Art & science

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The synthesis of art and science is lived by the nurse in the nursing act

Josephine G Paterson

Infection prevention and control Pegram A, Bloomfield J (2015) Infection prevention and control. Nursing Standard. 29, 29, 37-42. Date of submission: October 9 2012; date of acceptance: November 9 2012.

Abstract All newly registered graduate nurses are required to have the appropriate knowledge and understanding to perform the skills required for patient care, specifically the competencies identified in the Nursing and Midwifery Council’s essential skills clusters. This article focuses on the third essential skills cluster – infection prevention and control. It provides an overview and discussion of the key skills and behaviours that must be demonstrated to meet the standards set by the Nursing and Midwifery Council. In doing so, it considers the key principles of infection prevention and control, including local and national policies, standard infection control precautions, risk assessment, standard isolation measures and asepsis.

Authors Anne Pegram Lecturer, Florence Nightingale Faculty of Nursing and Midwifery, King’s College, London, England. Jacqueline Bloomfield Senior lecturer/director of pre-registration programmes, Sydney Nursing School, The University of Sydney, New South Wales, Australia. Correspondence to: [email protected]

ALL NEWLY REGISTERED graduate nurses are required to have the appropriate knowledge and understanding to perform the skills required for patient care, specifically the competencies identified in the essential skills clusters (Nursing and Midwifery Council (NMC) 2010). Introduced by the NMC in 2007 and updated in 2010, the five essential skills clusters are included in all pre-registration nursing programmes in the UK (NMC 2010). The essential skills clusters aim to ensure the development of skills and competencies required for safe and effective nursing practice, by identifying the key skills and proficiencies that nursing students must demonstrate to progress through their education and gain entry to the NMC register (Long 2009, NMC 2010). This article focuses on the third essential skills cluster: infection prevention and control. It provides an overview and discussion of the key skills and behaviours that must be demonstrated by nursing students in this essential skills cluster to meet the standards set by the NMC.

Keywords Essential skills clusters, infection control, infection prevention, patient care

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Importance of infection control All healthcare professionals, including nurses and nursing students, have a responsibility to protect the safety and wellbeing of patients, who may be receiving health care in the hospital setting, in the community environment or at home. Patients are susceptible to infection within the healthcare environment. This may be affected by factors such as reduced immunity related to ill health or disease, surgery or injury. Older or very young patients, and those with wounds, or indwelling devices such as urinary catheters or intravenous cannulas, are particularly at risk of developing an infection. The transfer of microorganisms in the healthcare environment is made easier by close proximity to sources of infection and contact between caregiver and

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Art & science essential skills clusters: 3 recipient of care (Royal College of Nursing (RCN) 2012). Therefore, infection prevention is a key role for healthcare professionals, which must be underpinned by a thorough understanding of the practitioner’s role in preventing infection and compliance with strategies to promote infection control. These requirements form the basis of the infection prevention and control essential skills cluster (NMC 2010).

Local and national policies and guidelines Local and national policies relating to the prevention and control of infection in acute and community settings (Department of Health (DH) 2001, 2003, 2005, 2006, National Institute for Health and Care Excellence (NICE) 2012, RCN 2012) provide nurses with a framework within which to work (Baillie 2009). Therefore, it is important that all nurses and nursing students have an understanding of these policies and how they apply to practice. At a local level, these policies are used to inform direct patient care and to provide guidance on decontamination of equipment, disposal of waste, acquisition of urine or blood specimens, care of indwelling devices, isolation of infected patients and maintenance of a clean and safe clinical environment (RCN 2012). Local policies also set out guidelines for dress codes and standards of personal hygiene that must be adhered to by healthcare staff. At a national level, policies and guidelines relevant to infection control also make recommendations regarding the standard principles for controlling and preventing healthcare-associated infections (DH 2001, 2003, 2005, 2006, NICE 2012, RCN 2012). Policies related to infection control are evidence based and aim to inform best practice, thereby optimising patient care and safety. The infection control team is instrumental to implementing local and national policies. It typically comprises specialist infection control nurses, consultant doctors and medical microbiologists. It acts as a source of advice and is responsible for implementing local guidelines to reduce or prevent the spread of infection. The team is also responsible for developing local infection control policies in accordance with national policy, managing outbreaks, performing infection control audits and educating staff and patients in infection control. Effective multidisciplinary team working is important for infection control and prevention. Nurses’ prompt recognition and reporting of common clinical signs of infection, such as

pyrexia, redness, localised inflammation and tenderness, will help to ensure the timely implementation of appropriate treatments, such as antibiotic therapy. Nurses should also be vigilant for other less common signs and symptoms that may be indicative of infection in patients they are caring for. These may include proteinuria, purulent sputum, subtle changes in vital signs, or confusion in older patients (Swanson and Jeanes 2011). Such clinical signs and symptoms should be reported to the medical team and documented, leading to prompt and appropriate investigation and assessment, such as blood tests, urinalysis or chest X-rays. A plan of nursing care that incorporates interventions to prevent the spread of infection should be developed, where appropriate. It is crucial to communicate this care plan to the patient and to other members of the multidisciplinary team, to ensure that all team members understand the rationale for any interventions and that they work together in the best interests of the patient.

Risk assessment Managing risk is an important aspect of a nurse’s role and is an important theme in the essential skills cluster on the prevention and control of infection. Undertaking a risk assessment is an important step in protecting the wellbeing of healthcare staff and patients. This involves considering factors that could cause harm, as well as identifying appropriate precautions that should be taken to prevent harm. It is also necessary to comply with legal and safety standards. Nurses should undertake risk assessment before carrying out any aspect of direct patient care. Healthcare-associated infections in patients can be minimised by reducing the risks associated with handling waste, disposing of sharps, handling contaminated linen, and cleaning up spillages of blood and body fluids (NMC 2010). This requires compliance with standard precautions, which are central to effective infection control and prevention.

Standard precautions: essential elements of infection control Standard precautions, sometimes called universal precautions, are fundamental infection control measures that aim to reduce the risk of transmission of blood-borne pathogens and other pathogens, through exposure to blood or body fluids among patients and healthcare workers (World Health Organization (WHO) 2006).

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Standard precautions incorporate nine elements of practice aimed at preventing or minimising the risk of cross-infection (Infection Control Nurses Association 2003). These are (Prieto and Kilpatrick 2011): 4Hand hygiene. 4Personal protective equipment. 4Prevention of occupational exposure to infection. 4Management of blood and body fluid spillages. 4Management of equipment used during care. 4Environmental control. 4Safe disposal of waste, including sharps. 4Linen. 4Appropriate patient placement. It is essential that nurses and healthcare workers are vigilant in adhering to standard precaution guidelines because of the risk of exposure to blood, body fluids and pathogens. The essential skills cluster specifies that the standard precaution guidelines are relevant to all fields of nursing (NMC 2010). Thus, nurses and nursing students must understand and practise in accordance with standard precautions.

Hand hygiene The hands of healthcare staff are thought to be the most common route by which microorganisms are spread to patients in hospitals (Wilson 2006). This is because many microorganisms are found on the hands, some of which have the ability to spread, multiply and cause infection. Various factors influence the situations in which hands should be decontaminated and the frequency at which hand decontamination should be undertaken, including (DH 2001): 4Level of anticipated contact with patients, equipment or objects. 4Type of patient care activities being performed. 4Extent of contamination that may occur. 4Condition of the patient and his or her susceptibility to infection. It is important that hand hygiene should be performed before any procedure that places the patient at risk of infection; if an activity carried out has, or could have, contaminated the hands; or if the hands are visibly contaminated. The ‘five moments for hand hygiene’ model (WHO 2009) defines five moments when healthcare workers should perform hand hygiene. This evidence-based, user-centred approach was developed to be easy to learn, logical and applicable to multiple healthcare settings. It recommends that healthcare workers clean their hands (WHO 2009):

4Before touching a patient. 4Before clean or aseptic procedures. 4After body fluid exposure risk. 4After touching a patient. 4After touching patient surroundings. Alcohol handrubs have become more widely used in the healthcare environment because of their convenience and speed of use, and have been promoted for routine hand hygiene (Gould and Drey 2008). However, it is important to remember that handwashing with soap and water is required when hands are visibly soiled, or when caring for patients with, or suspected to have, spore-forming infections such as Clostridium difficile (Gould 2012).

Personal protective equipment and prevention of exposure to infection Personal protective equipment refers to items that are used to protect healthcare workers and patients from exposure to blood, body fluids and pathogens. Gloves and aprons are the most common types of personal protective equipment, although gowns, eye shields, visors, face masks, caps and protective footwear may also be worn in some clinical areas. Risk assessments should be undertaken to determine when personal protective equipment is required. The most appropriate equipment should be determined for the activity that is to be undertaken, according to the anticipated level of exposure to blood, body fluids or pathogens. It is important that the healthcare worker covers any cuts or breaks in his or her skin to avoid entry of pathogens and potential exposure to infection. He or she should avoid actions that present a high risk of infection, such as re-sheathing needles, over-filling sharps containers and not wearing personal protective equipment.

Management of blood and body fluid spillages In the healthcare environment, it may be necessary to deal with spills of blood or urine. These may contain pathogens, which may be harmful to patients, visitors and healthcare staff. It is essential that such spills be cleaned up as safely and efficiently as possible. This can be achieved by cleaning the area with disinfectant. The equipment required for dealing with spills is often provided in a spill kit. Nurses and nursing students should be familiar with the contents of the spill kit and its location. Protective clothing must be put on before cleaning up spillages. The recommended procedures should be followed,

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Art & science essential skills clusters: 3 in accordance with local policy guidelines and the manufacturer’s specific product information. If a spill were to occur in the home setting on a carpet or soft furnishings, the area should be washed with detergent and water using disposable cloths (Lawrence and May 2003).

Safe disposal of waste including sharps Hospitals and other healthcare environments, including the home or community setting, generate vast amounts of waste every day that must be disposed of appropriately to prevent contamination and infection. Safe disposal is important both for health and safety reasons and to ensure compliance with environmental protection regulations. Clinical waste includes waste that has been in contact with blood or other body fluids (Nicol et al 2012). Clinical waste should be placed in appropriately coloured plastic bags or sharps containers (DH 2006). Typically, these are yellow in colour. Clinical waste must be incinerated to prevent harm. It includes: 4Blood or human tissue. 4Used incontinence pads. 4Soiled dressings. 4Swabs. 4Used syringes, needles or disposable surgical instruments. 4Urinary catheters. 4Sputum pots. 4Used aprons and gloves, and other items of disposable personal protective equipment that have been contaminated with body fluids. Used sharps such as needles, scalpels, suture cutters, intravenous cannulae and broken glass pose a considerable infection risk. Therefore, it is essential that the correct procedures are followed regarding their safe handling and disposal. Sharps must be disposed of in sharps containers. Local policy guidelines and relevant Control of Substances Hazardous to Health guidelines should be followed at all times (Health and Safety Executive 2015). Safe practice should be followed to prevent sharps-related injuries (Wilson 2006): 4Sharps should not be carried by hand. 4Sharps containers that comply with national standards should be readily accessible in places where sharps are used. 4Used sharps should be handled as little as possible and disposed of immediately after use into an appropriate sharps container. 4Sharps containers should not be overfilled. When the containers are three quarters full, the lids should be closed and secured.

4Needles should never be recapped or re-sheathed following use. 4Disposable syringes and needles should be discarded as a single unit.

Safe handling of linen Linen, such as bed sheets, blankets and towels, contaminated with blood or other body fluids is potentially hazardous to those who handle it, and it should be considered an infection risk. Safe practice to minimise the risk of infection from contaminated linen involves: 4Wearing gloves and an apron when in contact with contaminated linen and ensuring that hands are thoroughly washed after contact. 4Taking care when changing bed linen or soiled patient clothing, to avoid contaminating the environment. 4Ensuring that a linen bag is near to hand when changing linen. Contaminated linen should be placed in an appropriately coloured, soluble laundry bag to minimise direct handling by laundry workers. Typically, linen bags for contaminated linen will be red. This bag does not need to be unpacked when it reaches the laundry but will dissolve during the washing process. Care should be taken at all times to avoid over-filling linen bags. They must be secured and removed from the patient care setting as soon as possible. Shaking linen should be avoided to minimise the dispersal of microorganisms into the environment (Bloomfield et al 2008). Used linen should be placed immediately in the linen skip and care should be taken not to permit any contact with clothing, which may increase the risk of cross-infection (Pellatt 2007). In the home, soiled linen can be washed in a standard washing machine; however, if one is not available and hand washing of linen is required, carers should be advised to wear domestic-strength disposable gloves (Worsley et al 1994).

Management of patient care equipment The NMC (2010) emphasises the importance of reducing the potential risk of infection from the use of equipment in delivering patient care. Equipment for patient care may be single use, single patient use or reusable (RCN 2012). Single-use equipment includes needles, syringes and disposable washbowls, which should be used once only and discarded. Single patient use equipment can be used on more than one occasion for one particular patient and will be discarded when no longer required. An example

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of single patient use equipment is an oxygen mask. It is important to recognise that such equipment will require cleaning between uses. Examples of reusable equipment include commodes, bedpans, hospital beds and dressing trolleys. Thorough decontamination of this equipment is required between patients, and it is important to follow local guidelines regarding decontamination procedures.

Environmental control and appropriate patient placement All healthcare professionals have a duty to ensure that the necessary actions are taken to reduce the risk of patients developing healthcare-associated infections. The cleanliness of the healthcare environment should be maintained at the highest possible level and the necessary procedures should be undertaken to ensure that all furniture is decontaminated thoroughly to prevent cross-infection (Prieto and Kilpatrick 2011). It is important for this to include beds and mattresses as well as bathroom fixtures and fittings. Infection control audits should be conducted regularly, in accordance with local guidelines, to ensure that any deficiencies in cleaning or hygiene standards are promptly identified and rectified. Before transferring patients to a new environment, a risk assessment should be performed that is deemed most appropriate for their care needs to determine their risk of becoming infected or infecting others. Standard precautions are simple infection control measures that reduce the risk of transmission of pathogens through exposure to blood or body fluids among patients and healthcare workers (WHO 2006). Isolation procedures involve creating an effective barrier between an infected and a non-infected area to prevent cross-infection (Gould 2009). The need for isolation depends on various factors. These include the ease with which the infection is transmitted, the route of transmission – for example airborne or contact with the skin – whether infections are resistant to antibiotics, and the presence of vulnerable individuals, such as those who are immune suppressed. Within the acute hospital setting, isolation procedures comprise: 4Source isolation – isolating an infected patient. 4Cohort source isolation – segregating several patients with the same infection in one area. 4Strict source isolation – segregating patients with serious contagious infections in isolation units.

4Protective isolation – isolating patients who are particularly susceptible to infection. In the community setting, these principles must be adapted to the context of care. It is important to follow local policy when caring for a patient who requires isolation procedures, to seek advice and guidance where appropriate from the infection control team, to reduce the number of healthcare professionals who come in contact with the patient, to use standard precautions, and to explain these precautions to the patient and his or her relatives.

Asepsis The term asepsis means the absence of pathogenic or disease-causing organisms (Perry and Potter 2006). Aseptic technique is used to prevent the spread of pathogenic microorganisms that may be present on the hands or on equipment into an open wound or body cavity or to another susceptible site, such as a urinary catheter or intravenous cannula (Foster and Hilton 2004). Aseptic technique involves a procedure that is non-touch in nature. The basic principle underpinning any aseptic non-touch technique is that a susceptible site, such as a wound or cannula site, should not come into contact with any item that is not sterile. Adaptation of aseptic non-touch technique may be required in community settings, but it is important that the principles of aseptic non-touch technique are maintained (Swanson and Jeanes 2011). Aseptic non-touch technique may be achieved by ensuring that the area where a procedure is to be performed is clean, by performing effective hand hygiene procedures before and, where appropriate, during the technique, by using sterile equipment and minimising potential contamination by not touching sterile equipment (RCN 2012).

Conclusion Prevention of infection is a key role for all healthcare professionals, including nurses. Infection prevention must be underpinned by an understanding of how infection can be spread and by complying with strategies that promote infection control. These requirements form the basis of the NMC essential skills cluster on infection prevention and control. Nursing students must acquire the relevant knowledge and skills required for risk assessment and develop their practice to prevent or minimise the risk of cross-infection and maintain patient safety NS

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Art & science essential skills clusters: 3 References Baillie L (2009) Preventing cross-infection. In Baillie L (Ed) Developing Practical Adult Nursing Skills. Third edition. CRC Press, Boca Raton FL, 65-115. Bloomfield J, Pegram A, Jones A (2008) Recommended procedure for bedmaking in hospital. Nursing Standard. 22, 23, 41-44. Department of Health (2001) Standard principles for preventing hospital-acquired infections. The Journal of Hospital Infection. 47, Suppl, S21-S37. Department of Health (2003) Winning Ways. Working Together to Reduce Healthcare Associated Infection in England. The Stationery Office, London. Department of Health (2005) Saving Lives: A Delivery Programme to Reduce Healthcare Associated Infection Including MRSA. The Stationery Office, London. Department of Health (2006) The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections. The Stationery Office, London.

Foster J, Hilton PA (2004) Maintaining a safe environment. In Hilton PA (Ed) Fundamental Nursing Skills. Whurr, London, 75-127. Gould D (2009) Isolation precautions to prevent the spread of contagious diseases. Nursing Standard. 23, 22, 47-55. Gould D (2012) Skin flora: implications for nursing. Nursing Standard. 26, 33, 48-56. Gould D, Drey N (2008) Hand hygiene technique. Nursing Standard. 22, 34, 42-46. Health and Safety Executive (2015) Control of Substances Hazardous to Health (COSHH). www.hse. (Last accessed: February 18 2015.) Infection Control Nurses Association (2003) Infection Control Guidelines for General Practice. Fitwise, Bathgate. Lawrence J, May D (2003) Infection Control in the Community. Churchill Livingstone, Edinburgh. Long G (2009) A yardstick for good practice. Nursing Standard. 23, 50, 62-63.

National Institute for Health and Care Excellence (2012) Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care. Clinical guideline No. 139. NICE, London. Nicol M, Bavin C, Cronin P, Rawlings-Anderson K, Cole E, Hunter J (2012) Essential Nursing Skills. Fourth edition. Mosby, Oxford. Nursing and Midwifery Council (2010) Essential Skills Clusters (2010) and Guidance for Their Use. 5t45ftr (Last accessed: February 23 2015.) Pellatt GC (2007) Clinical skills: bed making and patient positioning. British Journal of Nursing. 16, 5, 302-305. Perry AG, Potter PA (2006) Clinical Nursing Skills and Techniques. Sixth edition. Mosby, St Louis MO. Prieto J, Kilpatrick C (2011) Infection prevention and control. In Brooker C, Nicol M (Eds) Alexander’s Nursing Practice. Fourth edition. Churchill Livingstone, Edinburgh, 499-517.

Royal College of Nursing (2012) Essential Practice for Infection Control and Prevention: Guidance for Nursing Staff. RCN, London. Swanson J, Jeanes A (2011) Infection control in the community: a pragmatic approach. British Journal of Community Nursing. 16, 6, 282-288. Wilson J (2006) Infection Control in Clinical Practice. Baillière Tindall, Edinburgh. World Health Organization (2006) Infection Control Standard Precautions in Health Care. publications/4EPR_AM2.pdf (Last accessed: February 18 2015.) World Health Organization (2009) WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge: Clean Care is Safer Care. tinyurl. com/ybwu8b5 (Last accessed: February 23 2015.) Worsley AM, Ward KA, Privett S, Parker L, Roberts JM (Eds) (1994) Infection Control: A Community Perspective. Infection Control Nurses Association, Cambridge.

Call for papers Nursing Standard is welcoming submissions from experienced or new authors on a variety of subjects, including: • • • • • • • •

hypertension managing infected wounds tissue viability care of patients with tuberculosis severe psoriasis anticoagulant therapy hand hygiene post-operative nutrition and hydration

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Infection prevention and control.

All newly registered graduate nurses are required to have the appropriate knowledge and understanding to perform the skills required for patient care,...
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