The critical care units of hospitals treat frequently treat patients by administering oxygen via the insertion of tubes into tracheostomies, the nose, or the mouth; nosocomial infections may result, leading to ventilator-associated pneumonia, or VAP (CDC.gov, 2015). The infection is not generally associated with non-sterile techniques during insertion, but rather from tube contamination. The nosocomial infection is most often diagnosed in intensive care departments and research has been directed toward identifying methods of oral care as a means of prevention. Comparisons of the effectiveness of sodium bicarbonate swabs with that of chlorhexidine swabs have been made and the hospital administration has expressed interest in processing a formal change in policy concerning oral care in prevention of VAP. The administrative bodies include the Executive Director and hospital Administrator, the Manager and the Director of the Intensive Care Unit, and the Policy and Procedure Committee.
A search of the literature comparing chlorhexidine swabs to other types of oral care in intubated paitents included Andrews & Steen (2013), Arroliga et al. (2010), Berry et al. (2011), Cutler & Sluman (2014), Feideer, Mitchell & Bridges (2010), Hillier et al. (2013), Klompas et al. (2014), Lawrence & Fulbrook (2011), Nicolos (2011), Oshodi & Bench (2013), Richards (2013), Roberts & Moule (2011). Each of the articles stated a preference for chlorhexidine swabs over other solutions. After careful consideration of the research, it is recommended that the hospital implement a policy change for the use of this type of swab in conjunction with mechanical brushing on a scheduled basis to decrease the present statistical presence of ventilator-assisted pneumonia in intubated patients in the intensive care units. The change will be in alignment with the mission statement of the facility, which is to highest quality of care and service to all people in the treatment and prevention of disease. In addition, the standard of treatment will promote the hospital’s vision to become the premier hospital for the best patient care and maintain the core values of excellence, departmental collaboration, innovative methods of care, and respect for staff, patients, and families.
Implementation of Policy Change
Implementing policy changes concerning standards for specific methods of oral care for intubated patients requires determination of a strategical process based on theories of change. There are three crucial elements inherent in organizational integrity: all stakeholders involved, the processes of change, and the perspectives of each stakeholder (McAlearney et al., 2013). The pioneer of change theories is Kurt Lewin who stated that in order to implement and maintain organizational change, it is necessary to pass through three stages; the first stage is unfreezing the current behavior, second is moving the new behavior into place, and the final stage is to refreeze the behavior when the new process has sufficient equilibrium (Marquis & Huston, 2015). Everett Rogers (2003) expanded Lewin’s theories with modifications incorporating awareness for the need for change, interest in implementing the change, evaluation of the process, trial of the change, and final adoption. Another change theorist, Ronald Lippitt proposed there were actually seven phases and this model may be considered a more appropriate strategy for nursing care (Marriner-Tomey, 2009). In a comparison of the theories of Lewin and Lippitt, there are major similarities (Mitchell, 2013). In Lewin’s UnFreezing Phase, which Rogers calls the Awareness Phase, Lippitt promotes three difference phases; Phase 1 includes diagnosing the problem, Phase 2 evaluates motivation and the ability to change, and Phase 3 assesses the hospital’s motivation for change and the resources available to do so. Lewin’s Moving Phase and Rogers’ Interest/Evaluation/Trial Phases are encompassed by Lippitt’s Phase 4 which selects the objective of the change, Phase 5 which selects the appropriate role of the agent of the change, and Phase 6 which maintains the change. Lewin’s Refreezing Phase and Rogers’ Adoption Phase are placed into Lippitt’s Phase 7, which demonstrates the changes no longer require assistance to maintain.
The initial step in implementing the change process is the determination of the need and appropriateness of the change by responsible entities of the facility, as indicated in Phase 1 of Lippitt’s model. Phase 3 of the model addressing the agent’s motivation and resources would come into play at this point. Disclaimers and concerns of liability will be discussed by the hospital’s legal department. A Leadership Team should be created to allow for input from staff members during each phase of the change, allowing discussion and insight concerning present problems and possible future obstacles and evaluating motivation as in Phase 2 of Lippitt’s model of change. The Leadership Team will also be responsible for staff education before, during, and after the process, setting goals for staff acceptance as stated in Phase 4 of Lippitt’s model. Phase 5 would address the role of the facility in coordinating the teams, committees, and departments toward implementation of the policy. The creation of a Compliance Team maintains and improves adherence of staff members to the new policy concerning VAP prevention through oral care. The Compliance Team members will use the methods of visualization and chart documentation for confirmation during Phase 6 and determine when staff entered Phase 7, when routine quality control would periodically evaluate compliance without undue supervision. In addition, the Compliance Team will be a link in a chain of command for conversations of problems and input for improvements. It is important that the department of Central Supply be apprised of the needs of the intensive care unit and the director of the department should have ways of obtaining sufficient supplies in the event of high numbers of admissions. The Quality Control Department should maintain statistics on past incidences of VAP prior to the change in order to compare results of the implementation.
The primary obstacle to implement the change to using chlorhexidine swabs in combination with manual brushing and suctioning will be the lack of cooperation by staff members who have used other methods and solutions in the past, in some cases for years. Fieder, Mitchell, and Bridges (2010) conducted a study of compliance by staff members after changes in policy and found adherence was sporadic by nurses concerning oral care of intubated patients. Surveys show that nurses feel oral care is more a comfort measure than one of VAP prevention. Nurses with more experiences performed the care more frequently and nurses with baccalaureate degrees were most consistent in suctioning patients before and after conducting oral care, a method that assisted in decreasing infection.
Evaluation of the Policy Change
It is vital to collect data for a period of time following a policy change in order to evaluate its effectiveness. It is suggested the length of collection be five years and the statistics should include what kinds of infections are diagnosed in intubated patients in the hospital, methods and results of treatment, other morbidities that may influence acquiring the infection, if the patient refused the oral treatment, documentation of the frequency of oral care, and compliance to the policy. Comparisons should be made with the same data collection prior to the policy change in order to determine change effectiveness and trends in results and costs.
Conclusion
Through the use of Lippitt’s model for organizational change, it is possible to break the steps for introduction, implementation, and evaluation into effective components. Policy changes within established routines of a health care facility are difficult and are not undertaken haphazardly. For this reason, a theory of change derived from Lewin’s initial theory is instrumental in a smooth flow in transition.
References
Andrews, T., & Steen, C. (2013). A review of oral preventative strategies to reduce ventilator-
associated pneumonia. Nursing In Critical Care, 18(3), 116-122. doi:10.1111/nicc.12002.
Arroliga, A., Pollard, C., Wilde, C., Pellizzari, S., Chebbo, A., & Song, J. et al. (2011).
Reduction in the Incidence of Ventilator-Associated Pneumonia (VAP): A
Multidisciplinary Approach. Respiratory Care.
Berry A, Davidson P, Masters J, Rolls K, and Ollerton R. (2011). Effects of three approaches to
standardized oral hygiene to reduce bacterial colonization and ventilator associated
pneumonia in mechanically ventilated patients: a randomised control trial. International
CDC.gov. (2015). CDC - VAP FAQs - HAI. Retrieved 19 June 2016, from
http://www.cdc.gov/HAI/vap/vap_faqs.html
Cutler, L., & Sluman, P. (2014). Reducing ventilator associated pneumonia in adult patients
through high standards of oral care: A historical control study. Intensive and Critical
Care Nursing, 30(2), 61-68. doi:10.1016/j.iccn.2013.08.005
Feider, L., Mitchell, P., & Bridges, E. (2010). Oral Care Practices for Orally Intubated Critically
Ill Adults. American Journal of Critical Care, 19(2), 175-183. doi:10.4037/ajcc2010816
Hillier B, Wilson C, Chamberlain D, and King L. (2013). Preventing Ventilator-Associated
Pneumonia Through Oral Care, Product Selection, and Application Method: A Literature
Review. AACN Advanced Critical Care, 24, 38-58.
Klompas M, Speck K, Howell M.D., Greene L.R., and Berenoltz S.M. (2014). Reappraisal of
routine oral care with chlorhexidine gluconate for patients receiving mechanical
ventilation: systematic review and meta-analysis. Journal of the American Medical
Association Internal Medicine, 174, 751-761.
Lawrence, P., & Fulbrook, P. (2011). The ventilator care bundle and its impact on ventilator-
associated pneumonia: a review of the evidence. Nursing In Critical Care, 16(5), 222-
234. doi:10.1111/j.1478-5153.2010.00430.x
Marquis, B. & Huston, C. (2015). Leadership roles and management functions in nursing. (8th
ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
McAlearney, A., Terris, D., Hardacre, J., Spurgeon, P., Brown, C., Baumgart, A., & Nyström, M.
(2013). Organizational Coherence in Health Care Organizations. Quality Management In
Health Care, 22(2), 86-99. http://dx.doi.org/10.1097/qmh.0b013e31828bc37d
Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing
Management, 20(1), 32-37. http://dx.doi.org/10.7748/nm2013.04.20.1.32.e1013
Nicolosi, L., del Carmen Rubio, M., Martinez, C., Gonzalez, N., & Cruz, M. (2013). Effect of
Oral Hygiene and 0.12% Chlorhexidine Gluconate Oral Rinse in Preventing Ventilator-
Associated Pneumonia After Cardiovascular Surgery. Respiratory Care, 59(4), 504-509.
doi:10.4187/respcare.02666.
Oshodi, T., & Bench, S. (2013). Ventilator-associated pneumonia, liver disease and oral
chlorhexidine. Br J Nursing, 22(13), 751-758. doi:10.12968/bjon.2013.22.13.751
Richards D. (2013). Oral hygiene regimes for mechanically ventilated patients that use
chlorhexidine reduce ventilator-associated pneumonia. Evidence Based Dentistry, 14, 91-
92.
Roberts, N., & Moule, P. (2011). Chlorhexidine and tooth-brushing as prevention strategies in
reducing ventilator-associated pneumonia rates. Nursing In Critical Care, 16(6), 295-
302. doi:10.1111/j.1478-5153.2011.00465.x
Shirey, M. (2013). Lewin’s Theory of Planned Change as a Strategic Resource. JONA: The
http://dx.doi.org/10.1097/nna.0b013e31827f20a9
Marriner-Tomey, A. (2009). Guide to nursing management and leadership. St. Louis, Mo.:
Mosby Elsevier.
