already-established thrombosis website, and posted information/guidelines and events on the intranet. To reach patients, we developed a VTE
information leaflet and encouraged clin- ical departments to make it available to all inpatients. The leaflet outlines the risk of thrombosis and what clinicians and patients can do to reduce the risk. It also informs patients of the signs and symp- toms of VTE and what to do if they develop.
Getting information This stage involved the thrombosis team collecting audit data and feedback from staff; the audit data gave us an idea of how well the trust was already performing. We worked closely with the IT depart-
ment and the business intelligence unit, and included data entry information in our education programme. To make sense of the data and under-
stand what was working well and what bar- riers were faced, we gathered more qualita- tive information from formal and informal discussions with key clinical staff. Gradually, we built a picture of what
was needed and where. It soon became obvious that each area had specific issues that needed to be tackled separately. At this point we began to enlist help from col- leagues throughout the trust as the work- load was more than one team could manage. We also felt that change was more likely to take effect if it was led from within the various departments. We found that VTE “champions” across professional groups already existed throughout the trust. Identifying these people and using their energy and drive was vital in spreading good practice. Soon after the VTE prevention project
began, we set up a VTE link nurse and mid- wife group, which was critical in achieving the trust’s VTE prevention goals. We arranged monthly meetings and quarterly study days for these link staff and secured funding for places on an accredited national VTE prevention course. As the network became established, we appointed a lead link nurse, allowing us to hand ownership of the network to its members and making communication between the network and the thrombosis team more efficient. The link nurses and midwives took on
the ownership for measuring the quality of care on their wards by conducting clinical audits, and giving feedback to colleagues. To highlight and celebrate progress, we introduced a monthly VTE champion award, which was given to an individual or team who had shown commitment, lead- ership and innovation in improving VTE
BOX 1. INVOLVEMENT CONTINUUM FIVE STEPS
● Giving information – education, raising awareness ● Getting information – audit, analysis, observation, feedback ● Forums for debate – dialogue, meetings, focus groups ● Participation – staff and patient involvement ● Partnership – sustainable development and progress as an organisation
prevention. The winners received a certifi- cate, had their photograph taken, and their achievements were described on the intranet. This is a good example of appre- ciative enquiry; successful strategies were shared so others could implement them. Staff told us that this acknowledgement
made them feel valued and motivated. Their hard work and accomplishments made throughout the year culminated in a VTE awards event hosted by the director of nursing and midwifery and the head of learning from the Royal College of Nursing.
Forums for debate This phase was carried out via formal and informal meetings with key members of staff and occurred throughout the process. Simultaneously we communicated with other hospitals and VTE groups to learn from work they had already done. A great deal of information that influ-
enced future strategy was gathered. We have continued to invest time and resources into discussions with staff, which assists in pre-empting and man- aging new issues, while continuing to cel- ebrate achievements and enabling us to implement future initiatives.
Participation This stage is about working together to find the best solutions; it overlaps with the debate stage in the methods used, but is focused on action rather than discussion. We worked with wards, link nurses and
midwives to develop a strategy for each clinical area to enhance successful aspects of the process and overcome barriers. Strategies were circulated to increase par- ticipation. The link nurses and midwives showed commitment by attending meet- ings and communicating with the group. We used the train the trainer concept by
training link nurses, midwives and prac- tice development nurses so that they could disseminate what they had learnt in their clinical areas.
26 Nursing Times 04.09.12 / Vol 108 No 36 /
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Partnership This stage represented engagement, a level at which patient care could be positively changed in a sustainable way. This was gradual and dynamic and we
achieved partnership with some areas sooner than others. In some cases, the strategy had to be revised when, for example, a ward manager left or wards were restructured. This stage marked a transition period
where the thrombosis team began to hand over responsibility to clinical areas. For example, after attending meetings with the thrombosis committee, a lead obstetri- cian and a group of midwives significantly improved VTE maternity care. This included the creation of a specialist obstetric VTE risk assessment by com- bining the Department of Health (2010) tool and the Royal College of Obstetricians and Gynaecologists (2009) VTE guidelines.
Conclusion Changing practice across a large trust was daunting. It was particularly challenging as the changes were perceived differently and had different relevance to each clinical area and staff group. Celebrating and learning from positive
aspects of practice was an effective way to form lasting partnerships and doing so rapidly improved care. The key to success appeared to be val-
uing the uniqueness of each clinical area and adapting strategies to suit them rather than imposing blanket methods of change. A lot of hard work, perseverance, resil-
ience, innovative thinking and leadership were needed from all involved and we have learnt a lot that will greatly enhance our future work in this field. NT
References
Department of Health (2010) Venous Thromboembolism (VTE) Risk Assessment. London: DH.
tinyurl.com/DH-VTE-risk Department of Health (2003) Strengthening Accountability. Involving Patients and the Public. Practice Guidance. London: DH.
tinyurl.com/ strengthaccount Kavanagh T et al (2010) Process evaluation of appreciative inquiry to translate pain management evidence into paediatric nursing practice. Implementation Science; 5: 90. National Institute for Health and Clinical Excellence (2010a) Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Hospital. London: NICE.
www.nice.org.uk/CG92 National Institute for Health and Clinical Excellence (2010b) VTE Prevention Quality Standard. London: NICE.
tinyurl.com/NICEvtestandards Royal College of Obstetricians and Gynaecologists (2009) Thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the Risk (Green-top 37a). London: RCOG. tinyurl. com/pregthrom
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