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evidence-based practice use in nursing for making decisions using evidences to provide care to patients. This assignment has highlighted five main principles of EBP. These principles should be considered while implementing EBP. Moreover, there are certain challenges and barriers in implementing EBP. This assignment focused on strategies for implementing EBP.
Introduction of evidence-based practice to the workplace:
Changing the accepted confirmation of an NG (nasogastric) tube
Currently, I am employed at a medical and geriatric unit in a rehabilitation hospital. The unit is such that the majority of the nurses (60%) have over ten years' experience of practice. Thus the nurses on the unit are highly-trained professions who are extremely competent at their jobs. However, nurses of this level of experience are also often extremely change-resistant. Due to the level of the morale on the unit, nurses are often reluctant to alter the standard operating procedures with which they have become familiar and they are somewhat mistrustful of the unit's leadership. This can make it extremely difficult to implement evidence-based practice in the workplace, even when the changes have been proven to be positive and supportive of a patient's overall health goals. Also, although all of the nurses in the unit were educated in standard medical programs for nurses and are familiar with the general concepts of EBP, not all are comfortable using journal articles, data, statistics, and critical approaches to inquiry to deal with patient problems and thus require guidance to understand and fully implement EBP.
Proposed change: Switching the confirmation of an NG tube by using pH paper and an X-ray vs. auscultation
A review of recently-published literature indicates that the method of administering NG (nasogastric) tubes to patients must be reconsidered. "In a two-year period from 2002 -- 2004, 11 patient deaths associated with wrongly positioned nasogastric tubes were reported to the Medical Devices Agency [in the UK] The guidance stated that blue litmus paper may not be sufficiently sensitive to detect whether nasogastric tubes were incorrectly positioned, potentially contributing to patient mortality…It also stated that blue litmus paper should be withdrawn and replaced by pH testing and that all personnel involved in testing nasogastric tubes should be trained to use the new testing method" (Earley 2005: 26). Auscultation of air through the tube (the 'whoosh test') has also been deemed to be equally unreliable, based upon available patent data (Earley 2005: 26). However, despite this fact, at present, auscultation is the preferred method deployed at our facility.
Preparing for change
While evidence-based practice indicates that a shift to pH paper is the preferred method, because of the long-standing acceptance of auscultation, combined with the fact that many nurses were taught while in school that this was the 'way' to do things, there has been great resistance even in the face of such evidence. In one hospital workplace in which the same change was instituted, "a huge culture shift had to be initiated, which would hopefully lead to a more successful change in practice. A trust guideline was proposed with opinions sought from representatives of practitioners involved in placing NG tubes and associated services and personnel" (Earley 2005: 26). Nurses need to clearly be educated in the value of evidence-based practice, but to convince them requires efforts using emotionally as well as logically persuasive techniques, otherwise they will likely 'shut down.' For care to be effective, nurses must believe in the processes of change, and cannot be unwilling enforces of these methods.
To institute a change, there must be a 'change plan' as well as a plan to change the medical processes themselves. Change plans must take into consideration the human dimension, not merely the technical demands of switching from auscultation. This begins with a diagnostic analysis of the nursing staff, or an "identification of all the groups involved in, affected by or influenced by the change" (Earley 2005: 26). What are the staff personalities, backgrounds and needs? What is the interpersonal dynamic between staff and leadership? On my unit, I would say that the nurses in question are highly competent, but extremely set in their ways. They tend to see change as unnecessary and regard it as an inconvenience and a burden, rather than as a positive step forward in making patients healthier and reducing risk. They tend to feel that they know best. Also, because many have not been in school for more than ten years, there is something of a suspicious attitude towards basing changes in patient care solely upon statistical data, versus common sense wisdom, to achieve best practices. However, regarding the other important group affected by the change -- the patients -- I would say that patients and their families would desire the uncomfortable process of receiving and NG tube to be as accurate as possible, to ensure that the procedure is effective and stress and potential damage is minimized. Also, using pH paper is not more cumbersome or uncomfortable than older methods.
The second step is the "assessment of the characteristics of the proposed change" (Earley 2005: 26). Is it challenging and does it require substantial organizational changes, or is it a relatively painless process? On one hand, the shift to pH paper will reduce error and thus could make the process of inserting an NG tube much more accurate. "When comparing correct placement due to x-ray method, the pH measurement agreed with the percentages of accurate placement. The ausculatory method, on the other hand, was not consistent when compared with an X-ray" (Mazurek & Weigel 2013:1).
The third step is the "assessment of the preparedness of the target group for the change" who will actually be implementing the change (Earley 2005: 26). Despite the change resistance amongst the workforce, the nurses on the unit are clearly technically prepared to institute the change in the sense they are capable of learning new methods. Still, a new training program must be instituted, given that some nurses may be unfamiliar with the use of pH paper as NG confirmation or not have used this method for many years.
Finally, there must be an "identification of potential barriers and facilitators to the change" (Earley 2005: 26). It is extremely dangerous to assume that positive changes will 'speak for themselves' and will automatically be adopted by staff. However, it is also important to note what positive aspects of the workplace culture and physical aspects of the facility layout can make change easier. Ultimately, the ideal is to accentuate the positive and minimize the negative.
After taking a 'change audit' of the unit and focusing on potential weaknesses, managers must also take steps to ensure that resistance and unexpected obstacles are minimized. For example, on one unit in a study by Earley (2005), when transitioning to the use of pH paper, "although the chosen pH paper was based on good evidence, nursing confidence in its ability to provide a true reading was low" and the type of pH paper had to be changed to ensure accuracy (Earley 2005: 26). While there was sufficient trust on the unit between staff and managers regarding the implementation of the new program, in another workplace environment (such as our own), the initial difficulties with the type of paper might be read as 'proof' of the ineffectuality of the shift.
Fighting change resistance: A model for the change process itself
Resistance to change is hardly specific to healthcare-related fields and many models exist which offer suggestions on how to overcome reluctance. One of the best-known methods is that of Kotter's 8-stage method of implementing change. The first step is creating a sense of urgency: nurses must be aware of the data that supports the change and also the opportunity costs of not implementing the change (Kotter's 8-step change model, 2013, Mind Tools). They should be aware of the statistics supporting the change, but also, on a personal level of the consequences to the patient and to their careers if there is no change. The second step is to create a powerful coalition of allies who support the organizational change (Kotter's 8-step change model, 2013, Mind Tools).It is important to recruit leaders in the organization who are persuasive, well-liked, and whom others look to as a source of information and inspiration.
The third step is creating a vision for the change; the fourth step is communicating that vision (Kotter's 8-step change model, 2013, Mind Tools). Once again, this underlines the need for a reason for the change that is emotionally persuasive to nurses and deploys an effective way of getting people 'on board.' I believe that smaller group sessions which troubleshoot organizational concerns and underline the 'big picture' of the change along with very specific practical and technical details are needed, versus impersonal office memos or disseminating copies of research studies to reinforce the policy shift. Worse yet is a top-down directive with little explanation of why change has occurred -- change by its very nature is often uncomfortable and awkward, and there is always anger when there…[continue]
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