Introduction This essay critically examines the role of risk assessment and quality

Introduction

This essay critically examines the role of risk assessment and quality improvement strategies in the delivery of high-quality and safe nursing care. The essay will critically examine the role of risk assessment, discussing the “Malnutrition Universal Screening Tool” (MUST). The Root Cause Analysis (RCA) as a quality improvement strategy will be employed to explain how quality and safe care can be delivered in nursing practice. This essay will provide a critical reflection discussing the factors which will influence my ability as a newly qualified nurse, to provide high-quality person-centred nursing care. The discussion will critically appraise available evidence including two articles which illustrate the impact of the factors on individuals with complex care needs. The Driscoll (2007) reflective cycle will be used for the analysis of reflection.

There are various tools used for risk assessment of patients in hospitals and those in nursing care homes. MUST represents a (Malnutrition Universal Screening Tool) it is an important tool used in assessing patients with malnutrition and those at risk of malnutrition (Elia, 2003; Beggs et al, 2021). Accordingly, the British Association for Parenteral and Enteral Nutrition (BAPEN), emphasizes that MUST is a validated five-steps assessment tools for screening of adults to detect if they have malnutrition or are at risk of malnutrition, undernutrition or obese in the community, hospital and in nursing care homes (Murphy et al 2018)

Cawood et al (2022) used the MUST tool to assess malnutrition status of 1183 patients in community and hospital settings in the UK. They found 40 percent of adults were at risk of malnutrition, of whom 28 and 12 percent were at high and medium risk of malnutrition respectively. Cawood et al (2022) have argued that the current prevalence of malnutrition in hospital and community settings is high in UK, costing the UK economy is £24 billion per annum. Hence, malnutrition is a serious health problem in the UK which needs to be addressed.

Managing the problem of malnutrition on patients admitted to hospitals and those in care homes requires assessing the patients using MUST screening tool (NICE, 2012). Screening using the MUST tool is effective for establishing the baseline nutrition status so that appropriate care plans and interventions are undertaken to ensure patients receive safe and quality care support while in hospitals and care homes (NICE, 2012). NICE (2012) provides quality standard guidelines for care and support of adults aged 18 years and above who have malnutrition or are at risk of malnutrition. The NICE standard guideline includes appropriate support, dietary changes, and for patients unable to feed themselves, should be supported through tubes (enteral) and veins (parenteral nutrition). Thus, adhering to NICE (2012) guidelines is essential for quality service delivery, and for preserving or maintain patient safety from the risk of malnutrition.

However, Frank et al (2015) provides a discussion on the effectiveness of the MUST tool for assessment of malnutrition in adults patients, argued that it is important for nurses and health care practitioners to provide accurate reading and recording of MUST scores to prevent missed detection which could undermine quality of patient care and risks quality improvement. (Hollenberg et al, 2019) supports Frank et al (2015) that correct use of the MUST screening scores is beneficial for detecting the risk of malnutrition in patients and where follow-up is undertaken to supporting patients with malnutrition to improve their nutritional status.

Nonetheless, it is also important to appreciate that although the MUST tool is universal as the name suggests and is widely used in screening of malnutrition; MUST has its limitations as it may not be suitable in some patients particularly those with pre-existing conditions, such as patients who are overweight, obese or with chronic illnesses (Branford et al,2019).

Sandhu et al (2016) conducted a study on self-administered screening of malnutrition among 154 outpatient adults with inflammatory bowel disease (IBD) using the MUST score tool. The results of outpatients who self-administered were compared with the scores taken by health care professionals. All patients completed used the MUST score tool and reported that it was easy to understand and use. Sandhu et al., (2016) concluded that the MUST is a reliable and valid tool for self-screening of malnutrition among outpatients in primary care, suggesting that MUST is an effective tool for use in community settings (Sandhu et al., 2016). They further argue that MUST could be used for self-completion among patients so that support is directed more efficiently to those unable to complete themselves; argued that this will improve efficiency, quality of care and patient safety and outcomes.

Studies have highlighted the importance of training on the use of MUST among health care professional as a key issue, as it has been observed that where health care staff are trained in the use of MUST, the effectiveness of MUST is higher compared to those who have not been trained (Cooper et al., 2013; Tewari et al, 2013). The effectiveness of the MUST depends on whether staff are trained on the proper use of MUST. With proper knowledge and skills on MUST, nurses and health care professionals could incorporate the use of MUST scores in their daily assessment of patients (Sandhu et al., 2016). Training on the use of MUST not only enhances the effectiveness of the MUST in screening of malnutrition in patients, but also it improves the efficiency and awareness of the health care professionals to screen patients which ultimately enhances quality of care and patient outcomes (Cooper et al., 2013)

Additionally, Tewari et al (2013) study has demonstrated that training of health care staff improves the use of MUST. This study discussed one occasion where 53 patients were supposed to be screened for malnutrition using the MUST. However, of the 53 patients only 28 had their MUST scores recorded, which was 53% compliance. A training of health care staff was conducted, and following the educational training on using the MUST, a second repeated screening of 42 patients using the MUST tool was undertaken after two months. The trained health care staff recorded the MUST scores of 37 patients, demonstrating compliance of 88% use of the MUST. These two studies reveal that training of health care staff improves the use of MUST screening tool. Tewari et al (2013) highlight that nurses appreciated the contribution of training on the improvement of the use MUST which enhances patients’ outcomes and quality and safety in line with quality improvement as recommended by NICE (2022) guidelines

Research emphasizes the importance of undertaking risk assessments in patients to identify patients at risk of malnutrition as this allows early intervention and preventative measures to be undertaken. Risk assessment of patients using the MUST is important because it can predict recovery, length of hospital stay and mortality (Beggs et al, 2021). Thus, the use of MUST is an important strategy for quality improvement, as the use of MUST score tool does not only demonstrate the effectiveness of the MUST tool but could be helpful in identifying areas of improvement, which might include the need to train health care practitioners on the effective use of the MUST tool for assessment of patients with malnutrition and those at risk of malnutrition (Branford et al, 2019).

Improving compliance to screening using MUST is a NICE (2012) compliance requirement which requires that patients receive care which considers their nutritional status, support and that they have a balanced nutritional diet while in hospital care.

According to the NMC (2015) it is the fundamental right of patients that they are entitled to receive care which maintains good, nutrition, hydration, bladder and bowel care, as this has shown to improve the quality of care and enhances recovery and prevents the risk of malnutrition in patients and thus promotes patient safety and quality of care.

Quality Improvement Strategy

Quality improvement is an important aspect of the NHS improvement framework and NICE quality standards guidelines (NHS, 2011; NICE, 2022). Thus, quality improvement should not be by chance but designed to improve the quality standard of care that will prevent risk and maintain safety of patients (Patole, 2015). Patole (2015) explains the root cause analysis (RCA) a tool for quality improvement which helps to identify active human errors and latent systemic errors which can occur in care settings. The RCA was not introduced into health and social care until the 1990s by Ishida Baigan and Richard Croteau. Since then, the RCA has become a very useful tool for quality improvements in hospital and care settings (NHS 2011; Patole (2015))

Hospitals use the RCA principles which underline the importance of retrospective thinking for identifying the root cause of problems and not ascribing blame to individuals. In essence the RCA is a tool for change that enhances quality improvement and thus preserves patient safety (NICE, 2022). The RCA, requires that the NHS identify the problem such as malnutrition in adult patients, collect comprehensive data, analyze it to identify the possible cases, and use the findings to recommend change in practice by translating the knowledge for practical use through clinical guidelines or recommendations (Patole, 2015).

Singh et al (2021) assert that the RCA is an effective tool for supporting an improvement strategy for safe delivery of nursing care in hospital settings. As Karkhanis and Thompson (2022) suggests, hospitals use the RCA as part of their initiatives to improve quality of care and patients’ safety. Identifying and managing risks is an essential role of nursing practice, such that it is important for health care staff to appreciate that actions or inactions on nursing care is about taking some risks (Forest 2012). The Kings Fund (2017) discusses the concept of quality improvement, that it is a cyclical process, which involves “testing, measurement, learning and change” (The Kings Fund, 2017).

The hospital uses the RCA in the management of risks for purposes of addressing adverse events which compromise patient safety and quality of life (Cerniglia-Lowensen, 2015). The RCA begins by identifying the problem, and establishing the root cause, and putting in place corrective measures so that the same or similar errors do not happen or are minimised in future (Cerniglia-Lowensen, 2015). There are some challenges pertaining to the implementation of the RCA, which include difficulties in gathering the evidence, organising the investigation team, and how the results of the RCA improvement are translated into practice in the NHS context (Okes, 2019)

To enable the writer to reflect, the Driscoll model provides a framework which the nurse must address. These three questions are, ‘What?’, ‘So what?’ and ‘now what?’ (Driscoll 2007). The following discussion considers factors which have been identified that might influence the newly qualified nurse (NQN) in the delivery of safe and high-quality nursing care to patients. The factors include, fatigue and workload management, team working.

What?

Mayo (2020) discusses the effectiveness of teamworking, highlighting that multidisciplinary teams (MDTs) bring expertise knowledge and skills to nursing care that could influence the newly qualified nurses (NQNs) to learn and gain skills and knowledge necessary for improving service delivery. Teamworking is fundamental for effective and efficient delivery of quality and safe nursing care (Anderson et al., 2019).

Fatigue is another experience, a factor that can affect safe and quality care delivery (Carayon and Gurses, 2018). Nurses and health care professions can experience fatigue because of competing work demands in clinical settings, pressure of work, workloads, working long hours with little rest or breaks (Dall’Ora et al., 2015). These factors are likely to compromise the quality of care and patient safety (Weinstein,2020). In nursing practice, Dall’Ora et al (2015) established that fatigue from working long hours (more than 8 hours) shift, increases nurses’ burnout. Dall’Ora et al (2015) explains that burnout is linked to emotional exhaustion of nurses due to extended working hours of more than 12 hours per shift, an aspect which undermines patients’ safety and delivery of quality patient care. Dall’Ora et al (2015) emphasise that “high burnout, may pose safety risks for patients as well as nurses” (Dall’Ora et al., 2015, p.1).

So What?

The Driscoll reflective cycle is a framework for the newly qualified nurse to use for reflective analysis of the experiences. The so What? Question requires that the NQNs make sense of the experiences (teamworking, and fatigue) discussed in the What? Question (Schon̈, 2016). Teamworking and fatigue are crucial experiences for the NQN to reflect as discussed on the ‘what’ section they influence and impact on the delivery of quality and safe patient care (Dall’Ora et al; 2015; Johnson et al., 2015; Van den Oetelaar et al, 2016; Magalhães et al., 2019)

However, Mayo (2020) asserts that communication is an essential strategy for effective coordination and collaboration of teamworking that improves performance and patient care. Furthermore, Mayo (2020) discusses the effectiveness of teamworking, highlighting that multidisciplinary teams (MDTs) bring expertise knowledge and skills to nursing care that could influence the newly qualified nurses (NQNs) to learn and gain skills and knowledge that is most likely to influence them improve service delivery.

The study by Fitzpatrick et al. (2022) emphasizes the critical link between communication failures and medical errors, highlighting the essential role of teamwork in patient safety. Additionally, Campbell et al. (2021) underscores the influence of collaborative teamwork and two-way communication in promoting patient safety culture. Research studies have demonstrated that high-performing teams lead to fewer errors, resulting in better healthcare outcomes, including enhanced surgical safety (Fitzpatrick et al., 2022). The significance of communication and collaboration between healthcare professionals has been emphasized, particularly in dynamic environments such as emergency departments and intrapartum care (Gharaveis et al., 2017; Skoogh et al., 2022).

Now what?

The now what question of the Driscoll model requires action plan to address teamworking and fatigue challenges discussed in the so what section. Burnout from fatigue is likely to result in patients’ complaints, and errors in medication administration (Magalhães et al., 2019). Van den Oetelaar et al (2016) asserts that to meet the complex care needs of patients and deliver high quality care, a good balance of nurse-patient ratio is essential. Furthermore, Van den Oetelaar et al (2016) suggest that a balanced level of registered nurses on staff level enhances patients’ satisfaction and delivery of quality of care. As such it is important for NQNs to reflect on the impact of fatigue and teamwork.

Effective teamworking is essential for achieving best practice and delivering quality and safe patient care. NQNs should prioritize developing delegation, supervision, and communication skills to enhance workload sharing and efficiency among staff (Anderson et al., 2019; Van Den Oetelaar et al., 2016). Poor communication with multi-disciplinary teams and lack of time are identified as barriers to effective patient care, particularly for patients with complex needs (Loeb et al., 2016). To address burnout among care staff, it is critical to learn skills that enable better understanding of how to care for patients with complex needs (Loeb et al., 2016). Regarding reflective models for addressing challenges and identifying improvements, while the Driscoll model has limitations in engagement for reflection, the Gibbs reflective model provides six steps for reflection (Forrester, 2020).

CRITICAL APPRAISAL

The study by Anderson et al. (2019) utilized a mixed methods design, combining a survey and semi-structured interviews to explore teamwork and nursing team experiences. The use of multiple data collection methods improved the comprehensiveness and depth of their findings. The authors’ commitment to methodological rigor is evident through the inclusion of ethical considerations and a pilot study.

However, a limitation of the Anderson et al. study is the lack of discussion about potential biases or constraints that may have influenced the results. This lack of addressing limitations may undermine the study’s reliability. The authors should have acknowledged and addressed any limitations to enhance their findings’ transparency and credibility.

Lindqvist et al. (2019) provides an example of a mixed methods study that involved face-to-face interviews with nurses, physicians, and pharmacists, along with a physician survey to measure collaborative working relationships. This approach complements the study by Anderson et al. and demonstrates the effectiveness of mixed methods in healthcare research.

Additionally, Zhao et al. (2020) utilized qualitative and quantitative data to explore teamwork and its impact on nursing care. The integration of data from multiple sources provided a more nuanced understanding of various teamwork aspects. These studies exemplify the utility of mixed methods in healthcare research.

While Dall’Ora et al, (2015) investigates the association of 12-hour shifts with nurses’ job satisfaction, burnout, and intention to leave across 12 European countries. The study’s focus on job satisfaction, burnout, aligns with the findings of several relevant references. For instance, Zhang et al., (2019) highlights the relationship between burnout and intention to leave among clinical nurses, emphasizing the impact of factors such as poor working environment, workload, and working relationships with co-workers on burnout.

Additionally, Al Sabei et al. (2022) explores the relationship between interprofessional teamwork, job satisfaction, burnout, and nurses’ intentions to leave, shedding light on the importance of a favourable environment and teamwork in increasing nurse retention.

However, it is important to consider the limitations of the study, as pointed out by Ferri et al. (2016). Ferri et al. considers cross-sectional study comparing the effects of night shifts and day work only on nurses’ health conditions and job satisfaction. While the study by Dall’Ora et al. sheds light on the impact of 12-hour shifts on nurses, it is crucial to consider the limitations mentioned by Ferri et al. regarding the negative effects of night shifts on nurses’ health and job satisfaction. The study by Wang et al. (2022) highlights the significance of factors such as nurses’ sense of organizational support, self-esteem, and perceived professional benefits in relation to their intention to leave. This provides additional context for understanding nurses’ job satisfaction and intention to leave, which are key aspects addressed in the study by Dall’Ora et al. (2015). Considering Wang et al.’s findings can contribute to a more comprehensive understanding of the factors influencing nurses’ well-being and job attitudes.

The study by Dall’Ora et al. (2015) could be improved by considering the potential influence of physical and mental health on job satisfaction and burnout, as suggested by Ferri et al. (2016). Additionally, organizational support and perceived professional benefits, as noted by Wang et al. (2022), should be considered to provide a more complete understanding of the factors contributing to nurses’ job attitudes and intention to leave.

Integrating the factors mentioned can enhance the methodological rigor of the study, allowing for a more holistic analysis of the factors that influence nurses’ job satisfaction, burnout, and intention to leave. The methodological approach adopted by Anderson et al. (2019) aligns well with the current research landscape on teamwork and implicit care. This includes various quantitative, qualitative, and mixed-methods studies, as emphasized by Zhao et al. (2020). Thus, the mixed-methods approach employed by Anderson et al. is consistent with the evolving methodological trends in the field of healthcare research.

In conclusion the essay critically examined the role of risk assessment and quality improvement strategies for the delivery of quality and safe care. The MUST is an effective tool for risk assessment of patients with and those at risk of malnutrition, as it has been used to demonstrate that malnutrition is a serious health problem in the UK. The Root cause analysis (RCA) is a tool for change in hospital settings for quality improvement and maintaining patient safety. The Driscoll (2007) model was used to structure the reflection on teamworking and fatigue as factors which influence newly qualified nurses on delivery of quality and safe care. The limitations of the Driscoll model were highlighted. Anderson et al (2019) and Dall’Ora et al (2015) methodological designs were appraised.

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