. Considering the research presented earlier, simple trainingand education would not be sufficient. Training should becomplemented by simulation and mentorship so as to allow individualsto transfer the lab skills into the factual world of operating table,where their skills are really required.

Chesttube control did not demonstrate any unmistakable advantage inimproving midsection tube patency. Therefore, solid confirmation wasnot found for the need to routinely control midsection tubes to helpmediastinal waste after cardiovascular surgery. Actually, strippingmidsection tubes might fundamentally expand negative intrathoracicweights that could bring about damage (for, tissue ensnarement,expanded dying, left ventricular brokenness), in this manner furtherdebilitating patients`

Levelsof confirmation

Wastefrom the mediastinal space is helped by suction and legitimatesituating of tubes, including the shirking of ward circles. Lab prooffrom 2 studies has demonstrated that waste from the pleural space ishindered when tubing is in a subordinate circle. In both of thesestudies, straight and looped tube positions were ideal for depletingliquid. What`s more, though lifting the seepage tubing like clockworkwill keep up satisfactory waste if a subordinate circle can`t bedodged, clinicians are instructed to consider the clinical resultswith respect to higher weights at the midsection tube and seepagetube association when ward circles are available.

F.Change Model.

Theperfect practice is to lay the tubing on a level plane over the bedor seat before dropping vertically into the midsection channelgadget. In the event that cautious evaluation recommends that somecontrol of the tube is important, contemporary master assessmentemphatically prescribes delicate manual crushing and discharging oflittle sections of midsection tubing between the fingers (draining)as opposed to stripping.

Inimplementing this change in the healthcare facility, the mostappropriate model would be Lippitt change model. Lippitt change modelis made up of a total of 7 phases. First, the entity would diagnosethe problem so as to determine its causes and any predisposingfactors for the same. Second, there would be an assessment of thecapacity or motivation for change. The third phase would involve anassessment of the resources and motivation of the change agent.Fourth, the entity would select the objective of the progressivechange. The fifth phase involves the selection of the appropriaterole of the change agent (Price, 2008). Once these have been done,the healthcare facility would concentrate on maintaining change.Lastly, the helping relationship would be terminated as the changewould already have been established. In this case, the Lippitt changemodel incorporates four intrinsically linked or connected elements.These include the assessment stage where the nurse would make adetailed evaluation of the situation in the healthcare institution,including the cases of chest tube complications and the reasons forthe same. Secondly, the nurse would come up with a plan foreliminating or reducing the complication cases in the healthcareinstitution (Szabla, 2007). It is well acknowledged that the maincause of these complications is the deficiency of knowledge,experience and proper supervision on how it should be doneappropriately. In essence, the nurse would collaborate with otherhealthcare practitioners so as to determine how the predisposingfactors would be eliminated. The third phase would involveimplementation, where the nurse would undertake, as well as documentthe care that was previously identified at the planning stage. Thelast stage would involve evaluation or assessment, which isundertaken consistently throughout the period of change and providesan assessment of the effectiveness of the adopted strategies ineliminating or meeting the needs of the patients.

Thereare varied benefits to the utilization of this model in implementingthe required change in the organization. As much as the detailednature of the model necessitates a higher level of comprehension, itwould be more useful to the nurse managers as it comes with a moredetailed plan regarding how change would be generated (Price, 2008).On the same note, it is founded on the four elements pertaining tothe nursing process including assessment, planning, andimplementation, as well as evaluation.

Ofcourse, the application of this model in the implementation of thepractice change would be guided by the phases that are incorporatedin the same. Already, the high number of deaths from thoracicinjuries has been credited primarily to the deficiency of knowledgeand proper training among healthcare workers including physicians whoare pretty much experienced (Szabla, 2007). This is especially withregard to the application of the relatively smaller and sharper bore10-12 French gauge drains using the Seldinger technique. Once theproblem has been diagnosed, the motivation and resources availablefor change would be determined. In this instance, the big query wouldbe the reasons for proper training or education for nurses caring forchest tube patients (Price, 2008). Does the healthcare facility havesufficient capacity for offering this training in terms of financialand human resources or even expertise? Eventually, the mainobjectives for the change would be identified, which, in this case,are the need for more safety for chest tube patients even as thesmaller gauge drain is used.

G.Barriers to Implementation of the Change

Likeany other project, the implementation of change in the organizationis plagued by varied challenges or problems. First, there may be adeficiency of willingness by the management to change the old way ofdoing things. It is often assumed that physicians or healthcarepractitioners who undertake the practice are well versed with all itsrequirements or would be learning while in the practice already(Szabla, 2007). Unfortunately, this tends to compromise the safety ofthe patients as it was acknowledged that a large proportion of chesttube complications and mortalities result from improper applicationof the tube by healthcare practitioners who have little or noknowledge pertaining to how it should be done.

Onthe same note, there is likely to be deficiency of financial support.Usually, healthcare facilities do not have disposable amounts thatlie idle in prospective for likely projects, rather it is often thecase that healthcare facilities operate on shoestring budget. Thiscould force them to charge high amounts of fees so as to meet theirtargets (Price, 2008). Regrettably, it implies there may beinsufficient financial and human resources to meet the need forchange in the entity. This, however, can be rectified through thecreation of a case that is based on sound data and research. Thiswould mean that the individuals are more likely to be convinced bythe data and, therefore, invest the time and money to the project(Price, 2008). On the same note, it would be imperative that thefacility or change drivers implement solid communication plans thatextend to every level of the organization and gains momentum viaobtaining early visible wins. This would have the effect of garneringsupport from other individuals within the organization once they areclear about the benefits of the project.

Further,the implementation of change in the organization could be affected bythe shortage or deficiency of resources that could lead the changeinitiatives. More often than not, healthcare professionals get toocomfortable with the current ways of doing things to such an extentthat they detest the idea of changing to another way no matter howeasy or efficient it could be (Price, 2008). This means that therewould be a deficiency of internal resources that could lead thechange initiatives. Of course, this could be solved through enlistingexternal assistance so as to drive the initial protects or evenobtain mentoring and training in conjunction with projects thatgenerate immediate results.

Thedespite the new proposed practice being better than the current willas well be demanding as it requires a lot of time hence patient andtolerance need to be observed among the key stakeholders as well asthe patient. However, this can de delimited through voluntaryselection of nurses to be trained for that instead of just imposingthem all on training.

H.Ethical issues that may affect the implementation of the change

Quitea number of ethical issues come up with regard to the implementationof any change in the healthcare sector. This is particularlyconsidering the sensitivity of the services that are offered withinthe sector, as well as the need to cater for the needs of allstakeholders particularly the patients (Price, 2008).

Oneof the major ethical issues in the implementation of change revolvesaround informed consent. This is based on the acknowledgement of thefact that the patient is independent and, therefore, should beallowed to make decisions pertaining to the procedures to which hisbody is subjected. There may be instances where the patients areaccustomed to the earlier procedures and refuse to get the newsmaller gauge chest tubes (Price, 2008). This means that as much asthe nurses and other healthcare practitioners are offered training onthe most appropriate way of offering the service, there would belittle likelihood that it would be applicable to such patients as theindependence principle necessitates that the will of the patient isrespected (Price, 2008).

Apoint to note is that the very changes would not take place in asudden manner rather gradual adoption of the lessons learnt will beundertaken (Price, 2008). This means that there could be continuedtreatment of patients with chest problems by individuals who do nothave proper qualifications to either undertake such services or offerappropriate lessons for the same or just do not have a calling in theprofession.

Insum, before beginning chest tube removal, educate the patient thatthe chest tube will be evacuated, and quickly depict the stepsincluded. Verify the patient is premeditated to alleviate torment andsimple uneasiness. Instruct the patient how to do the Valsalva move,which he or she must perform before tube expulsion to keep air fromreappearing the pleural space.

Assemblethe supplies needed, including sterile gloves, goggles, outfit, veil,dressing supplies, sterile suture-evacuation unit, elastic tippedhemostats, and wide occlusive tape. The patient ought to be placed inthe semi-Fowler`s position and cushion put underneath the midsectiontube site to catch any waste.

Afterthe dressing is uprooted and the sutures are cut, the specialistclasps the midsection tube with hemostats. Teach the patient toperform the Valsalva move as the specialist rapidly uproots the tubeat most extreme motivation. Promptly after tube evacuation, apply anocclusive dressing to the site and secure it with tape. Anothermidsection X-beam ought to be taken a few hours after the fact toguarantee that the lung is still completely expanded.

References

Epstein,E., Jayathissa,S &amp Dee, S (2012). Chesttube drainage of pleural effusions—an audit of current practice andcomplications at Hutt Hospital. TheNew Zealand Medical Journal, Vol.125, Issue. 1354

Fremlin,G. Baker, R. Walters, G. Fletcher, T. (2011). Are nursing staffsufficiently educated and competent in managing patients with a chestdrain? Thorax,Vol. 81

Naicker,T.R &amp McLeod, D T. (2012). Chest Tube Insertion Training- What IsThe Effective Way? AmericanThoracic Society Journals

Naicker,T.R &amp McLeod, D.T (2010). Chest drain insertion training issimulation training the answer? Thorax,

Maskell,N.A., Medford, A., &amp Gleeson, F. V (2010). Seldinger chest draininsertion: simpler but not necessarily safer. Thorax&nbsp201065:5-6&nbsp

Wallace,S.M., Doy, L.E., Kedgley, EN &amp Ricketts, W.M (2010).Evidence-Based Emergency Oxygen Guidelines Are Not Being Followed InThe Emergency Department. Thorax,Volume 65, Issue Suppl 4

PriceB (2008) Strategies to help nurses cope with change in the healthcaresetting. Nursing Standard. 22, 48, 50-56.

SzablaD (2007) A multidimensional view of resistance to organisationalchange: exploringcognitive, emotional and intentional responsesto planned change across perceived change leadership strategies.Human Resource Development Quarterly. 18, 4, 525-558.

Proper Training of Nurses Caring for Chest Tube Patients

PROPER TRAINING OF NURSES CARING FOR CHEST TUBE PATIENTS 19

ProperTraining of Nurses Caring for Chest Tube Patients

ProperTraining of Nurses Caring for Chest Tube Patients

Theimportance of the healthcare industry cannot be understated as far asthe wellbeing of any country is concerned. At the heart of thehealthcare industry are nurses who are charged with theresponsibility of taking care of families, individuals andcommunities so as to ensure the attainment, recovery and maintenanceof quality of life and optimal health. The profession is involved inthe maximization, promotion and defense of abilities and heath, theprevention of injury and illness, the advocacy in the care ofpopulations, communities, individuals and families, as well as thealleviation of suffering via proper diagnosis and treatment of thehuman response. Nurses, like other healthcare practitioners arerequired to safeguard the safety of the patients all the time. Thisis especially in the case of chest tube patients, where research hasindicated that few nurses and other healthcare practitioners know theappropriate procedure to follow in such cases.

Surveyspertaining to chest drain insertions have demonstrated thatover-penetration of the trocar and even visceral injuries utilizingArgyle-type chest drains take place even among experienced thoracicsurgeons and respiratory physicians. It may also be acknowledged thatthoracic injuries are credited with 25% of the total trauma deaths.In spite of the severity of the injuries, less than ten percent ofthe blunt chest injuries and between 15% and 30% of the penetratingthoracic trauma necessitate thoracotomy. As much as the ultimateobjective of draining the pleural cavity may have remained the same,the actual method pertaining to chest tube thoracostomy hassignificantly changed since its inception. Of particular note is thefact that chest tube insertion, given its clinical utility, iscategorized as a mandatory skill that every physician that providescare for injured patients has to acquire. It is unfortunate that thispotentially life-saving procedure also causes considerable morbidity.Generally, chest tube complications may be classified as infective,positional or insertional. In particular, about 30 percent of thecases have reported pain, improper tube positioning, vascular injury,inadvertent removal of the tube, longer hospital stays, postremovalcomplications and pneumonia. These are considered as pretty muchnormal since major visceral and vascular structures are in closeproximity not only to the chest tubes and the different insertionlocations.

Currentpractice

Conventionally,large-bore Argyle-type drains would be inserted. However, the lastone decade has seen a shift from this to inserting of a small bore10-12 French gauge drains by the use of the Seldinger technique. Thetechnique was thought to result in a reduction in the patientinvasiveness and discomfort, with physicians vouching for it as aresult of the apparent speed and ease of insertion given thesmallness of the drain (Maskellet al, 2010).Some of the complications pertaining to small bore chest tubes couldinclude hospital-acquired pleural infections by the use ofnon-aseptic method, puncture of the intercostals artery, insufficient“stay” suture which results in the falling out of the chest tube,blockage of the tube unlike the case of the larger bore Argyledrains, as well organ perforation as a result of theover-introduction of dilator to the chest cavity.

Thisunderlines the fact that accidents or complications have a highlikelihood for occurring irrespective of the efficiency of the methodthat is used on a patient. Of course, the major question revolvesaround the factors that could be credited with these problems.Scholars have acknowledged that the incidents are largely caused bythe deficiency of experience of the operator, insufficientsupervision levels, inability to follow the instructions of themanufacturer, suboptimal imaging, poor patient positioning andselection of suboptimal insertion site, as well as the deficiency offamiliarity with the published guidelines pertaining to chest draininsertion.

Ofparticular note is the fact that a large proportion of nurses andeven experienced general physicians are not well versed with the mostappropriate way of inserting the chest tubes on patients irrespectiveof the type used, or even about the most appropriate and safe way fortaking care of the resultant wound. Even the physicians offeringsupervision to the nurses could still be vague or not well versedabout the proper way of taking care of chest tube patients, in whichcase they cannot offer appropriate guidance on the same. Thisnecessitates an evaluation of the effects that training would have onthe efficacy of nurses in the field, as well as complication ratesfor patients that have chest tubes inserted on them. It goes withoutsaying that proper education, training and instruction needs to begiven to the nurses so as to decrease the rates of complications, inboth the short-term and the long-term.

KeyStakeholders within the Healthcare Setting who are a Component of thecurrent Nursing Practice

Likein every other institution, there is bound to be varied stakeholdersespecially considering that the healthcare industry involves numerousrelationships between different players. Three categories ofstakeholders, however, may be identified including those that offerinputs to the organization, those that compete with it and those thatincorporate a particular special interest in the manner in which theorganization operates.

Withinthe first category, there is the financial community, third partypayers, suppliers and patients. The relationship between thesestakeholders and the organization is usually symbiotic in naturewhere the organization is dependent on them for its survival (Maskellet al, 2010).Of course, there are variations in the magnitude of dependence of theorganization on the stakeholders subject to the relativeattractiveness and number of the alternative providers of the sameservices. The stakeholders, on the other hand, are dependent on theorganization to take the outputs. The stakeholders would not survivewithout the organization or similar entities, in which case therelationship between the two is one of mutual dependence.

Itmay be acknowledged that there are variations in the level ofinterest or stake that different entities have in a particular changeor project. With regard to the enhancement of the level of trainingfor nurses catering for chest tube patients, varied stakeholders comeinto play within the nursing community (Maskellet al, 2010).Nurses, physicians and thoracic surgeons would be the mainstakeholders.

Rolesof the Key Stakeholders in Supporting the Proposed Change in Practice

Eachof the key stakeholders will be undertaking particular roles each ofwhich would be aimed at allowing for enhanced quality of serviceswithin the healthcare facility. It is worth noting that the mainobjective of the key stakeholders would be to ensure that the highestquality of service and safety is offered in the healthcare entity.

Inthe case of the first category of stakeholders, they may be seen asthe initiators or triggers of the change process. For instance, thepatients are testament to the utility of any mode of treatment thatis offered, in which case they determine the need to retain,maintain, improve or eve change it. In the case of the chest tubes,patients would be the main indicators of how appropriate thetechnique is in the treatment of such cases. The financiers use theirpurse strings to determine the timing, type or even the magnitude ofchange that would be adopted. The amount that they leave at thedisposal of the healthcare facilities would determine the magnitudeof change that would be adopted or even how fast and when the changeswould be implemented.

Asmuch as competitors do not seem to play much of a role in determiningthe taking up of a change in the organization, it is often the casethat they stimulate certain modifications. For instance, competitorsalways challenge organizations to be better so as to remain relevant(Maskellet al, 2010).As noted earlier, competitors could be seeking to attract thepatients of the healthcare facility or its professional staff. Inthis case, they create the standards by which the organization wouldmeasure the quality of its services in both the short-term and thelong-term. Organizations are always seeking to have improvedservices, in which case they share information with similar entitieson the most appropriate ways of solving the current problems.

Thethird category of stakeholders lobby the healthcare facility iscomposed of the special interest groups. In spite of their politicalnature, they would point out the wrong aspects pertaining to theorganization, outlining their significance and ultimately providingpossible solutions to the identified problems. On the same note, theylobby or put pressure on the healthcare entity to improve itsservices especially in instances where the deficiencies causenumerous deaths as is the case for chest complications.

Citation

Evidence Strength (1-7) and Evidence Hierarchy

Wallace, S.M., Doy, L.E., Kedgley, EN &amp Ricketts, W.M (2010). Evidence-Based Emergency Oxygen Guidelines Are Not Being Followed In The Emergency Department. Thorax, Volume 65, Issue Suppl 4

Evidence strength: 1

Systematic review: This article is based on the impact that the publication of the first Emergency Oxygen Guidelines in 2008 has had on patient safety. As much as an audit carried out in 2009 demonstrated improvement in the utilization of target saturations within the inpatient setting, there are concerns that the uptake of the guidelines has been considerably less impressive within the emergency departments. In this case, a study was carried out examining three time periods including immediately before and after the publication of the guidelines and 18 months after the publication. In total, about 253 individual attendances were examined with the results demonstrating that there was frequent inappropriate utilization of the tubes in ED and that there was no improvement even after the publication of the guidelines. It was demonstrated that the most common basis for failure to follow guidelines was excess utilization of oxygen. A large number of patients also experienced their first inappropriate reception of excess oxygen, meaning that the adherence of guidelines is sib-optimal in the ambulance service. The main reason for the low adherence to instructions and guidelines may be the deficiency of awareness beyond the medical specialties. On the same note, the trust had no oxygen champion, in which case the appointment of one would go a long way in enhancing the situation as is the case for an education program.

2. Naicker, T.R &amp McLeod, D.T (2010). Chest drain insertion training is simulation training the answer? Thorax,

&nbspEvidence Strength 1

This study was carried out on CMT trainees who had undertaken the Chest-drain insertion using Porcine-Recine Model. The authors sought to underline the fact that as much as the trainees may have performed well, they required experience in the field so as to be competent in the profession. In essence, two groups composed of 12 and 18 trainees respectively were selected based on the trainer availability rather than their desire to participate. The results of the study demonstrated that averagely, the trainees within the mentored group undertook 10.5 procedures within the previous 6 months while those from the general pool had undertaken only 2.2 procedures. Perhaps one of the most disappointingly universal feedbacks was given by the participants from the general group as they stated that they quickly lost the skill and confidence that they had obtained as trainees. This was blamed on varied issues including the deficiency of opportunity to exercise their skill, the numerous cases of radiologists undertaking the routine tasks, and particularly the deficiency of supervision. In essence, as much as the simulation training could have imparted familiarization and confidence of the trainees with the chest-tube insertion, it was required that the individuals undergo another 5-7 supervised insertions on the patients so that they can do procedures without direct supervision. This underlines the necessity of close mentoring and supervision in mastering the skill.

3. Fremlin, G. Baker, R. Walters, G. Fletcher, T. (2011). Are nursing staff sufficiently educated and competent in managing patients with a chest drain? Thorax, Vol. 81

&nbspEvidence Strength 1

In this study, the authors acknowledged the importance of instructions from doctors and the right training of nursing staff in lowering the prevalence or averting the possibility of chest drains. The study aimed at determining the levels of knowledge that nurses had with regard to the management of chest drain, as well as the support and direction that doctors offer after drain insertion. It was noted that there was high potential for serious accidents. Further, as much as all nurses reported that they had managed the drain, only about 12% of them had formal training on the same even as a meager 34 felt confident to manage the drain. It is noteworthy that the nurses in the respiratory wards seemed to have limited knowledge pertaining to drain management, while a large proportion of them (78%) felt that the ward doctors had offered them inappropriate or poor instruction regarding the chest drain management. In essence, it was concluded that deficiency of evidence-based nursing care and inadequate training may have caused uncertainty and a deficit of knowledge on crucial aspects pertaining to the care of chest drain. In addition, the provision of poor instruction by doctors to nurses after chest tube insertion compromised patient care even more. It was determined that the post-insertion complications could be minimized through carefully designed, as well as implemented care programs.

4. Naicker, T.R &amp McLeod, D T. (2012). Chest Tube Insertion Training- What Is The Effective Way? American Thoracic Society Journals

&nbspIn this study, the authors underline the notion that as much as chest tube insertion is one of the main competencies pertaining to medical trainees at the ST2 level, there exists no formal training for the same. The study examined a simulation training in chest tube insertion through the use of a novel porcine rib model that was deemed valid for training on chest tube insertion. In essence, the study would examine whether the trainees that had undertaken simulation training can transfer the skills so obtained to the bedside or rather the real medical world.

In this study, all the trainees that participated underwent a one-day training on chest-tube insertion through the use of the porcine rib model. These trainees would then enhance their skills under supervision in the course of their academic year. In addition, 16 randomly selected doctors were paired with a mentor so as to determine the impact that individual mentoring had. Given that the training was not a requirement or mandatory, it was possible to create three categories. First, there was the group that received conventional training, while the second group had obtained simulation training and conventional training. The third group had obtained simulation training in addition to mentorship. The results of the study demonstrated high statistical variations between the three categories. As much as the simulation group was performing better compared to the conventional training group, it still lagged behind the group that had both simulation training and mentoring. By transitivity, the third group did much better than the first as well. This was a clear demonstration that the simulation training gave individuals a head start as far as chest tube insertion was concerned. However, the consolidation of the knowledge and transferring of the skills to the bedside necessitated that one undertakes mentoring as well.

5. Epstein, E., Jayathissa,S &amp Dee, S (2012). Chest tube drainage of pleural effusions—an audit of current practice and complications at Hutt Hospital. The New Zealand Medical Journal, Vol. 125, Issue. 1354

Evidence Strength 3

&nbspThe article was based on the need to compare the chest drain insertion practices for fluid with those in other institutions. It was determined that the complication rates were almost uniform. Indeed, it was noted that the small-bore tubes made up around 91 percent of chest tube insertions and formed 92 percent of the complications, with close to 55% of the chest drains that were placed for empyema necessitating cardiothoracic surgical intervention. Nevertheless, it was emphasized that procedural training for junior medical staff and the maximization of the safety of drain insertions using ultrasound guidance, coupled with clear guidelines and clinical governance pertaining to chest tube insertions are crucial in the minimization of harm that could come from this procedure.

E.Specific Best Practice based on the Summary

Itgoes without saying that chest tube training comes as extremelyfundamental to the health of the country and that of the populationat large. This is particularly considering the high prevalence ofchest ailments and injuries. It is required that the healthcaresector continually grows so as to allow for the treatment of patientsin a safer and more effective way in both the long-term and theshort-term. However, the fact that there has been deaths as a resultof complication of the chest tube whether with regard to position orinfections and other injuries by the tube underlines the need for achange. Considering the research presented earlier, simple trainingand education would not be sufficient. Training should becomplemented by simulation and mentorship so as to allow individualsto transfer the skills from the lab to the real world of operatingtable, where their skills are really required.

F.Change Model

Inimplementing this change in the healthcare facility, the mostappropriate model would be Lippitt change model. Lippitt change modelis made up of a total of 7 phases. First, the entity would diagnosethe problem so as to determine its causes and any predisposingfactors for the same. Second, there would be an assessment of thecapacity or motivation for change. The third phase would involve anassessment of the resources and motivation of the change agent.Fourth, the entity would select the objective of the progressivechange. The fifth phase involves the selection of the appropriaterole of the change agent (Price, 2008). Once these have been done,the healthcare facility would concentrate on maintaining change.Lastly, the helping relationship would be terminated as the changewould already have been established. In this case, the Lippitt changemodel incorporates four intrinsically linked or connected elements.These include the assessment stage where the nurse would make adetailed evaluation of the situation in the healthcare institution,including the cases of chest tube complications and the reasons forthe same. Secondly, the nurse would come up with a plan foreliminating or reducing the complication cases in the healthcareinstitution (Szabla, 2007). It is well acknowledged that the maincause of these complications is the deficiency of knowledge,experience and proper supervision on how it should be doneappropriately. In essence, the nurse would collaborate with otherhealthcare practitioners so as to determine how the predisposingfactors would be eliminated. The third phase would involveimplementation, where the nurse would undertake, as well as documentthe care that was previously identified at the planning stage. Thelast stage would involve evaluation or assessment, which isundertaken consistently throughout the period of change and providesan assessment of the effectiveness of the adopted strategies ineliminating or meeting the needs of the patients.

Thereare varied benefits to the utilization of this model in implementingthe required change in the organization. As much as the detailednature of the model necessitates a higher level of comprehension, itwould be more useful to the nurse managers as it comes with a moredetailed plan regarding how change would be generated (Price, 2008).On the same note, it is founded on the four elements pertaining tothe nursing process including assessment, planning, andimplementation, as well as evaluation.

Ofcourse, the application of this model in the implementation of thepractice change would be guided by the phases that are incorporatedin the same. Already, the high number of deaths from thoracicinjuries has been credited primarily to the deficiency of knowledgeand proper training among healthcare workers including physicians whoare pretty much experienced (Szabla, 2007). This is especially withregard to the application of the relatively smaller and sharper bore10-12 French gauge drains using the Seldinger technique. Once theproblem has been diagnosed, the motivation and resources availablefor change would be determined. In this case, the main question wouldbe why there is need for proper training or education for nursescaring for chest tube patients (Price, 2008). Does the healthcarefacility have sufficient capacity for offering this training in termsof financial and human resources or even expertise? Eventually, themain objectives for the change would be identified, which, in thiscase, are the need for more safety for chest tube patients even asthe smaller gauge drain is used.

G.Barriers to Implementation of the Change

Likeany other project, the implementation of change in the organizationis plagued by varied challenges or problems. First, there may be adeficiency of willingness by the management to change the old way ofdoing things. It is often assumed that physicians or healthcarepractitioners who undertake the practice are well versed with all itsrequirements or would be learning while in the practice already(Szabla, 2007). Unfortunately, this tends to compromise the safety ofthe patients as it was acknowledged that a large proportion of chesttube complications and mortalities result from improper applicationof the tube by healthcare practitioners who have little or noknowledge pertaining to how it should be done.

Onthe same note, there is likely to be deficiency of financial support.Usually, healthcare facilities do not have disposable amounts thatlie idle in prospective for likely projects, rather it is often thecase that healthcare facilities operate on shoestring budget. Thiscould force them to charge high amounts of fees so as to meet theirtargets (Price, 2008). Unfortunately, this means that there may notbe sufficient financial and human resources to meet the need forchange in the entity. This, however, can be rectified through thecreation of a case that is based on sound data and research. Thiswould mean that the individuals are more likely to be convinced bythe data and, therefore, invest the time and money to the project(Price, 2008). On the same note, it would be imperative that thefacility or change drivers implement solid communication plans thatextend to every level of the organization and gains momentum viaobtaining early visible wins. This would have the effect of garneringsupport from other individuals within the organization once they areclear about the benefits of the project.

Further,the implementation of change in the organization could be affected bythe shortage or deficiency of resources that could lead the changeinitiatives. More often than not, healthcare professionals get toocomfortable with the current ways of doing things to such an extentthat they detest the idea of changing to another way no matter howeasy or efficient it could be (Price, 2008). This means that therewould be a deficiency of internal resources that could lead thechange initiatives. Of course, this could be solved through enlistingexternal assistance so as to drive the initial protects or evenobtain mentoring and training in conjunction with projects thatgenerate immediate results.

H.Ethical issues that may affect the implementation of the change

Quitea number of ethical issues come up with regard to the implementationof any change in the healthcare sector. This is particularlyconsidering the sensitivity of the services that are offered withinthe sector, as well as the need to cater for the needs of allstakeholders particularly the patients (Price, 2008).

Oneof the major ethical issues in the implementation of change revolvesaround informed consent. This is based on the acknowledgement of thefact that the patient is independent and, therefore, should beallowed to make decisions pertaining to the procedures to which hisbody is subjected. There may be instances where the patients areaccustomed to the earlier procedures and refuse to get the newsmaller gauge chest tubes (Price, 2008). This means that as much asthe nurses and other healthcare practitioners are offered training onthe most appropriate way of offering the service, there would belittle likelihood that it would be applicable to such patients as theindependence principle necessitates that the will of the patient isrespected (Price, 2008).

Inaddition, it is acknowledged that the small gauge chest tubes comewith sharper ends that could puncture the organs of the patientsirrespective of the experience of the healthcare practitioner that isoffering the service. On the other hand, the nurses have aprofessional duty to ensure that the safety of the patient issafeguarded at all times.

Further,the provision of this training is based on the perception that thecurrent population of nurses is not well versed with the variedissues pertaining to chest tubes. Once they obtain the education andtraining, they will still practice the lessons on patients, whichmeans that the patients will be the unwilling participants in anongoing process of improvement that could essentially havedevastating effects on their health in the long-term and theshort-term. On the same note, the changes would not take place in asudden manner rather gradual adoption of the lessons learnt will beundertaken (Price, 2008). This means that there could be continuedtreatment of patients with chest problems by individuals who do nothave proper qualifications to undertake such services or offerappropriate lessons for the same.

References

Epstein,E., Jayathissa,S &amp Dee, S (2012). Chesttube drainage of pleural effusions—an audit of current practice andcomplications at Hutt Hospital. TheNew Zealand Medical Journal, Vol.125, Issue. 1354

Fremlin,G. Baker, R. Walters, G. Fletcher, T. (2011). Are nursing staffsufficiently educated and competent in managing patients with a chestdrain? Thorax,Vol. 81

Naicker,T.R &amp McLeod, D T. (2012). Chest Tube Insertion Training- What IsThe Effective Way? AmericanThoracic Society Journals

Naicker,T.R &amp McLeod, D.T (2010). Chest drain insertion training issimulation training the answer? Thorax,

Maskell,N.A., Medford, A., &amp Gleeson, F. V (2010). Seldinger chest draininsertion: simpler but not necessarily safer. Thorax&nbsp201065:5-6&nbsp

Wallace,S.M., Doy, L.E., Kedgley, EN &amp Ricketts, W.M (2010).Evidence-Based Emergency Oxygen Guidelines Are Not Being Followed InThe Emergency Department. Thorax,Volume 65, Issue Suppl 4

PriceB (2008) Strategies to help nurses cope with change in the healthcaresetting. Nursing Standard. 22, 48, 50-56.

SzablaD (2007) A multidimensional view of resistance to organisationalchange: exploringcognitive, emotional and intentional responsesto planned change across perceived change leadership strategies.Human Resource Development Quarterly. 18, 4, 525-558.