Project Title
Policy Change for Caring of Neonates with Drug Withdrawal syndrome.
A. Organizational approval letter is provided as an attachment.
B. Preceptor agreement letter is provided as an attachment.
Problem Identification
In 2013 illicit drug use in pregnant women between the ages of 15-17 was as high as 14.6% as per the data published by National survey of drug use and health (Kelly, Zatzick, & Anders, 2014). It also revealed that 18-25 age group showed 8.6% and 26-44 age group showed an average of 3.2% pregnant women were using illicit drugs, during their pregnancy.
The problem identified in this unit is the care of neonates admitted to the unit for neonatal drug withdrawal syndrome. As we are seeing an increase in the number of infants admitted with drug withdrawal whether it is maternal abuse of illicit drugs or prescription drugs, the challenge
Rationale for Change, Quality Improvement, or Innovation
The current policy in place of treating the infants with drug withdrawal is not enough to take care of these very vulnerable infants. When these infants are not cared for properly as they should, it increases the length of stay and also cause burn out of nurses taking care of these infants. There has been instances of family altercation resulting in unnecessary tension in the unit.
The data collected shows that there is a need for improvement in the care of NAS infants. A survey conducted in the unit among the care givers also revealed that staff felt overwhelmed in taking care of these infants and needed a better policy or practice change for being better equipped and educated in taking care of the very challenging NAS patients. As a result of this data and survey the management has agreed to address this issue in the unit as a priority. The current policy for care of NAS infants is too brief and does not address the need for consistency in scoring these infants. The scoring method currently used in the unit is a modified Finnegan score. One of the challenge in scoring is the inconsistency in how we score the infant on the subjective aspects of the scoring system. The other aspect that is lacking in the current policy is how to educate the parents who come to visit their infants once a day or once in two days that why the child has been scoring high and what they can do to help their child. Part of the problem remains that the nurses and ancillary staff who takes care of these infants are not well educated and well equipped on the topic so they can provide quality care to their patients. The current practice and policy is not sufficient enough to address these problems and needs revision.
Causes of the Problem
As these are vulnerable infants requiring special care and patience from the care givers it has been a challenge to keep the nurses from getting burnt out with these assignments and consistency and continuity of care. For instance there is inconsistency in practice as to when to start scoring these infants, or when to score infants after they are placed on pharmacological treatment. As half of the nurses in the unit have been practicing in NICU for a long period time the ways they have done things traditionally does not always align with the current evidence based practice. Also the new nurses hired are not comfortable enough to take care of these
infants making assignment of these infants to same nurses causing burn out and less job satisfaction among those. Another issue is the inconsistency of continuity of care of these patient population. The way nurses approach and care for these infants wary resulting in frustration from parents and occasionally resulting in confrontation with nurses.
Identification of Stakeholders
The stake holders involved in these proposal would be unit manager, MD who is in charge of the program in treating the drug withdrawal infants, nurse educator, and lead/charge nurse in the unit and staff nurse who is involved with patient care.
Stakeholders’ interest, power, and influence
MD who is in charge of this program is interested in this proposal because it ensures that the program is implemented correctly and we have educated nurses who are capable to taking care of these infants. MD is also interested in this proposal because it will lead to better outcomes and consistency in the care of these patients. He can influence this proposal with his extensive knowledge about the topic how the scoring should be done on these infants and what data should be included while caring for these infants.
Nurse educator of the unit will be interested in this proposal as the person who is in charge of educating nurses in the unit. She can influence this proposal with her knowledge and experience as the person who wrote the initial policy for neonatal abstinence scoring (NAS) and care of these patient population.
Charge/Lead RN will be interested in this proposal as the person who is involved with dealing with parents who are upset about the care of their infant. She will also be interested in this change proposal as the person who is in charge of staffing and assignments. She can make better assignments as there will be more educated and trained nurses to take care of these infants which will improve the patient satisfaction and more happy nurses in the unit.
Staff nurse or bedside RN is important as a stake holder in this proposal as the person who is involved with direct patient care. This proposal will be important to bedside nurse as they will be more trained and equipped with the knowledge to take better care of these infants. She can give input regarding what needs to be added to this proposal to achieve the best results and patient outcome.
Purpose of Project
The purpose of this project is to make changes to the current policy on caring of the neonates with neonatal drug withdrawal syndrome and educate nurses with evidence based practice. This will also equip nurses with the knowledge how to provide consistent and continued care for their patients.
Proposed Solution
The solution this author is proposing for this problem is revising the current policy for NAS and further education of the nurses in caring for the infants with drug withdrawal symptoms. This includes revision of policy and including online study material for nurses.
Proposal for a series of class room lecture by the program director which can be conducted as short sessions. This also includes proposal to the nurse educator to include a video presentation, pre and posttest for the nurses on the topic. A presentation to all the stake holders regarding the change required. Once the policy is revised and education is conducted a feed-back from the nurses caring for the patient population is also suggested.
Evidence Summary
In US approximately 225,000 infants are exposed to illicit drugs annually. Neonatal Abstinence Syndrome or NAS is the term collectively given for both physiological and behavioral signs and symptoms of drug withdrawal seen in infants. This may be either due to exposure in utero due to maternal exposure to prescription or illicit drugs or due to the use of narcotics in NICU for treatment of pain control (MacMullen, Dulski, & Blobaum, 2014). In either case these infants need special care and attention from their care givers. MacMullen et al. (2014) recognized that many of the nursing interventions and care of the NAS infants was based on tradition rather than evidence based practice. This calls for a change in the ways we treat and care for the NAS patients.
Asti, Keels, Wispe, and Mcclead (2015) observed that the intervention that made the biggest impact in length of stay (LOS) for infants diagnosed with NAS was the development of education for nurses and implementation of a standardized treatment protocol. Prolonged LOS has a significant burden on the financial aspect of the otherwise burdened health care system. It also adversely affects the maternal- child bonding and can lead to harm to NAS patients (Asti et al., 2015).
A study done by Lucas and Knobel showed that current inadequacy of using a standardized guidelines and tools, results in suboptimal care of NAS infants (Lucas & Knobel 2012). They also recognized that with adequate education to the care givers and standardizing
the protocols the outcome was better. This indicate the need for furthering the studies on the subject and educating the nurses and other members of the health care team caring for the NAS patients.
According to Hudak and Tan (2012), fifty to 95 percent (50-95%) of infants who were exposed to opioids or its derivatives will develop NAS. According to American Academy of Pediatrics (AAP) guidelines, every NICU or nursery caring for NAS infants should have a set protocol and standardized guidelines in taking care of these infants (Hudak & Tan, 2012). It also suggests that non pharmacological interventions such as quiet dark room, swaddles and sitters should also be considered. To treat and care for these very vulnerable population, NICUs should have adequate education programs for the nurses and staff caring for NAS infants.
NAS is a growing concern nationwide which has increased the cost of health care and is growing economic health concern (Casper &Arbour, 2014). NAS is a very challenging health condition which imposes the multiple challenges to the frontline health workers such as nurses and practitioners. Nursing intervention should be based on evidence based best practices. The lack of education promotes for inconsistent nursing practices while caring for NAS infants. This complex issue requires proper education and consistent approach by all interdisciplinary parties so that the outcomes of these infants are optimized (Casper& Arbour, 2014).
Reference List
Asti, L., Magers, J., Keels, E., Wispe, J., & Mcclead, R. (2015). A Quality Improvement Project to Reduce Length of Stay for Neonatal Abstinence Syndrome. Pediatrics.
Casper, T., & Arbour, M. (2014). Evidence-Based Nurse-Driven Interventions for the Care of Newborns With Neonatal Abstinence Syndrome. Advances in Neonatal Care, 376-380.
Hudak, M., & Tan, R. (2012). Neonatal Drug Withdrawal. Pediatrics.
Kelly, R. H., Zatzick, D. F., & Anders, T. F. (2014). The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics. American journal of psychiatry.
Lucas, K., & Knobel, R. (2012). Implementing Practice Guidelines and Education to Improve Care of Infants With Neonatal Abstinence Syndrome. Advances in Neonatal Care, 40-45.
MacMullen, N., Dulski, L., & Blobaum, P. (2014, July 1). Evidence-Based Interventions For Neonatal Abstinence Syndrome. Retrieved January 18, 2016, from http://www.pediatricnursing.net/ce/2016/article40051.pdf
Implementation Plan
Plan of Action
The plan of action regarding this proposal is going to take place in several steps. First step is to identify the portions of the policy to be revised. A meeting with the stake holders will be arranged to discuss the several steps involved with the implementation of this proposal. In the
next step the policy will be revised. Nurse educator will develop online study material along with pre and posttests. Short onsite classes will be conducted for small group of nurses at bedside by MD in charge of the program. Stake holders will submit their feedback regarding the online course and classes. Feedback from practicing bedside RN’s will be collected and reviewed and assessed for the need for any improvement.
Timeline
The overall time line for this project is 5 weeks. In first week meetings with stake holders and revisal of the policy will be done. During this week the schedule for the short classes will also be decided and posted for nurses to attend. Second week nurse educator will develop online study materials along with pre and posttest. Next two weeks nurses will attend the short classes and review the online classes and take the tests. Last week feedback from stakeholders and
nurses will be collected to assess the success of the project.
The resources needed for this project includes but is not limited to IT assistance and computer resources for the development of online tools. The IT professional can help the nurse educator in technical aspects of the program and also assist in arranging the schedule for the computer lab. It will also require dedicated time from the MD for the classes he needs to conduct. The MD will have to make schedule arrangements with other attending physicians to incorporate the new class schedules. Nurse Manager needs to allocate time for the nurses to
complete the online module. This will also include the cost of the education hours to be added in the budget by the manager. Stakeholder’s time and resources is needed for feedback and implementation of the project. All stake holders input and feedback will be required to assess the success of the changed policy
Proposed Change Theory
The current policy in the NICU at Dignity Health Siena Campus, for caring infants with NAS needs revision and the nurses needs more education in this topic for better patient outcomes. The proposed change theory which will be used to implement this project is Lewin’s
change model. The Nursing and Midwifery Council (NMC) says nurses 'must deliver care based on the best available evidence or best practice', which suggests there is a continual need to update, or make changes to, practice. Lewin’s change model has a definite plan, goal and is very rational (Kritsonis, 2005).
Lewin’s change theory has 3 steps, which are unfreezing, moving and refreezing. During the first step unfreezing or assessing the need for change and changing the status quo happens. The second step is moving, during this the change is implemented and all stake holders are involved and move towards achieving the goal. In the third or final step refreezing or the changes are made permanent and becomes a new norm. In this step employees are rewarded and recognized for their effort to accept the change and adherence to it (Mitchell, 2013). .
In this first step the staff is assessed and the rationale for change is enforced. Evidence based knowledge is parted with all parties involved and everybody comes to an understanding for the need for change this includes classroom education discussions and tests for all the staff members involved. The implementation of the new policy and reinforcement of the changes occurs on a regular consistent basis. In the final step of refreezing data is collected to show the progress made in the care of these infants. Feedback and input from the staff is evaluated and
the policy and practice changes are made and recognized as the standard of care in the unit for care of infants with NAS.
Barriers to Implementation
One of the barriers identified for the implementation on this project would be resistance from the staff for the change. Change can be difficult and stressful especially for people who work in already a highly stressful environment. Another barrier would be staff not following the new policy and regress back to doing the old ways resulting in no change. There could be technical errors related to software or hardware issues in launching the study module resulting in delay in the implementation of the project.
Learning Objectives and Outcomes
The learning objectives for the staff involved are
∙ Identifying the need for further education in regards to caring for NAS infants.
∙ Identify that the old policy is not sufficient enough to provide optimal care for the patient population.
Understand the new and better ways to care for these infants which is based on evidence based practice.
The staff recognizes and is accepting of the new changes and trends in the field of NAS.
Staff members will review the new policy and complete the online tests.
Staff will attend the class room lectures.
The outcomes for the staff involved would be
∙ Staff will follow the new and revised policy.
∙ Staff will be better equipped with knowledge in the care of the infants with
NAS.
Staff will provide feedback regarding the new revised policy and how it is affecting the care of their cliental.
∙ Patient satisfaction will improve.
The staff members will be recognized for the efforts in caring for the NAS patients.
Data will be collected in the unit to evaluate the efficacy of the policy change.
References List
Asti, L., Magers, J., Keels, E., Wispe, J., & Mcclead, R. (2015). A Quality Improvement Project to Reduce Length of Stay for Neonatal Abstinence Syndrome. Pediatrics.
Casper, T., & Arbour, M. (2014). Evidence-Based Nurse-Driven Interventions for the Care of Newborns With Neonatal Abstinence Syndrome. Advances in Neonatal Care, 376-380.
Hudak, M., & Tan, R. (2012). Neonatal Drug Withdrawal. Pediatrics.
Kelly, R. H., Zatzick, D. F., & Anders, T. F. (2014). The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics. American journal of psychiatry.
Kritsonis, A. (2005). Comparison of Change Theories. International journal of scholarly academic intellectual diversity, 8(1), 1-7.
Lucas, K., & Knobel, R. (2012). Implementing Practice Guidelines and Education to Improve Care of Infants With Neonatal Abstinence Syndrome. Advances in Neonatal Care, 40-45.
MacMullen, N., Dulski, L., & Blobaum, P. (2014, July 1). Evidence-Based Interventions For Neonatal Abstinence Syndrome. Retrieved January 18, 2016, from http://www.pediatricnursing.net/ce/2016/article40051.pdf
Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 32-37.
