Change Paper
Nursing 427
By
Jennefer Grady

Table of Contents
Introduction………………………………………………………………..3
Lewin’s Theory……………………………………………………………..4
Problem Statement………………………………………………………….5
Proposed Solution…………………………………………………………..6
Moving Forces………………………………………………………………7
Restraining Forces…………………………………………………………...8
Change Integration…………………………………………………………..8
Refreezing Process…………………………………………………………..9

Introduction On patients requiring bipap masks, what is the effect of applying duoderm to bridge of nose compared to not using any barrier to prevent skin breakdown while in the hospital? This paper is about a problem that has been identified in the nursing field and the change process. Patients who need to wear a bipap mask for better oxygenation are having complications with the mask causing a pressure ulcer on the bridge of the nose. This is not only painful to the patient but also increases health cost. This paper is about Lewin’s change theory and how to implement this new change and overcome resistance. It will talk about the freezing, moving and refreezing process, changes that need to be made and how to implement this plan. As well as what is necessary to enforce this change so that it becomes status quo.

Lewin’s Theory Kurt Lewin was born in Germany and immigrated to the US in August of 1933, after Hitler came to power. He had originally been involved with schools of behavioral psychology before changing directions and going into research. He is well known for his writings on group dynamics, group therapy and social psychology. His most influential theory was his model of the change process in human systems. While studying human behavior, Lewin concluded that driving forces push in a direction where change is inevitable. Individuals have a hard time with change and often become a restraining force that opposes change. Lewin identified several rules that should be followed when change is necessary: (1) change should be implemented only for good reasons. (2) Change should always be planned and implemented gradually. (3) Change should never be abrupt. (4) Everyone affected by the change should be involved in the planning process. (Cherry, 2014) In order to overcome resistance, Lewin identified three classic stages of change; unfreezing, moving and refreezing stage. The unfreezing stage involves the change agent to gather information about the problem, assess the problem, decide if there is a need for change and then make others aware of the need for change. Individuals will not consider change unless you make them believe change is possible. The moving stage is the planning and implementing stage. It involves the change agent to clearly identify goals and objectives, involves everyone affected by change in the planning, identify areas of support and resistance, develop a plan with a target date, implement the change, be willing to support and encourage others through the process and lastly evaluate the change and make modifications. The refreezing stage involves the change agent to integrate the change into the organization as status quo. It requires and enforces compliance with the changed process and support and encourages others until the change is no longer viewed as new but considered the standard. (Cherry, 2014)
Problem Statement One significant problem facing hospitals today is prevention of pressure ulcers. Pressure ulcers are a common concern in hospitals across the nation. They are associated with an increase in morbidity rate and higher health care cost. The actual cost of treating pressure ulcers is unknown but it is estimated that one stage 3 pressure ulcer can cost between 5,000 and 50,000 to treat. Hospitals are losing millions if not billions of dollars a year due to hospital acquired pressure ulcers. Several insurance companies are refusing to reimburse healthcare facilities for cost related to pressure ulcers. (Cooper, 2013) Pressure ulcers are caused by friction, moisture, shear, or pressure on a bony prominence. The most common areas are the coccyx, heels, sacrum and ears. One area that nurses often do not recognize as a problem is the bridge of the nose with patients on bipap masks. While doing a quality improvement study on skin breakdown, my current employer recognized a problem with skin breakdown at the bridge of the nose on patients wearing a bipap mask. This identification resulted in a change agent and Lewin’s change theory was put in place. After searching through several data bases and web surfing, no evidence based studies were found specifically on bipap mask alone but according to one article 10% of pressure ulcers results from respiratory devices. These pressure ulcers usually develop on the bridge of the nose or at the smile lines where the mask causes friction with the skin. (Cooper, 2013) One study found by the research was a study performed by Minnesota Hospital Association. They conducted a study between October 2008 and October 2009 on the prevalence of pressure ulcers from medical devices. According to their findings there were 122 cases of pressure ulcers reported within that year. While the majority of the pressure ulcers were caused by cervical collars at 45%, eleven percent was caused by bipap masks. (Kula, 2011) This problem is relevant not only because it increases health care cost but also because pressure ulcers can be very painful to the patient and may increase noncompliance with wearing the mask. Hospitals are looking for ways to prevent all forms of pressure ulcers and ones caused by respiratory devices, specifically bipap mask, are no exception.
Proposed Solution One solution to help decrease the risks of developing a pressure ulcer due to bipap masks is using some type of barrier between the skin and mask. Current studies suggest that by using a hydrocolloid dressing, such as Duoderm, the surface area of pressure ulcers were reduced by 34%. A hydrocolloid dressing works by producing a moist environment, managing exudates and helps with pain management. Hydrocolloid dressings also provide a barrier from friction of a mask in order to prevent breakdown. (Fletcher, 2011) The proposed solution for my employer is to do a trial involving patients that need to wear a bipap mask for over 4 hours at a time. Included in this implementation are nurses and respiratory therapists. After assessing patients at risk for pressure ulcers on the bridge of the nose, the primary nurse or respiratory therapist will place a duoderm dressing on the bridge of the nose. The nurse must document the placement of the dressing and appearance of the dressing at least once a shift. Duoderm dressings must be changed every 5 days or as needed. After the patient is able to advance off of a bipap mask, the duoderm is to be removed and the area is to be assessed for breakdown.
Moving Forces According to Lewin’s change theory, it is important for a change to be implemented for a good reason, should always be planned and implemented gradually and never abruptly and everyone affected should be involved. In order to encourage staff members to adapt to thed changes the change agent will use the three stages of Lewin’s change theory; unfreezing, moving and refreezing stage. Several things will occur in order to facilitate change. 1) Speaking to staff members, respiratory therapist that work on the unit and patients who have had to wear a bipap mask during this hospital stay. This gives the change agent some information about the problems patients have with wearing a bipap mask. 2) explain the national cost of pressure ulcers and how it affects the patients overall hospitalization at the bimonthly charge nurse meeting. This brings attention to the problem and now it can be focused on. 3) Develop a quality improvement project with a target date of 3 months. One charge nurse will be responsible for developing a form to assess the incident of pressure ulcers and the patients at risk. This will give accurate assessment of the problem. 4) After collecting the data the change agent will present the results as well as evidence based articles suggesting the use of hydrocolloid dressings preventively for the bridge of the nose to administrative personal and the head of the respiratory department. This enables them to discuss a plan for using hydrocolloid dressings and set target dates. 5) After deciding that there is a need for change the change agent will have a meeting with the nursing staff and inform them of the importance of change. This also allows for goals and objectives to be discussed. 6) Identify areas of support and resistance. This way the change agent can develop strategies to overcome resistance.

Restraining Forces Anytime change is necessary there will be some resistance. Part of Lewin’s change theory is recognizing that resistance is a natural response to change and that identifying resistance will help identify strategies to overcome this resistance. Unfortunately, most of the restraining forces will come from the nursing staff because they will be mostly affected by this change. The following are some restraining forces that the change agent may encounter during this process. 1) Nurses being noncompliant with using the hydrocolloid dressing because they do not see any need for change. The change agent will have to bring attention to this problem area so nurses understand the importance for change. 2) Nursing not having the supplies needed in order to implement the change. The change agent will have to speak to central supply about how to eliminate this problem. 3) Nurses and respiratory therapy saying they do not know how to apply the hydrocolloid dressing correctly. The change agent will have to make sure the staff are educated on how to use the dressing properly. 4) Preventing the staff from falling back into old ways once the change is implemented. The change agent will have to enforce the use of hydrocolloid dressings. 5) Working within the unit budget. These hydrocolloid dressings may be expensive and would have to be worked into the unit budget.
Change Integration In order to integrate the use of a hydrocolloid dressing on patients wearing a bipap mask the change agent must have a staff meeting explaining the importance of this new change. Here she will discuss the evidence based research promoting the effectiveness of the change and any questions or concerns her staff may have. She will then have to educate her staff on identifying patients who are at high risk for pressure ulcers on the nose and educate them on how to apply the hydrocolloid dressing properly. Next she will have to implement a quality performance project where staff members evaluate each other in order to make sure that the staff is in compliance with the new changes. She will have to follow up on these results weekly so as to speak with staff members who seem to be having difficulty with the change. Here she can offer support and encouragement through the process.
Refreezing process It is important to complete the change process by integrating it throughout the unit and making sure that it becomes the standard requirements. By doing this the change agent is preventing individuals from falling back into old habits and having the staff take accountability for their actions. There are several ways the change agent can do this: 1)The change agent will do a poster board highlighting the main ideas of how often this breakdown occurs, financial burden hospitals face and the effectiveness of using a hydrocolloid dressing to prevent these ulcers. This will help remind nurses of the importance of this change. 2) Continue to complete quality performance interventions and enforce negative consequences when not followed. If staff knows they will have a disciplinary action if not following guidelines they may be more apt to comply. 3) Continue to offer support and encouragement for the unit to do better. This will allow the staff to feel like they have an important role to play in the change process. 4) Offering a reward every quarter if the unit has full compliance. This will give the staff an incentive to do better. 5) Offer positive feedback weekly. When the staff realizes that what they are doing is benefiting the patient, staff and hospital they will want to continue the new process.

References

Cherry, B. &. (2014). Contemporary Nursing: Issues, Trends and Management. St. Louis, Missouri: Elsevier.
Cooper, K. R. (2013). Evidence Based Prevention of Pressure Ulcers in the Intensive Care Unit. Critical Care Nurse , 33 (6), 57-66.
Fletcher, J. M. (2011). Pressure Ulcers and Hydrocolloids. Wounds International , 2 (4), 1-6.
Kula, L. N. (2011). Pressure Ulcer Prevention-Respiratory Devices. Retrieved from www.mnhospital.org