According to the British Medical Association (BMA) (1), the Vancouver style of referencing is named after the work of a committee of medical journal editors who first met in Vancouver in 1978; this group subsequently became the International Committee of Medical Journal Editors (ICMJE). The system was developed by the United States (US) National Library of Medicine, and adopted by the ICMJE as part of the standard requirements for papers submitted to biomedical journals (1). The Vancouver system differs from the Harvard (author-date) system of referencing by using numbers instead of the author-date to indicate references. The Vancouver referencing style uses either a bracketed or superscript number in the text, which connects with a list of references at the end of the work (2). The same number can be repeated if a source is used more than once in the same text (2). The Vancouver style has many advantages over other referencing styles; firstly, the main text reads more easily, with the references being less obtrusive for the reader (1). Secondly, references in the reference list are directly correlated to the numbers in the main text; this saves the reader time searching for a specific reference in the list (1).
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To demonstrate effective use of the Vancouver referencing system, this example work will briefly review literature pertaining to one of the most important aspects of clinical nursing practice: hand decontamination. The review will be referenced throughout using the Vancouver system, with the reference list supplied in numerical order at the end of the work.
Hand decontamination in clinical practice: A brief review of the evidence
For many decades, it has been well reported in nursing literature that effective hand decontamination significantly reduces the spread of hospital acquired infections (HAI), such as Methicillin Resistant Staphylococcus Aureus(MRSA) (3). Endemic HAI have been strongly linked to the contaminated hands of healthcare workers (4). According to Loveday et al., hand decontamination should take place before and after all patient contact, after contact with the patient’s environment and/or body fluids, when hands are visibly soiled, before and after an aseptic procedure, and after removing gloves (3).
Despite a wealth of educational campaigns, literature, and professional guidelines in recent years, the literature suggests that many healthcare workers remain non-compliant with hand decontamination procedures; the impact on patient safety of this non-compliance is significant (4). Many authors suggest that there are a number of barriers affecting hand decontamination; these barriers include professional issues such as lack of time, unmanageable workloads, reduced staffing levels, and frequent admissions to the ward or unit (5, 6, 7).
In addition, other theories around the behaviours of healthcare workers and non-compliance with hand decontamination have also been proposed (4). Jackson and Griffiths conducted a qualitative, interpretative study of the drivers of nurses’ behaviours in relation to infection control. Interestingly, the authors found that as nurses’ familiarity with their patients increased, their rate of hand decontamination decreased (8). Jackson and Griffiths suggested that hand decontamination was viewed as a ‘protection of self from unknown dirt’, and as the nurses’ ‘disgust’ with the patient decreased (due the increased familiarity), their hand washing also decreased (8). This implies that hand decontamination is behaviour driven, rather than driven by scientific knowledge of infection control (9, 10). This, perhaps, goes some way to explain why the extensive educational campaigns and guidelines for healthcare workers on hand decontamination have had little impact on the rates on compliance (4). It is important to note, however, that the majority of studies investigating compliance with hand decontamination are either observational, or utilise self-reporting; self-reported data is often vastly different to the observed reality (11). Furthermore, Jenner et al. note that nurses are able to identify poor or non-compliant behaviours in others, but rationalise their own behaviours, meaning self-reported studies should be viewed with caution in terms of reliability (11).
Given the importance of hand decontamination in minimising the spread of HAI, it is fundamental that a solution is developed to overcome the problem of non-compliance (3, 4). Many authors suggest that a multifaceted approach is needed in order to achieve this (12). The United Kingdom (UK) Department of Health (DoH) recommends that all healthcare workers receive training and supervision on correct hand decontamination practices (13). The World Health Organization’s (WHO) ‘My Five Moments for Hand Hygiene’ guideline is an evidence-based, field-tested, user-centred approach which is designed to be applied in a wide range of healthcare settings (14). This approach could be readily implemented in those clinical areas where compliance with hand hygiene is problematic. Additionally, national and international educational campaigns about hand decontamination, such as those by the WHO and the National Patient Safety Agency (NPSA), must be supported by senior hospital management and medical staff, in order to be successfully implemented and to have a positive impact on staff compliance (7). Finally, further novel research to examine behaviours as drivers of hand decontamination, and strategies to alter or manage those behaviours, could also be a means of solving the problem of non-compliance (8).
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To demonstrate the effective use of the Vancouver style of referencing to the reader, this example work has presented a review of the literature pertaining to hand decontamination in clinical nursing practice. The essay also demonstrates how numerical referencing in-text is less obtrusive to the reader than other forms of citation such as the Harvard author-date style. A brief exploration of the literature has shown that non-compliance with hand hygiene continues to be problematic in most healthcare settings; this is driven by both the behaviours of healthcare workers, and also by professional issues, such as lack of time, heavy workloads, and poor staffing levels. A multi-faceted approach is clearly needed to overcome the problem of non-compliance with hand decontamination; several solutions have been proposed in this review. Throughout the review, contemporary nursing literature has been cited using bracketed numbers in the text; these connect to a comprehensive reference list presented in numerical order at the end of the work, as required for the style of Vancouver referencing.
(1) British Medical Association. Reference Styles Internet]. UK: BMA; 2017. Available from: https://www.bma.org.uk/library/library-guide/reference-styles – Vancouver
(2) Neville C, Referencing: Principles, Practice and Problems. RGUHS Journal of Pharmacology Science. 2012; 2(2): 1-8.
(3) Loveday HP, Wilson JA, Pratt, RJ, et al. epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hosp Infect. 2014; 86, S1–S70.
(4) Rigby R, Pegram A, Woodward S. Hand decontamination in clinical practice: a review of the evidence. Br J Nurs. 2017; 26(8), 448–451.
(5) González ML, Finderman R, Johnson KM, et al. Understanding hand hygiene behavior in a pediatric oncology unit in a low-to mid-income country. J Nurs Educ Pract. 2016; 6(9)
(6) Seibert DJ, Speroni KG, Oh KM, et al. Preventing transmission of MRSA: a qualitative study of health care workers’ attitudes and suggestions. Am J Infect Control. 2014; 42(4): 405–11.
(7) Lankford MG, Zembower TR, Trick WE, et al. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerging Infect Dis. 2003; 9(2): 217–23.
(8) Jackson C, Griffiths P. Dirt and disgust as key drivers in nurses’ infection control behaviours: an interpretative, qualitative study. J Hosp Infect. 2014; 87(2): 71–6.
(9) Jackson C, Lowton K, Griffiths P. Infection prevention as ‘a show’: a qualitative study of nurses’ infection prevention behaviours. Int J Nurs Stud. 2014; 51(3): 400–8.
(10) Curtis VA. Dirt, disgust and disease: a natural history of hygiene. J Epidemiol Community Health. 2007; 61(8): 660–4.
(11) Jenner EA, Fletcher BC, Watson P, et al. Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals. J Hosp Infect. 2006; 63(4): 418–22.
(12) White KM, Jimmieson NL, Obst PL, et al. Using a theory of planned behaviour framework to explore hand hygiene beliefs at the ‘5 critical moments’ among Australian hospital-based nurses. BMC Health Services Research. 2015; 15: 59.
(13) Department of Health. The Health and Social Care Act 2008 Code of Practice on the Prevention and Control of Infections and Related Guidance. UK: DH; 2015.
(14) World Health Organization. My Five Moments for Hand Hygiene [Internet]. Geneva: WHO; 2009. Available from: http://www.who.int/gpsc/5may/background/5moments/en/
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