Knowledge Natter: In conversation with Knowledge Award Champions Perdi Welsh and Niamh Clancy on developing Registered Veterinary Nurses’ skills and confidence in quality improvement initiatives

Knowledge Natter: In conversation with Knowledge Award Champions Perdi Welsh and Niamh Clancy on developing Registered Veterinary Nurses’ skills and confidence in Quality Improvement initiatives

Perdi Welsh DipAVN(Surgical) RVN and Niamh Clancy DipAVN (small animal) RVN

RCVS Knowledge:

Welcome to this knowledge natter by RCVS Knowledge. Here we have friendly and informal discussions with our knowledge award champions and those who are empowered by quality improvement in their work. Whether you’re a veterinary surgeon, veterinary nurse, receptionist, or member of management, quality improvement will and can positively impact your everyday life. Listen and be inspired.

Lou Northway:

Hello and welcome to this RCVS knowledge natter. My name is Lou Northway, quality Improvement Clinical Lead here at RCVS Knowledge. Today, I’m very excited to be talking to one of our RCVS Knowledge Award champion teams. I will be speaking with Director of Veterinary Nursing Perdi Welsh and teaching fellow Niamh Clancy from the School of Veterinary Nursing at the Royal Veterinary College. Without further ado, hello ladies.

Perdi Welsh:

Well first of all, Lou, thanks so much inviting us. And I should probably point out at this point that Niamh and I are just to of a slightly bigger team who are involved in this. But, anyway. I shall get going with who I am. I’m Perdi Welsh and I’m a veterinary nurse. And, my day job is that I’m the Director of Veterinary Nursing at the Royal Veterinary College, and, I’m also the course director of the postgraduate certificates in Advanced Veterinary Nursing courses here at the RVC.

Niamh Clancy:

And, I’m Niamh Clancy, as she said, at the start. I am an anesthesia nurse at the Queen of the Hospital for Animals. So, the RVC’s Big referral hospital. And I’m also the teaching fellow at Veterinary Nursing School of Veterinary Nursing and deputy co-course director for the certificates in advanced veterinary nursing. A bit of a mouthful. And I’ve been a veterinary nurse for quite a while with the RVC now as well.

Lou Northway:

So, you both do a lot by the sounds of things. Very busy people. Lovely. So, I thought we’ll start just by going over really your journey with QI, both individually and from the RVC in particular. So, please share.

Okay, well shall I kick off, Niamh?

Niamh Clancy:

Yeah. Go for it. Yeah.

Perdi Welsh:

So, I guess in around 2020, as you’ll know Lou, the RCVS restructured the framework for post-registration advanced qualifications for veterinary nurses. And, I really wanted the RVC to be part of offering this career development opportunity for veterinary nurses. So, we set up the certificates in advanced veterinary nursing and applied for and received RCVS accreditation. And, we were excited to welcome our first intake in 2001. And, at the start we offered two pathways, one in anesthesia and analgesia, which Niamh created in runs and one in emergency and critical care, which is looked after by another colleague of ours, veterinary Nurse O’Byrne. And, very excitingly this year, we’ve also welcomed our first cohort of medical nursing pathway students. And, they’re being led by a medical RVN from the Queen Mother Hospital, Gina Parkes and a medical specialist there Barbara Glanemann.

So, these are part-time online courses that last just over a year. And, our students learn more deeply about their chosen pathway topic, obviously. But, importantly they have opportunity to develop leadership skills that they can take back to their practices. And, really it’s about enhancing patient and client care and smooth running of the hospital and the practice that they’re working in. So, I know I don’t need to convince you, Lou, that quality improvement and clinical governance activities are really essential activities in clinical practice. But, I suppose they’re relatively new in the veterinary profession. And, although we’d heard of them and we knew that we should be doing them, many of us I think in the profession we’re never taught formally about what it actually involves, or how to do them.

So, when we set up the course, the AVN course, we really wanted to give our learners the opportunity to gain confidence to lead on aspects of clinical governance in their own practices, and also to be able to train others, if necessary. And also, importantly, to disseminate their findings, not only to their colleagues in their workplaces, but also to the wider veterinary community. So, to do this in their first AVN module, they’re taught about clinical governance, and in particular how to carry out clinical audits and how to undertake knowledge summaries. And then, they design set up and run their own clinical audit in their practice as part of their coursework.

Lou Northway:

Yeah. It’s really brilliant. And, what’s the feedback been like for the students when they’re faced with, this is their first module. Are they a bit like, “Oh, this is isn’t something that nurses do, is it?” And then, are they pleasantly surprised? Or what’s the feedback been like?

Niamh Clancy:

I think at the very, very start, because obviously they will initially do Perdi’s modules, which are fundamentals in advanced veterinary nursing practice, where they’ll learn about doing clinical audits. And, I think obviously, me being clinical myself, I think they’re all dying to get to the anesthesia part. And, I think what happens then is they leave the fundamentals, go into anesthesia, and then they realize that they have to put into practice the plan that they made of their audit plan. And, I think initially, at the start when they started off doing it, I think they feel a bit, “How does this play into my anesthesia stuff that I’m doing?” and everything else like that. And, I think, actually by the end of it, they realized the impact that doing these clinical audits really can have in their practices. And, I mean, I’m a convert myself. When I first got involved with this course and [inaudible 00:05:41] had already set up these summative assessments, so the clinical audit being part of their assessments. And, I remember thinking, “Oh, I’d much rather there was something like another anesthesia patient-care report or something.”

But, I’m completely converted. Done a clinical audit of my own now and everything in the QMH. Because I do think, and from what the students say to me, is that the change they can make in practice, particularly in a topic like anesthesia where it often feels like as nurses we don’t get a say, because it’s the vet who prescribes the drugs … Where I think for a lot of them, we’ve managed to get them to have their say, but by using information that they’ve gained from their clinical audits. And then, having an implementation stage that’s not necessarily changing the doses of a drug or the drug they’re giving, but they’ve been managed to, let’s put it a way, get what they want, by doing their clinical audits. So, I think it’s really empowered them and I think they’ve definitely felt empowered and particularly students.

We have some students where they have three of them all from the same practice doing this course. And, I remember this was in 2022 London Vet Show, the three of them came up to me and I was like, “Does your practice hate me?” And they were like, “[inaudible 00:06:50] our practice is so happy and everything’s changed for the better. And, all the other nurses feel really empowered as well.” So, I think it’s particularly in a subject anesthesia that it can often feel like nurses don’t get a say. And, I think this really does help with that. So, I think by the end of it they love it. But, through the trials and tribulations maybe not so much. But, that’s like everything.

Perdi Welsh:

Yeah. [inaudible 00:07:13] Oh, sorry. I was just saying, I was chatting to a student this week whose right in the middle of it. So, the current cohort will be submitting in September, their final clinical audit reports. And, she was a bit stressed about writing the report up and the reflective part of it. And, she was just telling me about her audit and she’d started off and I think she had something. She was looking at pain scoring post surgery and she said that in the first audit round, I think it was something like 7% of patients were being pain scored and recorded as pain scored. And then, she did her intervention, which was some sessions with the practice. And then it’s gone up to something like 65%.

Lou Northway:

[inaudible 00:07:53] Really good.

Perdi Welsh:

And I was saying, “My, God! The impact of what you’ve done. Do you see that?” She hadn’t realized until we were chatting about it. I said, “What do your practice think?” She was like, “Yeah. Yeah. They want me to share my results.” I was like, “That’s amazing!” But, for her at the moment, so in the thick of it, she couldn’t actually see-

Niamh Clancy:

[Inaudible 00:08:12] Yeah. I think that’s an interesting thing about for coming up with the implementations as well, because I think that a lot of the implementation stages of all the clinical audits that we have are education. And, I think it’s true for most things. You can change a form, you can change this, you can change that, but at the core of it, there needs to be education and the importance of whatever the topic is [inaudible 00:08:32] that you’re auditing. Yeah. Exactly. And I think then, for a lot of them, they weren’t aware of the impact that just having one chat with someone can really have on the changes in practice.

As I said, I did a clinical audit in the QMH about pain scoring as well, and that was one thing that I noticed is a group of different areas that definitely came to the talk. Their area, they have improved drastically in the pain score and they deliver. Whereas, other areas that might not have been able to come due to scheduling conflicts, they haven’t improved as the other departments have. So, I think it’s super interesting to see that education is a huge part of any implementation stage of any clinical audit. And, as Perdi said, getting that information out across your practices, or submitting to the RCVS knowledge as well is a really, really important part of it, I think.

Lou Northway:

Yeah. And, like you say, the sharing element of doing the audit has the biggest impact and to say widely on the profession, like pain scoring’s such an important area.

Niamh Clancy:

Yeah.

Lou Northway:

And, it’s so welfare focused, isn’t it, as well? And, it’s actually something that I’ve been auditing in my practice month on month this year, as well. And, we’ve improved month on month as well. But, it just makes you think about, if it’s not being performed, why not? Is it confidence? Is it because the sheets always run out? So, accessibility? Is it time? What are the factors? And, it can make just such a big difference. So, going back to subjects, what the students have covered, could we go over some of the others, the other areas that have been looked at?

Niamh Clancy:

Yeah. Definitely. I think we tend to get, particularly in anesthesia runs of themes, I’ll call it. So, our first intake there was definitely a theme towards hypothermia, which again, obviously we had a chat at BSAVA this year, didn’t we? So, we know the importance of hypothermia in anesthetized patients. So, there was a huge drive towards that and there was loads of clinical audits involved in that. And, it was very interesting to see all the different implementations that different people did during the audits. So, that was really, really great, and obviously makes such a difference to your anesthetic and is very a nurse-centered part of anesthesia. And, this year, there was a huge drive towards filling in of breeding anesthetic checks. So, like the AVA checklist. Doing ASA grading as well. Recovery handovers. So, stuff that I think a lot of the time in anesthesia, people wouldn’t consider the importance of that, but actually it’s got a huge importance and the AVA are doing a huge drive with their checklist as well.

So, I think it’s nice to see the themes that come up as well. But, obviously, my heart will always lie in pain scoring things. So, I always love it. So last year we had a pain scoring one for ophthalmology patients. And this year, we had one, just a generalized for canine post-surgery patients. So, I always find them really interesting reads, because it’s such an area where we don’t have a lot of research about it in pain in animals, particularly if you’re going to do cats, even less. But, I think it’s super interesting for those ones. And Anna Costa who works with us in the QMH, she did that really, really great one, which was about low flow anesthesia and its impact on the environment. And, how as a hospital as big as the QMH could reduce their environmental impacts as well. But I shouldn’t talk only about the anesthesia ones.

Lou Northway:

I love that one, though. That one I got really excited when I read that one, because I was like, “Oh, my gosh!” Because everyone puts their circle onto three and then forgets that it’s on three. And, it’s just wasting everything and spitting out ISO into the environment. So-

Niamh Clancy:

[inaudible 00:11:55] It’s funny you should say this. A friend of mine was anesthetizing a tiger the other day and she … Yeah. I know. And, she was asking advice about stuff and I was like, “It’s just a big cat.” But, she was like, “I’m going to put it really high in the oxygen.” I was like, “But, you’re using a circle?” And she’s like, “Yeah.” And I was like, “Go down a half a liter. You’ll be fine.” But, yeah. So, there’s some really good ECC ones definitely as well. So, Sam McGower who got honorable mention at the awards, she did hers on nutrition in ICU patients in the QMH. And I thought that was really …

Because I’m Irish, so I’m a feeder. I feed everything on recovery from anesthesia. So, I’m always giving things chicken when I shouldn’t be. But, her one was really good, because it was just looking at a general RER. And, I think when you have those intensive care patients, it’s so easy to overlook something like nutrition when you have lines coming out of every vessel possible, and ventilators and things like that. So, I think that was a really good one. And, we had Illy who did one on indwelling urinary catheters in neurological patients. So, I was really amazed by that one as well. I thought it was really interesting.

Lou Northway:

Yeah. She reduced her complication rate, or infection rate by 20%, didn’t she?

Niamh Clancy:

Yeah. I know-

Lou Northway:

… by developing a new SOP and doing training. I was like, “This is fantastic.”

Niamh Clancy:

Yeah. It’s really good. And, particularly in those neurological patients where you want to reduce their time in the hospital. And, I think that’s a really important thing of all these QI initiatives that we’re doing. As much as we want to keep them in hospital, because I love cuddling them, we need to get them out of the hospital and up and moving and out as quickly as possible. So, anything we can do to … I mean, reduce hypothermia, gets them up quicker, out the hospital quicker, reduces infection. For any of those neurological patients who are trying to get over having a spinal surgery, having a urinary tract infection as well, it’s just going to prolong that stay in the hospital. So, I think of all these initiatives that people have done, a lot of it is actually just reducing healing times, which is such a nursing-based aspect towards veterinary care, I think. But, maybe some vets would think differently. I don’t know.

Lou Northway:

The other angle I thought about the indwelling urinary catheter one and infection, was about antibiotic use. So, if you could reduce your antibiotic use as well because your patients are not getting tract infections from their indwelling catheter, then that’s brilliant as well, isn’t it? So, it impacts so much wider than we initially think.

Perdi Welsh:

Yeah.

Lou Northway:

And, what have you thought about the projects that have come forward Perdi, on the qualification?

Perdi Welsh:

It’s been amazing. It’s been really, really inspiring to work with people when they’re coming up with their ideas. And also, I think it’s important to point out some of the ones we’ve mentioned have been nurses who’ve been working in referral practices. But, we’ve also had some great ones from primary care practices as well. And, that’s the beauty of clinical audits and governance activities. It doesn’t matter where you work. So, yeah. The ones where people are looking at, for example, record keeping and how the extent to which particularly the record keeping of hospitalized patients, the extent to which that forms or records are being kept and filled in … The paperwork’s being filled in properly. And then, again with those implementations … And, as Niamh said earlier, a lot of the intervention is having practice meetings or chats with people and spreading the word and the message across and, just coming up with some of the … It’s that thing about it not being a blame. This isn’t about identifying individuals or situations that are necessarily bad, but it’s about improving situations and everybody learning from that.

Niamh Clancy:

Definitely, one of the best first opinionly based ones that I worked quite a lot with was one of our 2021 intake students. And, initially she wanted to reduce the amount of methadone these bitch spays were getting, because she thought that was what was making them nauseous and making them hyper salivate and need more and recovery and maybe even before being induced for anesthesia. And, I think it was through talking with her of going, “As nurses, we can’t really tell the vets you have to give this amount,” kind of thing. So, further working and developing and getting to spend so much time with the students over what was essentially a year, is getting to work through their projects with them. And, eventually what we decided on, well, what she decided on, was fasting times for these patients. And, actually it turned out that they were on talking … Because bitch spays coming in, so not things that you have complete control over when you feed them or not.

And, some owners were feeding them at 6:00 PM and then not feeding them. And then, they weren’t getting induced for anesthesia until 2:00 PM in the afternoon. And, then they were hyper salivating and possibly nauseous and needing Roptain. So, they reduced their fasting times by telling owners and also following the AAHA guidelines and giving a very, very small meal four hours before, a small bowl of wet food. And, they reduced the need from Roptain by, I think it was 50% or something. A massive drop in hypersalivation and signs of nausea in these patients. So I think that was a really good one on a first opinion basis of, even something as straightforward, not straightforward, but something that we do every day-

Lou Northway:

Well, every day.

Niamh Clancy:

Yeah. Something like a bitch spay. But, you can make such a difference in your planning of these patients.

Lou Northway:

And, I think that’s why QI’s so great, because we are … I think it’s possibly wrong to say we’re programmed, but you get so used to doing things a certain way, over and over again year upon year, but actually it helps you stop and review how actually you are doing. So, when we spoke about earlier pain scoring, is there analgesia appropriate? You may find out, actually, it’s really not, but unless you’re measuring it and doing things about it, you can’t know.

Niamh Clancy:

Well, I think that’s a really interesting thing about going into any of these audits. So, I went into the audit in the QMH and pain scoring with the initial plan of thinking, “Oh, I want to see if a patient who … ” We’ve got set limits of when you get this intervention or that interventional of analgesia. And I was like, “Oh, I want to see if a patient who pain scores seven is getting the same as a patient who’s pain scoring 12,” because we have a cutoff with that. So that was what I started off doing. And, much like that student started off seeing, trying to see what the nausea was caused by, I was trying to find out if we were treating our pain adequately. But, then it turned out, I realized very quickly, we weren’t really pain scoring them that often. So, therefore, it’s like you learn to adapt very well when you’re doing these QI things, to realize that your plans might go completely differently. And, we always teach the students, don’t think that you know what your implementation’s going to be, because you don’t know what your results are going to be. Because they come to us with their plan and they think, “Oh, in my implementation I’m going to do X, Y, Z.” And, we’re always like, “Hold on. You don’t know what you’re going to find. So, wait until you get that”

Perdi Welsh:

That was like Tanya. So Tanya who works in a practice in Northern Ireland, in Belfast. So, she wanted to assess incidents of complications associated with feeding tubes in hospitalized patients. And then, during the data collection she realized that there was inconsistency with the team with the way notes were recorded on the hospital chart. So, actually, what she then did, her implementation was actually different, because it was about … I think she introduced a protocol that was standardized. To record the checks that were being made on patients with O tubes. And then, yeah. So then, of course, on the reorder when she looked at it again, there was a great improvement in the way information was recorded on those feeding tube charts.

And, that’s the nice thing, again, that then potentially in six months time you could revisit that either looking to see that that’s still maintained, or you could look at this, go back to, “Okay. Let’s now go back to the original idea of the audit,” which in Tanya’s case was to assess the incidents of complications. So they’re movable, they’re a bit flexible, which I think is … When you start that process, you can modify it if you need to, based on what’s needed in the practice.

Lou Northway:

Yeah. And, it really opens up your mind, doesn’t it? Because, like you say, when you start a project, you think, A to B, that’s where you’re going. But, actually with QI you have a spider’s web of things by the end. And, I sometimes find I have to really reign it in, because I think, “Oh, actually, I could also be looking at this.”

Niamh Clancy:

Yeah. When I first started collecting my data for the clinical audit, I had a mess of an Excel sheet, which had so much information. I had information of did the patient have a block? Did they have this? And then by the end of, because I was getting about 100 patients. By the end of the 100 patients, I was like, “Did it, or did it not, have a pain score?” I’m cutting back all the information I have, because I’ve got far too much. So, I think it’s so easy when you tap into that ability to gather that information within your practice to overwhelm yourself. But, as much as it’s adaptable, you have to still keep a very clear set in your mind of, “What am I trying to achieve here?” And yes. What you’re trying to achieve might change, but you can get overwhelmed by data and want to find out everything. So, I think doing smaller little projects, focusing on one particular thing, but do lots of them over however long you’re working in the practice, is always useful.

Lou Northway:

Yeah. And, I wondered whether we could also touch on the leadership side of the course, because you have a leadership module, don’t you? And, some of your nurses on your course commented that with QI alongside the leadership really helped them feel like they could make a change in practice. So, could we touch on that a little bit?

Perdi Welsh:

Yeah. So it’s not really a leadership module. It’s part of the first module that they do on the course. It’s got a very long-winded name. It’s fundamentals in Advancement Nursing Practice. And, it incorporates evidence-based and clinical governance. We also cover stuff about the code of conduct and keeping within the law. And also, leadership. So, we have topics within a module and leadership forms part of that first module. We teach some theory associated with leadership models and leadership behaviors. And, students are encouraged to think about their own style that they might develop and way of doing things. So, at that point we encourage them to start thinking about themselves as leaders and identify areas of professional interests that they’re passionate about, so that look at their values and how that ties in with what they might like to lead on in their own practices.

And then, in that module, part of the assessment is to come up with their clinical audit plan. So, they write a plan for their clinical audit. And, we ask them to disseminate that to their colleagues as part of this, developing that leadership skill, so that they’re telling people about why they’ve come to this decision for auditing a particular topic and try and get people on board. And, particularly for those practices that aren’t involved in doing clinical governance activities, or aren’t as familiar, introducing change can be challenging. And so, we talk a little bit about change management and get them to think about how the best way for their practice to introduce a topic and an idea for change.

Lou Northway:

And, what themes came through the knowledge summaries? Were they very similar to the audit topics that they also did? Or, did they do completely separate things?

Niamh Clancy:

I think some people [inaudible 00:23:27] yeah. Some people did, some people didn’t. I think for certain topics, I think as we said before, there’s so … I’m going to say so little literature in veterinary, but it’s only in comparison to humans, is what I’m saying. But, for certain areas there’s particularly even less literature. So, the students, I think it’s hard to find a PICO question that fits directly completely into your clinical audit for every single person. And then even after you find a PICO question for that, it’s then finding the literature to answer your PICO question. So, one of the requirements of our courses, to do the knowledge summary, we let them take in from human literature and from veterinary literature, which might to be different to RCVS knowledge summaries. So, it’s slightly different, because that would be more driven just to answering the PICO question.

And, I think, it was a hard going for a lot of people, because the knowledge summary’s obviously a big chunk of work to do, particularly in the timeframe of what we’ve given them in the course. So, now we’ve slightly adapted it to make it a little bit more friendly, let’s say, and welcoming, call them. But, it was a big body of work. But, a lot of people did try and do it around their clinical audit topic. So, we spoke about earlier about Anna’s low-flow anesthesia one. Hers was a particularly interesting one, because it was taken in from, because you can in that topic … Because it’s low-flow anesthesia, it’s not based around small animals versus humans. So, she could take in from human medicine and there was so much interesting things about low-flow anesthesia and summarizing the knowledge behind the benefits of it.

So for that, she could then use what she learned in her knowledge summary as part of her implementation stage for the education part with people, because she had learned so much from doing it. And, I think when I didn’t do a knowledge summary, but when I was doing clinical audit stuff as well, I looked into what way would be the best way to encourage people to use pain scoring systems. And, through doing a knowledge search like that, I found out that education improves the use of pain scoring systems in nonverbal humans. So, it’s quite interesting in that. And, a lot of the hypothermia things as well that the students did, their knowledge summaries were on about, does the use of a hot dog blanket versus a bear hugger improve perioperative temperatures in canines? Or whatever. So. There was some really good things that came out of that.

So, a lot of them trying to do it, but there was some that were just so hard to actually find literature on. And, obviously, for an RCVS knowledge summary, you can’t just say, “There is no knowledge. Here is the gap.” But, for us and in this course, we need them to be able to review and critically appraise some literature in order to pass that module. So, I think it was a bit hard to try and fit everything into what they wanted to do for the clinical audit. But, in my opinion, I think probably about 90% of people did do it on a question related to their clinical audit. There was just some very few that, it just couldn’t fit very well, unfortunately. I think they just struggle then for it. But, yeah.

Lou Northway:

I’m sure it’ll really inspire nurses, though, to actually consider performing their own research as well, because they think they going, looking for stuff that’s not there, and then hopefully they’ll feel inspired to lead their own research projects in practice.

Niamh Clancy:

Yeah. Definitely.

Lou Northway:

Fingers crossed.

Niamh Clancy:

[inaudible 00:26:40] Yeah. Exactly. They always fingers crossed for everything. But, one of the things was the ophthalmology patients. And, there is no pain scoring system that’s just for eyes, that’s validated, kind of thing. Now, that is something that would take years and possibly a PhD to create, but I think one of the nurses who did that was now in talks with some of the senior anesthetists and ophthalmologists at the QMH about maybe developing that. But, I think it’s now gone to be part of the anesthesia team more than ophthalmology. But, I think that’s, as you said, that showed a real gap in knowledge and a gap in literature that we have. So, I think that’s been something that’s inspired a lot of people in the QMH to think, “Oh, maybe this would be a nice project for someone to do.”

Lou Northway:

Brilliant. And, reflection for veterinary nursing in general now, we’re encouraged to reflect on everything we do. And, I think that’s why QR just works so well, because you will end up walking around in practice every day thinking, “Hm. I wonder when we last looked at this. Are we being effective? What could we do better?” But, my colleagues sometimes tell me to rein it in a bit because, “Oh, should we look at that? Should do another audit?” “No. We’re doing enough at the moment, Lou.”

Niamh Clancy:

Well, you say that. But those three students that were in that practice together … As I said at the start, I honestly was terrified that their boss was going to hate me.

Lou Northway:

I want to go there. I want to see what it’s like.

Niamh Clancy:

Well, this is the thing, because it was so interesting. I think that was the nausea one as well. So, it was the nausea, hypothermia and, or pre-warming, so it was related to hypothermia. There’s pre-warming and then there was something using different blankets. So, I was like, “You guys must have streamlined your anesthesia in your first opinion patients.” And, they were like, “Yeah. It’s great.” And they’re like, “We’re going to do it on this and this next.” And well, one of them did also say to me, she was like, “I’m trying to convince my boss to buy … ” Now, I told her she should get a ventilator, but she’s trying to convince her boss to buy her something else. But, she’s going to do an audit for it instead, to show that they have a need for it. And I was like, “This is what we do. To get what we want, that’s what you have to do.”

Lou Northway:

Yeah. You do, absolutely. I did an audit a few years ago looking at adverse events in anesthesia. So, we only had one multi parameter at the time, and often we would have more than one patient anesthetized, so we’d always have to prioritize who was going to have the machine, who was called Colin, just for reference. And, so every time the machine highlighted something that I wouldn’t know with my hands-on nursing skills. I recorded that, basically. So, I said, “Out of 100 patients … ” I can’t remember what it was now, but a large proportion had something I couldn’t know just with my hands-on monitoring skills. So, how about all of the other patients this week? How many of them would’ve needed intervention, which we’ve missed, because we wouldn’t know. And then, after that, they got three more multi-parameter monitors. So, every station in our primary care practice has the works. But, that’s the way it should be, isn’t it?

Niamh Clancy:

But also, again, even thinking about that and what I was saying earlier on, I think sometimes it can be hard to convince people the importance, I guess, of being able to notice those things and react to them. And, sometimes as a nurse you can feel like you’re finding problems. But, actually what you probably notice is when you do react and you find that information, you react to information, your patients recover quicker, they spend less time at one-to-one nursing. Your nursing staff is free to do other cases and move on case to case. And, I know it’s not about money, but you generate more money in that way as well. And, actually it’s better for the patients. So, I think it’s getting people to see a bigger picture of what you’re actually doing. And, I think QI’s really good at that, seeing this is the bigger picture. And, actually, when you do see those improvements after your implementation of your patient’s care and recovery times, it just I think makes such a difference to the practice. And everyone’s eyes open, go, ” [inaudible 00:30:26]. This is great.”

Lou Northway:

Yeah. It’s really motivational, isn’t it? And also, I think it massively enhances culture. Like the nurses, you were just saying, the three of them, in practice I bet they are a force to be reckoned with. But, I’m sure everyone’s talking, everyone’s open, everyone’s sharing ideas. And, that is the type of practice you want to go and work in.

Niamh Clancy:

Yeah. Exactly. Yeah. Definitely.

Lou Northway:

Lovely. Well, thanks so much for spending time with me this afternoon. I thought we could finish just by, if you would share with us your top tips for nurses that are thinking of maybe doing the CertAVN, or for QI.

Perdi Welsh:

Oh, okay. Well definitely nurses thinking about doing the CertAVN, definitely recommend it. It’s a great course. We’ve got great module leaders with Niamh, Gina, and it gives you so much more than just as we’ve been discussing, so much more than the advanced knowledge in the pathway topic that you’re taking. So, please get in touch with us and we’d be very happy to chat to you if you’ve got any questions. I suppose top tips for others maybe starting their QI journey. I think if you’re new to QI, and in particular carrying out things like a clinical audit, my tips would be to go for it and don’t be frightened of it. And, have some fun experimenting, particularly at the start. Sometimes they’re talking about things that are quite big and unmanageable. So, I would say, start off small and focused and have something that you are interested in or have a real passion for.

And things like, for example, starting off with a retrospective audit, looking back at clinical records, to see if there’s any patterns in particular areas could be a nice one to start off with. Or, I don’t know, looking at number of post-op wound issues, for example, or the number of records that have been filled in fully. Again, I mentioned earlier, but I think it’s important to point out that audits aren’t about identifying or assigning blame to people, but they’re about the team learning how to do things better, or more effectively or more efficiently, to improve patient care or client care or the smooth running of the practice. And well, VNs are ideally placed people in practice to lead on all aspects of this. So, I think it’s a real area of potential growth for veterinary nurses and career development, or just making the working day more interesting. And, it’s a great way of building up knowledge relating to veterinary nursing issues as well.

So, I mean, I think there are lots of documented barriers to clinical audit. And so, I think it’s a good idea to be aware of these. One of the things that’s always cited is lack of knowledge and skills and confidence in the process. But, the thing is there’s loads of great resources out there and structured programs like RCVS Knowledge pages. I’ve got lots of stuff and they’ve got the short courses and there’s courses like the CertAVN that we run at the RVC, where we take people step by step through the process and give people the chance to practice. And, so I was going to say people probably worry about the lack of time in practice, so busy and particularly increasingly in clinical practice, it’s crazy. So, I think starting off with something straightforward and uncomplicated to gain that confidence and skills is a good way to get going and show how they can be fitted in alongside other clinical activities.

Niamh Clancy:

I do think as well that a lot of times there as RVNs, there was a lot of us and SVNs who we don’t feel like we’re leaders. And, I think it needs to be shaken out of us a little bit, because actually I think every single RVN that I know is in some way a leader in something that they do, anyway. And, I think it’s a inner leader that needs to be just dragged out with them and something like a clinical audit can actually really do that for them. And, I think I spend a lot of time with the students doing the CertAVN and the anesthesia designation, saying to them, talking to them in the language that then they can take that language and bring it back to their practices. And, a lot of them have said to me that they knew what they wanted, but they just didn’t know how to use the words to describe it, or to get what they wanted.

So, these are the students who are just now finishing up their anesthesia designation. They’re saying, “Oh, I was able to have a debate with a vet about using a particular drug,” and they already knew before they took this course why they wanted that drug, but now they’ve done the course and now they’ve got the language and they have the clinical audit behind them to prove why they want to use a certain drug or do a certain thing. And, I think that’s a really good thing about it.

So, leadership skills will develop as you do QI initiatives. So that’s my top tip, to not think that, “I’m not a leader,” or, “I’m not the head nurse in my practice,” or, “I’m just a first-year qualified RVN.” It doesn’t make a difference. You’ll develop leadership skills. And then, obviously if you come and do the CertAVN in anesthesia, you’d have me as your little cheerleader. So, that would be your reasoning for coming to the CertAVN. But, I think, yeah. A lot of people, we just need that inner person to tell us that you can do this and you are a leader and you are capable of doing it.

Lou Northway:

Yeah. And, I think you are absolutely right. People probably feel a bit intimidated, or don’t really know how to get going. So those of you listening, I would recommend you log onto the RCVS Knowledge website. Have a look at all of the case examples, because it walks you through all the different types of areas that you could look at. And, yeah, step by a step. So, you could literally mimic that, shadow that in practice and see how your team is doing and then make changes and go from there. And, if you ever need any help or support that RCVS Knowledge team are here also. So, ladies, thank you so much. I could talk to you for hours and hours and hours more about QI, but this is only a short natter. But, thanks again and congratulations. I hope you all feel extremely proud. You should be. And, hopefully we’ll talk again very soon on something else.

Perdi Welsh:

Yeah. Thank you.

Niamh Clancy:

I’m glad you kept us this short of time. I would’ve waffled for ages!

Perdi Welsh:

Yeah. Niamh can talk for Ireland.

Lou Northway:

Oh, I know.

Perdi Welsh:

I was just going to add in that actually winning the knowledge award, the RCVS Knowledge Award was the icing on the cake for us. But, it’s been such a pleasurable, and it continues to be such a pleasurable experience seeing students, our students transition and their journeys with QI, and in particular, the clinical audits. So, yeah. Thank you for letting us share that, and for also the fact that the knowledge award just help spread that message and hopefully encourage lots of other veterinary nurses out there to get involved.

Lou Northway:

Yeah. Well, your course, ultimately by embedding QI in it, has so massively, positively influenced nursing. And, they have then got out into practice and spread it even wider. So, it’s a full circle, really positive thing. So, well done.

Perdi Welsh:

Thank you. Thank you.

Niamh Clancy:

Thank you.

RCVS Knowledge:

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