NUR 590 Benchmark – Evidence-Based Practice Proposal Project Framework or Model for Change

Nursing care has played a prominent role in caring for patients while in the clinical environment. The implication is that nurses usually use various strategies to enhance patient care quality and safety. However, various events in the care environment usually end up compromising patient safety and the quality of patient care services offered in the clinical environment. Patients in various hospital departments usually face different challenges. A particular patient population of interest in this proposal is patients in the postanesthesia care unit (PACU). While patients in the PACU may face several challenges related to the surgical procedures performed on them, one of the most common challenges is pain (Koehler et al., 2018). Various strategies have been used in recent years to control and manage pain. For example, opioid-based medications have widely been used even though they have negative outcomes such as addition. Therefore, the purpose of this project is to explore the potential use of non-opioid-based medications in the PACU.  As such, various aspects will be studied, including the problem statement, organizational culture and readiness, literature review, change model, the implementation plan, and the evaluation plan.

Problem Statement

One of the major concerns among surgical patients is pain management. Patients in the PACU may experience extreme pain, which needs appropriate attention and control for better patient outcomes. In most cases, patients in the PACU usually rate their pain as 8-10 on a scale of 1-10 after undergoing complex surgical procedures (Luo & Min, 2017). Such acute postoperative pain can lead to adverse problems resulting in poor outcomes if left unattended. It is worth noting that many of the patients who undergo complex surgical procedures need to spend the immediate postoperative phase in the PACU; therefore, a need to appropriately manage the resulting pain. Even though opioid-based medications have been used in most cases to control pain among patients in the PACU, these medications lead to addiction. This calls for an exploration of new and better medications, preferably non-opioid-based medications, that can be used in the management of pain among patients in the PACU.

Organizational Culture and Readiness

The implementation of the change projects in organizations requires that the organizational culture and readiness are assessed to ensure that the project can be implemented successfully with little to no resistance (Melnyk & Fineout-Overholt, 2018). Therefore, it is key to assess the organizational culture and readiness. Some of the aspects that are important to explore include the organizational core values, vision, and mission and how interprofessional collaboration and engagement can possibly support the evidence-based practice project change.

Description of the Organizational Culture

According to Mannion & Davies (2018), organizational culture entails the organization’s mission, vision, and values. Building a culture capable of promoting employee success needs the leaders to support various initiatives. Managers can assist in this respect to ensure standards and expectations are aligned to boost the chances of arriving at success. Another important aspect entails engaging the stakeholders that have the capacity to influence the employee attitude and organizational culture to promote and enhance the quality of patient care.

The organization has a mission of nurturing the healing ministry of the church supported by research and education. The mission also emphasizes social justice and human dignity to help in formulating healthier communities. In addition, the organization’s vision is to live the core values and mission, improve the health of the communities, and pioneer systems and models to boost care delivery. The organization’s core values include excellence, compassion, integrity, and reverence. The organization also has leaders with a lot of experience and is mission-driven to promote healthcare. The implication is that the organization can offer a conducive environment that promotes the implementation of the change project.

The Organizational Readiness Tool

An appropriate organizational readiness tool is key when assessing the readiness of an organization in terms of supporting project implementation. Therefore, the selected tool is the TeamStepps tool. This tool is appropriate for healthcare professionals focusing on improving patient safety through an evidence-based teamwork system (“AHRQ,” 2019). Upon using the assessment tool to assess the readiness of the organization, the survey results indicated that the organization is ready for the change implementation. Hence there are higher chances that the implementation of the proposed project would be successful. In addition, the assessment done using the tool revealed that there will be a need to continually monitor if there are any changes to the answers given in reply to the survey questions. Even though the assessment revealed several positives, the only concern is that it was not clear to which extent will the senior leaders would support the project. However, one fact that would counter any potential weakness is that the nurses and the anesthesiologists who are part of the project are supportive.

The Health Care Process

The health care process in place can hugely influence the implementation of a change project. Our organization uses Six Stigma as the health care process to enhance the cost-effectiveness, safety, and quality within the organization, as this method is effective in reducing waste within the system. The unit also uses a huddle board to measure the ongoing metrics, which allows for the identification of the best practice, which is then embedded into the workflow. The huddle board uses the gathered data from front line drivers through a continuous-learning loop, enabling teams to update improvements throughout the organization, which leads to a reduction of waste, and decreasing cost (HealthCatalyst, 2021).

The Proposed Strategies

It is important to explore strategies that can be key in facilitating the organization’s readiness for the change process. Therefore, the chosen strategy is shared governance. Since the organization is a Magnet designated organization, there are multiple councils available in the facility that supports information sharing. As such, using the shared governance council in the implementation process is key to enhancing the organization’s readiness (Medeiros, 2020).

The Stakeholders and Team Members

Stakeholders and team members entail an important part of the organization hence the implementation of the proposed project. Therefore, it is important that the team members and the internal stakeholders collaborate to enhance the success of EBP change implementation. Such collaboration helps facilitate buy-in and commitment, sharing of resources and experiences, as well as visions to ensure that there is a balance (Ost et al., 2020). The stakeholders would include senior leadership, such as the director and/or VP as the leading champions for the project; other stakeholders would include the anesthesiology team, which would assess the patients for indicators of opioid or non-opioid pain management. Team members would include the change leader, who would monitor the process to ascertain if the changes implemented needed modifications. The coach or mentor would involve the employees in the change process hence making them take ownership. The process owner is the team member that oversees the process and should be able to communicate effectively to allow for buy-in from the stakeholders and other team members (Ost et al., 2020).

Information and Communication Technologies

Utilization of information and communication technologies help are key in implementing EBP change. Therefore, as part of the plan, Six Sigma and Lean Management are to be used in implementing the EBP as it fosters the dissemination of information and communication throughout the practice change by applying the DMAIC process. Through this process, the project objectives are identified, input and outcome measurements and establishment of a baseline of what is to be measured are accomplished. The analysis of the collected data is then followed by the team identifying the root causes or defects that impacts the process and then formulating strategies to improve (Selim, 2019).

The implementation of the controlled process can enhance the improvement of care delivery and nursing practice to support teamwork and enhance care delivery among patients in the PACU. It is hoped that the utilization of the data and outcomes of this change project will enable the patients in the PACU to verbalize pain control using the rating scale when using the non-opioid-based medications in comparison to the use of opioid-based medications.

Literature Review

The experiences of pain in which patients have post-surgical procedures in the PACU has attracted attention from various stakeholder in recent times. As such, while some researchers have focused on pain management using opioid-based medications, others have explored the application of non-opioid medications to manage the pain experienced by the patients. Therefore a literature review was conducted to find relevant peer-reviewed articles that deal with pain management in the PACU and articles which support the proposed project. The formulated PICOT statement was used as a guide to conduct a search for relevant articles that support the proposed project. Therefore a comprehensive search was conducted in various article databases. One of the useful databases was google scholar. In addition, a search was also conducted using CINHAL, PubMed, Cochrane Library, and Trip database. The search was conducted using various keywords such as pain management, PACU, non-opioid medication, and opioid medication.

Literature synthesis

The literature search led to several peer-reviewed articles. However, only the eight most relevant articles were chosen and therefore reviewed and synthesized in this section. Recently, Ali et al. (2021) carried out research with the aim of comparing the impacts of opioid-free and opioid-based medication in managing pain among patients undergoing functional endoscopic sinus surgeries. The study used a randomized comparative clinical study design. While the participants in the opioid-free group were given lidocaine infusion, magnesium sulfate, and paracetamol, those in the opioid group were given fentanyl. Upon the analysis of the data, the researchers realized that those who were recruited in the opioid-free group showed a better capacity to manage the pain, as shown in superior VAS scores. It, therefore, shows that non-opioid-based medications can be efficacious in pain management.

Bhardwaj et al. (2019) also conducted another relevant study that focused on comparing the effect of opioid-free and opioid-based anesthesia in pain management among urological surgery obese patients. The researchers recruited a total of eight patients, where half were randomized into the control group and study groups, respectively, in a randomized controlled trial. While the control group used fentanyl and Atracurium, the intervention group used Dexmedetomidine and Atracurium. The analysis of the data showed that the postoperative analgesic requirements and discharge times were less among the individual in the intervention group. The intervention group also had fewer side effects, showing that the use of opioid-free medication is largely tolerable. As such, opioid-free medication use in pain management is again supported in this source.

Another study was conducted by Hakim & Wahba (2019) with the aim of comparing the impact of opioid-based and opioid-free medications in controlling pain among patients in the postoperative patient recovery mode. These researchers employed a prospective randomized controlled comparative study design. The participants in the opioid-based group were offered intravenous fentanyl, while the ones in the opioid-free group were given intravenous Dexmedetomidine. The Analysis of the data revealed findings that are key to this proposed project. For example, the patients in the opioid-free group showed better pain management as shown by their better pain scores as compared to the individuals in the opioid-based medication group. This study also shows the efficacy of non-opioid-based medications in postoperative pain management.

Recently, Toleska & Dimitrovski (2019) carried out a study that compared the impact of using opioid-based and opioid-free medication in managing pain among patients undergoing laparoscopic cholecystectomy. In a prospective randomized clinical study, the researchers divided the participants into opioid-based and opioid-free medication groups. Whereas the patients in the control group were given fentanyl, those in the study group were offered dexamethasone. Upon analysis of the data, the researchers realized that the patients in the control group reported higher pain scores in comparison to the ones in the intervention group. This indicated the efficacy of non-opioid-based medications in managing pain as they can be superior when compared to opioid-based medications.

Another study that compared the efficacy of the opioid-based medication and opioid free-medication in pain management was recently accomplished by Aboelela & Alrefaey (2021). This research focused on managing pain among patients undergoing abdominal gynecological surgery. The researchers recruited a total of sixty-eight patients to participate in the prospective randomized double-blinded study. The patients were equally divided into the control and the intervention groups. While the patients in the intervention group were offered Atracurium and Ketamine, the individuals in the control group were given Atracurium and fentanyl to help in managing their pain. The analysis of the data showed that the individuals in the intervention group displayed lower pain scores in the first four hours post-operation when compared to the individuals in the control group. This research shows that non-opioid-based medications can be used to effectively manage patients’ pain post-operation.

The next study was carried out by Arif et al. (2019). This study had the main objective of exploring the effectiveness of non-opioid-based (lidocaine) intravenous infusion on postoperative pain scores among individuals undergoing abdominal surgery. The researchers recruited a total of eighty patients to participate in the study, with forty of them randomized into the control group while the rest formed part of the study group. This study used a randomized controlled study design. The individuals in the study group experienced lower pain scores in the first 12 hours post-operation. In addition, these patients gave no reports of toxicity. The implication is that non-opioid-based medications can be key in controlling pain during the post-operation period.

More recently, Rudikoff et al. (2022) carried out a study that investigated if the introduction of a combination of Dexmedetomidine and acetaminophen can eliminate the need to use opioid-based medication in managing pain post-operation. These researchers compared the efficacy of this combination of medications with the impact of fentanyl, which is one of the most common opioid-based medications used in controlling and managing pain. Upon the analysis of the data, the researchers realized that the use of the combination of the medication eliminated the need to use fentanyl to manage pain in the postoperative recovery time. This source also shows the efficacy of non-opioid-based medication in managing pain.

The next study was conducted by Leas et al. (2019), who aimed to examine the safety, feasibility, and efficacy of the use of opioid-free medication in managing patient among patients undergoing shoulder arthroplasty. These researchers gave the patients gabapentin and celecoxib before undergoing the operation and gabapentin and ketorolac after the operation. The researchers observed low pain scores, which were stable even after one day. This observation indicated that non-opioid-based medications could be key in managing pain post-operation.

The Change Model

Change models are key in the EBP implementation process as they offer a framework upon which the parts of the project can be implemented appropriately. Therefore, it is important to choose the best and most relevant model that can successfully be used in the project, depending on the nature of the project. Therefore, the framework for change chosen for this project is the Iowa model of evidence-based practice. The Iowa model has five main steps that can be used in guiding a change process. The first step involves the identification of a problem or a trigger; this is followed by selecting, appraisal, and critiquing relevant research. The next step entails piloting the evidence-based practice change, with the fourth step entailing an integration and sustenance of the change. The final step involves the process of disseminating the implemented change to the stakeholders (Haulesi Chiwaula et al., 2021).

The Iowa model will be used in guiding the implementation of the proposed project using the five steps. The first step will entail the identification of the problem that is valid and relevant to the identified clinical setting. The successful identification of the problem will then be followed by formulating a focused and answerable question which will then be used in guiding the practice change of using non-opioid-based medications in controlling and managing pain among patients in the PACU. The next step entails selection and critiquing the available research (Haulesi Chiwaula et al., 2021). This involves a comprehensive literature review where the research is reviewed for its weakness, strength, and how they can be applied for practice change. It is important at this stage to let every stakeholder have an idea of what the proposed change entails and how it is likely to impact them. This involves offering relevant education to the stakeholders and the staff so that they can develop a positive view regarding the change and visualize the change contents to enhance the successful implementation of the change initiative.

The next stage would then entail piloting the project after identifying relevant stakeholders and building teams that can assist in the implementation (Haulesi Chiwaula et al., 2021). One of the most important aspects is to identify a change agent or champion who can engage and influence the team as appropriate. It is important at this stage to pay attention to and listen to the feedback from stakeholders and staff so that necessary adjustments can be made to enhance the success of the change process. In addition, it is key to identify the possible barriers and timeously formulate possible solutions to overcome them. Sustaining change after piloting is key, and it is important to engage the stakeholders in every step. Change monitoring is important as it allows the process of making adjustments to various processes and ensuring that the change is sustainable. It is also key that the change is also embedded into the organizational culture.

In the final phase, the findings will be disseminated. Data and information obtained in every stage of the project will be distributed to help in making key decisions. According to Buckwalter et al. (2017), dissemination is an important step in the research process since it enables the leaders to engage in a fruitful decision-making process. As part of the plan, the senior leadership and valuable stakeholder will be key in disseminating the results for practice change as through them; the introduced change will be streamlined throughout the right channels.

The Implementation Plan

Implementation is one of the most important stages in the EBP project implementation. Therefore, it is important to come up with a timeous plan on how to implement the project (Melnyk & Fineout-Overholt, 2018). As such, this section focuses on the implementation plan.

The Project Setting

The project is to be implemented at Baylor St. Luke’s Medical Center in the cardiovascular postanesthesia care unit (PACU). Patients are admitted to the PACU after surgery to receive post-surgical care; once their recovery care is complete, which should be within 60 minutes, barring complications, the patient will be discharged or transferred to an appropriate post-surgical care unit. The targeted practice change entails using either non-opioid or opioid-based medication to manage pain. However, there is no particular consent for using the pain medication, and it is reflected in the Disclosure and Consent-Anesthesia and/or Perioperative pain management that is usually completed by the assigned anesthesiologists.

The Timeline

A project timeline is key in guiding how the project is implemented to help achieve particular goals within a specified timeline (Melnyk & Fineout-Overholt, 2018). The first item is to come up with education on the proposal and dissemination of the information. This is followed by the proposal implementation. A period of around one week will be appropriate to kick off the project. As part of the timeline, a daily data review will be undertaken to help in monitoring the progress with the exercise expected to run for one month upon implementation. The pre-and-post data will then be reviewed in an effort to evaluate change. Such a review is expected to take a period of one week. Lastly, the qualifying data will be presented to senior leadership and stakeholders during the weekly quality improvement meeting.

The Research Design

It is key in to consider the kind of research design to apply when conducting research as the accuracy and dependability of the results largely depend on the design. As such, a quantitative or a qualitative design can be chosen. In addition, a research design is also key in answering the research question. The three aspects of design, which include the strategy, structure, and plan, are all key when coming up with hypotheses, data analysis, and data interpretation (Bloomfield & Fisher, 2019). Therefore, the chosen design is quantitative research design as it is more robust and can prevent research factors that could influence bias. The best quantitative research design that fits this project is the experimental research design, as it offers a high level of control and has been known to be a gold standard for quantitative research design (Bloomfield & Fisher, 2019). This design will be key in studying the cause-and-effect relationships. While the intervention is using non-opioids, the study outcomes will be the verbalization of pain reduction as indicated in the 0-10 pain numeric scale.

The Implementation Methods.

Various methods will be used in implementing the project. One of the methods to be applied is the numerical rating scale, a self-reported pain assessment using a scale of 0-10 to verbalize where the patients’ pain lies after using the intervention. The lowest end of the scale, where there is 0, means that there is no pain, while the other end of the scale would suggest the worst pain that can be experienced by an individual. The project focuses on a pain rating of 3.

The Evaluation Plan

Evaluation is one of the most critical steps in the evidence-based practice project cycle. This phase comes immediately after the implementation phase. The major focus of this phase is to evaluate the outcomes and changes to ensure that the correct intervention has been implemented and if there is a need to make necessary adjustments for possible improvements. In addition, the evaluation process serves to find out how effective the processes used in the implementation have been. While interventions can be successful in the controlled trial period, there is no guarantee that the interventions can work well in clinical settings. As such, the process of evaluation of the EBP change also comes with monitoring which is key to identifying possible flaws and determining if the obtained results are different from what exists in the literature (Cardoso et al., 2021). As such, this section focuses on evaluating the efficacy of using non-opioids in comparison to the use of opioids to manage pain in the post-surgical patients in the postanesthesia care units.

The Expected Outcomes

The implementation of the proposed project is likely to impact the surgical patients in the postanesthesia care units to have better pain management as they are prone to have unsatisfactory pain management, which usually impacts their recovery negatively. According to the Centers for Disease Control, the benefits that could come from the limited use of opioids can outweigh the risks in the cases where pain management using non-opioid therapies are not adequate (CDC, 2022). One of the expected outcomes of this project is that the post-surgical individuals in the postanesthesia care unit will verbalize adequate pain management within an hour of using the administered non-opioid medication by using the numeric pain scale of 0-10. This verbalization is to be documented by the nurse in the Epic system.

Data Collection

It is important to visualize the nature of data collection methods to be applied as the accuracy and completeness of the data largely depend on the data collection methods. As earlier indicated, the experimental research design has been chosen as the design to use in this project. Therefore quantitative data will be collected and statistically analyzed. One characteristic of these kinds of data is that they can be measured or counted, and they can also be assigned numerical values, such as in the case of measuring a patient’s pain on a scale of 0-10. An ordinal scale is usually applied to the pain scale and reports the ordering and ranking of data (Kim, 2017).

It is important to use an appropriate tool when collecting data. Therefore, the numeric pain rating scale is to be used in collecting data. This pain rating scale has a scale that ranges from 0-10, where 0 represents no pain while 10 represents the worst pain that an individual could experience. The tool to be used is valid and simple to use. In addition, it is the most common tool that is used in reporting pain (Walker & Berde, 2019). The tool is also reliable since the patient validates it by showing on the pain scale how intense the pain is by choosing a numeric value between 0-10. The bigger the number, the more intense the pain.

The Statistical Test

Among the most used pain scores are the verbal rating scale (VRS), the numerical pain rating scale (NRS), and the visual analog scale (VAS). The pain scores are usually applied at predetermined intervals and are compared in a bid to understand if the medications like non-opioids in the proposed project are superior to the standard care offered. ANOVA can be applied in statistical testing or parametric testing, and variation analysis can be done if the pain scores are normally distributed (Nair & Diwan, 2020). Therefore, ANOVA has been selected as the most appropriate statistical test for the proposed EBP project

The Applied Methods

Electronic medical records are vital in data collection. Therefore, the healthcare system applies it in collecting patient data as it helps in capturing multiple sources of health information. The major focus of electronic medical records is to obtain patient information and generate a unique patient identification capable of eliminating potential errors (Melnyk, B., & Fineout-Overholt, 2018). As such, in this project, electronic medical records will be used in collecting data input from the anesthesiologists and nurses. Before surgery, the patients are to be asked to rate the pain they feel on a scale of 0-10 and where they would desire their pain to be post-surgery. This data will be vital and valuable in measuring the pain management treatment results and accomplishing evaluation.

Framework or Model for Change

Selected Model

The trans-theoretical model of change will be employed for implementing the evidence-based proposal project. Prochaska and DiClemente developed the model to guide organizational changes. It providers strategies needed in organizations for the implementation of change. The applicability of the model is that it will promote systematic implementation of change as well as monitoring and evaluation of the change initiatives. The steps of change, as stated in the model include pre-contemplation, contemplation, preparation, action, maintenance, and termination (Singh & Ramdeo, 2020).

Stages of Change and their Application

Pre-contemplation is the first stage in the model where the adopters are unaware of the need for change and not ready to change their behaviors in the near future. They lack understanding of the negative effect of their current behaviors on organizational outcomes. The nurses and other healthcare providers are not aware of the benefits of integration of health information technology on safety and quality of care at this step. They do not intend to change their approaches to medication administration in the organization (Singh & Ramdeo, 2020).

Contemplation is the second step where there is a willingness for change from the adopters. They understand the benefits of change and need for innovative practices in their routines (Hodges, 2020). Nurses and other healthcare providers are aware of the disadvantages of their behaviors on patient safety, making them contemplate adopting integrated health information systems to prevent medication errors. Preparation is the third step where the adopters are prepared to implement the change in the near future. They are aware of the benefits and risks of the change in their routines. They initiate steps that would ensure desired change in their routines. Nurses and other healthcare providers start using integrated health information systems in this stage (Singh & Ramdeo, 2020). They use it gradually focusing on its strengths, weaknesses, and opportunities to enhance its effectiveness in use.

Action is the fourth step in the model where the implementers have embraced the change and are willing to sustain its use. The implementers modify their actions to support the successful implementation process. Nurses and other healthcare providers have experienced the benefits of the change in this step and willing to change their behaviors to sustain the change (Lynda et al., 2021). Maintenance is the fifth step where the implementers have achieved sustainable change and willing to engage in activities that prevent relapse in behaviors. Nurses and other healthcare providers have understood the benefits of change on medication safety. As a result, they strengthen successful behaviors needed for the change. Termination is the last stage where the implementers are not willing anymore to relapse to their old behaviors that increased medication administration errors (Singh & Ramdeo, 2020). The nurses and other healthcare providers have not willing to use the conventional methods in this stage. As a result, the change is incorporated into the organizational culture for its sustained and consistent use in patient care.