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Capstone Project Change Proposal: Implementation

As noted in previous chapters, the chosen practice change for preventing pressure ulcers (PU) is repositioning and turning patients with decreased mobility. This task is one of the nurses’ duties, and the theory that may explain how nurses approach patient care is the Three Cs of Lydia Hall. According to this philosophy, three main circles describe the sphere of patient care – care, cure, and core (Sumarno, 2019). The core circle defines the patient and how they receive nursing care. Hall poses that patients have specific needs and feelings which help them create their own goals for treatment. Next, the cure circle includes all medical treatment, including that by physicians and nurses. Finally, nurses’ focus is the care circle – the process of nurturing patients. This theory has been used to describe PU’s prevention and treatment as this process requires nurses’ continuous attention to patient needs and overall health. Hall’s approach demonstrates that such an intervention as turning combines the three circles, and nurses have to be vigilant, educated, and responsive to the patients’ condition.

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The implementation of a new practice in nursing care requires several steps to ensure that both nurses and patients are prepared for the project. First, the plan for specific turning and repositioning instructions has to be created. According to Chew et al. (2018), studies do not present concrete results on the most effective timeframes for this intervention. However, most articles find the two-hour period to be a standard for PU prevention (Pickham et al., 2016). Thus, following practice-based evidence principles, this timeframe will be utilized in the project. Second, Woodhouse et al. (2019) urge organizations to ensure that all nurses have a similar understanding of PU stages and turning requirements. Before the intervention is started in the unit, all staff engaged in the plan will undergo training that will demonstrate the correct turning techniques with practical demonstrations (Woodhouse et al., 2019). Moreover, it will refresh their knowledge of PU detection and staging.

The implementation plan will also include a new schedule for nurses. They will turn patients at risk of HAPUs every two hours and encourage patients to reposition every 15 minutes if possible (Pickham et al., 2016). Here, Hall’s theory dictates that patients’ intrinsic motivation plays a great role in care delivery. Next, nurses will collect data about PUs, including whether the PU is new or existing, number, location, and stage (Zulkowski, 2018). Head-to-toe skin assessments will be completed to look for pressure ulcers and update records.

The outcomes of the practice change should document the number of hospital-acquired PUs (HAPUs) to see whether the new intervention is more effective than the previous system of care. Thus, the incidence rather than the prevalence is the primary measure for the project. It is the number of people who developed a PU after admission to the unit divided by the overall number of patients admitted to the unit in the chosen period (Zulkowski, 2018). This outcome measure will be collected by nurses during skin assessments and documented using the hospitals’ health records.

The main focus of the evaluation plan is a functional improvement. The outcome measure that records every instance of a HAPU in the unit during the intervention will be used to determine HAPUs occurrence. Then, the percent of new PUs can be compared to the incidence before the intervention in the unit. This calculation should reveal whether the practice change affected the unit in particular and changed the experiences of patients at risk of PU development. Next, the incidence in the unit should be compared with national benchmarks to see whether the hospital provides quality care or needs further improvement. Finally, nurses’ feedback on the new schedule should be collected to determine how their experiences have changed and what future changes should be added to increase their ability to care for patients.

The main barrier to plan implementation is a knowledge and training gap for the participating staff. As noted above, nurses should follow specific instructions when turning in patients. Furthermore, they should assess PUs’ stages using a national system. Woodhouse et al. (2019) find that nurses may have difficulties following the intervention’s instructions without a preparatory program with a demonstration. To overcome this barrier, a training session is included in the implementation plan. Next, improper or insufficient documentation of results is the next potential obstacle to a successful outcome. Nurses should be attentive when assessing PUs, especially when reviewing patient records to find HAPUs and existing PUs. Skin-to-toe skin assessments should help in overcoming this problem, along with the use of electronic health records in the unit.

Overall, the implementation plan for this practice change is based on Hall’s theory of core, care, and cure circles. It includes a preparatory stage to provide nurses with training and ensure that they understand all guidelines of the project. The intervention consists of nurses turning patients every two hours and encouraging them to reposition every 15 minutes if they can. The outcome measure is the incidence of hospital-acquired pressure ulcers. Apart from that, nurses’ self-assessment and the comparison to national benchmarks should demonstrate whether the intervention is effective.

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Chew, H. S. J., Thiara, E., Lopez, V., & Shorey, S. (2018). Turning frequency in adult bedridden patients to prevent hospital‐acquired pressure ulcer: A scoping review. International Wound Journal, 15(2), 225-236.

Pickham, D., Ballew, B., Ebong, K., Shinn, J., Lough, M. E., & Mayer, B. (2016). Evaluating optimal patient-turning procedures for reducing hospital-acquired pressure ulcers (LS-HAPU): Study protocol for a randomized controlled trial. Trials, 17(1), 1-8.

Sumarno, A. S. (2019). Pressure ulcers: The core, care, and cure approach. British Journal of Community Nursing, 24(Sup12), S38-S42.

Woodhouse, M., Worsley, P. R., Voegeli, D., Schoonhoven, L., & Bader, D. L. (2019). How consistent and effective are current repositioning strategies for pressure ulcer prevention? Applied Nursing Research, 48, 58-62.

Zulkowski, K. (2018). Measuring pressure injury rates and prevention practices [PDF document]. Web.

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