The author’s intention is to identify an aspect of clinical practice which lends itself to change at a micro level. The definition of a micro-change is an intervention of change aimed at the individual or the way small teams work. The micro-level change is not to be confused with a service change (Walsh, 2009).

When considering a change in practice we need to firstly understand why we need to make a change? Secondly when making a change, we need to justify a decision. This can be achieved by exploring the components which encompass decision making within nursing practice. Cullum et al (2007) identifies four requirements:-Clinical experience, valid researched evidence, available resources and lastly but no less important the patient preferences and experiences.

The area of clinical practice to be studied is within a community district nursing team consisting of 7 qualified nurses and 3 health care assistants. The location is situated within a seaside town with a large population of over 65 year olds. Through clinical experience, the author has found a flaw in quality of care when nursing staff are using the overview assessment document which has been adapted from the single assessment process produced by the Department of Health (DOH, 2002). When assessing nutrition there is a series of six questions and an asterisk to consider the “Malnutrition Universal Screening Tool” (MUST, 2003) however experience in practice would suggest the tool (MUST, 2003) isn't used and a local unknown screening tool is used on some rare occasions. The author feels management of these vulnerable patients is lacking and in order to improve patient care a clarification of guidance and service change maybe required.

Exploring Cullum's (2007) theory of decision making, the author needs to justify the service change with valid researched evidence. As a nurse in practice it can be argued that evidence based practice isn’t routinely reviewed as part of our practice and guidance is given from colleagues and Pravikoff et al (2005) acknowledges this. However Melnyk et al (2004) also recognized that nurses as individuals need to be educated on acquiring valid evidence. Consequently Melnyk et al (2004) believes practitioners’ should have access to evidence based mentors’ and be able to attend workshops. Harbison (2001) alleges nurses’ are resistant to analysis of new approaches, this in reflection correlates strongly in current practice with some colleagues.

The author considers the simplest way of finding out best practice is by using guidelines. According to Field & Lohr (1992) guidelines are “systematic developed statements to assist practitioners and patients decisions for specific clinical circumstances.” Evidence is always current and a generous collection of many different systematic research reviews with multiple random control trials are available (AGREE, 2000). These types of trials are graded at the top level of hierarchy (Guyatt et al 2002).Nevertheless in contrast Devereaux and Yusuf (2005) argue that top level hierarchy is not a guaranteed deviation from the truth in randomized trials. The clinical guidance used is the National Institute of Clinical Guidance (NICE 2009) is based in the author’s homeland and is an independent organisation responsible for providing guidelines. The ethos behind NICE (2009) is to promote and prevent poor health nationally involving the public, health professionals and patients in the process (NICE 2009).

In 2006, NICE published the guidelines on Nutritional support in adults – oral nutrition support, enteral tube feeding and parental nutrition (NICE 2006). There is a section within the guidance named “Screening for malnutrition and the risk of malnutrition in hospital and the community” (NICE 2006 pp63-69) this section inevitably lends itself to the author’s micro change in development. The recommendation within the guideline agrees that malnutrition is a major concern in healthcare and accepts the need for health professionals in the community to screen patients. However, only if there is clinical concern e.g. wound care or weight loss. The guideline also supports the need to routinely take assessment of weight and height to determine body mass index (BMI) and risk of malnutrition. Arrowsmith (1999) and Jones (2002) both argue the fact that many nutritional screening tools have been developed without using a BMI. According to the guidance, “screening should also be considered if there is a likelihood of future weight loss or impairment of nutritional intake”. In conclusion for the recommendation to be carried out, NICE (2006) state “The Malnutrition Universal Screening Tool (MUST, 2003), for example may be used”.

However, the research recommendations appear problematic, the end quote for example “may be used” is vague. The guidance development group (NICE 2006) criticizes the lack of evidence in supporting the claim that screening methods are beneficial in general .To combat this problem, they develop a consensus statement and summarize “ as a priority it is important that we determine the need for screening and intervention in the community’(NICE,2006).

The contributing studies within the nutritional report (NICE 2006) felt malnourished people could be highlighted as a risk using the tool and the supplements were a benefit although conversely the mortality rates didn’t change (Wouters-Wesseling, 2002) .Cost effectiveness of screening is also a key issue in any guideline and there was limited evidence to substantiate. Douglas and Normand (2005) report that NICE guidance (2004) is having a top down effect on managers in nursing, however nurse managers still need to be aware of cost at a local level. Only one study completed in three hospitals in the Netherland, which showed an increase in patient weight gain (Rypkema et al, 2004). The results lacked validity as cost effectiveness could not be weighed up with the patients’ variable length of stay (NICE 2006). The author at this point was confused and felt let down by the supposed hierarchy of knowledge. There was certainly a gap in the evidence which needs investigation. As suggested by NICE there is further research recommendations needed (NICE, 2006).

Having read the guidance the author needs to research other hierarchies of evidence to gain a bigger range of evidence. When researching evidence based practice Nollan et al (2005) believes it is imperative to formulate a concise structured question when searching for evidence required. On reflection in practice the author would admit in the past to conducting a literature search by inputting on the computer with many a “one word search” which gave a very poor outcome. The end resulting spurning out every research paper known to man, without the one specific area required.

A helpful tool in formulating a concise question can be useful for practitioners. PICO format (Sackett et al 2005) covers four elements of structuring a question enabling the practitioner to select better quality research. Using the author’s question as an example, a direct comparison of the Universal MUST tool against local tools or none at all would be needed to be analysed in order to highlight the best tool to be used for patient care. This will illustrate the evidence which needs to be provided to determine service change. Elements of the PICO format (Sackett et al 2005) can be broken down and they are as follows:-. The first being the population, this may relate to a specific patient group. In the author’s case the patient group is considered to be the over 65 year olds. The second consideration is the intervention or area of interest. In this section the author believes this to be the use of the Universal MUST screening tool to record malnutrition in the primary care setting. The third intervention would be the comparison of the subject. In the author’s case study another local tool is used or none at all. The last element is the outcome, which we are hoping to achieve. The case study is looking at patient care and the author would like to see a reduction in malnutrition. When the author synthesised the components together a question was developed:- In over 65 year olds does the use of the Universal MUST screening tool achieve good patient care and a reduction of malnutrition in the primary care setting compared to using a local nutritional screening tool or none at all?

A review of the available literature provides an abundance of examples highlighted the problems with malnutrition as highlighted in the NICE guidance( 2006) and the need to use a nutritional screening tool is also recognised (Burden et al 2001, Scott 2008, Fletcher 2008 and Whitehead et al 2008). The evidence signals a need for the chosen nutritional tool to be validated. Fletcher (2008), Scott (2008) and Elia (2003) all advocate the use of the MUST tool, partly due to the tool been validated. Burden et al (2001) emphasises the need to choose a tool which actually becomes reliable with consistent results. Arrowsmith (1999) indicates “that measuring the sensitivity and specificity of nutritional screening will only identify the accuracy of the classification of the results of the screening”

Within the PICO results Raja et al (2008) attempted to compare the use of the MUST tool against the Malnutrition Screening Tool. The study involved a combined method of design using both qualitative and quantitative studies, this included a focus group and survey of patients’ records. Kyle (2006) found the MUST gave a sensitivity result of 61% and a specificity of 76%.The gold standard of tests would be predicting as near to 100% as possible (Walsh, 2009) The author translates the results to indicate fair results for picking up patients with nutrition, but this also indicates a fair amount of people who are screened and do not have malnutrition in relation to the specificity. The sensitivity of the validated MST tool gave results of 93% sensitivity and specificity (Ferguson et al 1999) showing good convergent and predictive validity. This perhaps would suggest the MST as a better tool for picking up malnutrition.

Interestingly, the PICO question did not lead the author to any clinical guidelines however It did answer the question focusing on the author’s micro change, the guidance suggests the use of a validated screening tool which has all the attributes of the MUST tool. In comparison the currently used local nutritional tool has not been validated and does not match the requirement that NICE guidance supports (NICE 2006). The author feels that some areas didn’t reflect in the PICO question as there is no specific age group to the results amongst other factors. Possibly this is due to the formalization of the question.

As the author has found a need for a micro change, the question should be how will the change be made? In practice the author needs to devise and implement a micro-change to stop nurses in practice using the local nutritional tool and to enforce the evidence based method of screening MUST tool (2003).In order to achieve this, available resources of change need to be analysed (Callum et al, 2007).

Rimmer et al (1998) identifies structured conceptual models’ to enable practitioners to focus on implementation of change in practice. Rimmer et al (1998) also reports that models have been used many times in practice and there are two different types of models which lend themselves to change: - classical models and planned models. To enable the author to make a decision on which type of model, it is important to critically evaluate each type of model by focusing on one or more from each model and applying the author’s own micro-change to the concept.

Classical Approach
Everett Rogers is a classical theorist who first developed his beliefs in 1962 on diffusion (2003). Previously he had studied farmers in Iowa and had some experience of working within the health care system. Classical theories lend themselves to more descriptive ideas and there’s no design within the model to cause a change (Cullum, 2007) “Diffusion is the process in which an innovation is communicated through certain channels over time amongst the members of the social system (Rogers 2003p.5). Rogers (2003) has five innovation factors influencing adoption. The author will work through each one applying the proposed micro change:-
Relative advantage- How much better is this than what it replaces? The MUST tool in practice would be cost –effective as it is free. The NICE guideline development group has patients on the board which ensures patient choice and above all the tool is validated and is suggested by NICE a national guidance tool (NICE 2006).
Compatibility- with existing values, beliefs and practice
Currently the team is using a local tool or none at all. The author highlights the similarity of the previous tool which is already in use. The NMC Code of Conduct (2008) state it’s in patients’ best interest to give quality, evidence based care. The single assessment overview already suggests the tool and the overview assessment originates from the Department of Health (2002).
Complexity-How difficult is the innovation to use or understand?
The MUST tool is easy to use with only a one hour training session. There is also a simple step by step system in collecting data.
Trial ability-Can you try it out on a small scale?
The author would suggest trialing the MUST tool for one month and then evaluate the use of the tool with a team meeting and possible patient audits.
Observability -Can people see immediate results/benefits/
The author felt that staff would develop more of an awareness of malnutrition, however no immediate benefits would be seen. After using the tool consistently staff would find the tool quick and easy to use.

Within the factors of adoption, Rogers realized the importance of personal communication to the people accepting the innovation, face to face communication was imperative (2003). The author would set up a planned meeting to encourage good communication and discuss the proposed tool within the team. The clinical guidelines would be discussed, a one hour training session on the tool would be put in place and the author would discuss the innovation factors within the team asking for team feedback. Rogers believed people needed to evaluate innovations subjectively by involving others (2003).
Rogers (2003) also believed the dynamics of the team in practice would influence the innovation. People can be described as having negative or positive tendencies to change. Heterophilly people tend to like new ideas and change. Furthermore these people like to interact with different people. Negatively, homophily people tend not to like change at all, staying in their own comfort zone and interacting with similar people to themselves. Therefore, the heterophilly agents tend to lend themselves as the innovators of change, with early adopters and the early majority on the over hand heterophilly people lend themselves as the late adopters or skeptics and the very staunch traditionalist as the laggards.

On reflection the author can identify each person within the team using the adopter categories. Subsequently the author would aim the innovation at the early innovators in order to gain confidence within the team. Rate of adoption can evaluate the innovation and Rogers’s diffusion Curve highlights a slow rate of adoption at first when the innovators believe in the change but as time progresses the early adopters and majority agree eventually the innovation takes hold. If the rate of adoption doesn’t increase the innovation has failed.
Planned change approach

In a planned change approach the model is set with logical concepts that are explained in a systematic way .The RNAO Toolkit was developed by Alba DiCenso and a team of Canadian nurses (2005). The purpose was to set up a guideline implementation using a six step approach. The author will critically evaluate the planned change model using Di Censo’s RNAO Toolkit (2005), applying the author’s own micro-change to the concept.
Step 1- Implementation of Clinical Practice Guidelines
The author needs to identify a credible organization as step 1. Previously the National Institute of Clinical Excellence (2006) was chosen due to its credibility and was also easily accessible on the computer. Once the guideline has been chosen the stakeholder involvement has to be identified. There are many external stakeholders identified largely representing prescribed nutritional feeds and drinks .Most importantly these stakeholder are bound to benefit financially if the guidelines encourage nutritional aids. Internally a large amount of hospitals, primary care trusts and many patient career organizations have involvement (NICE, 2006) when stakeholders have been identified four to six members of the team need to review the guideline (AGREE, 2000). The review seems thorough, however the author doesn’t consider this to be manageable in practice, due to time constraints. The process seems to lend itself to a more organizational change rather than a micro-change.
Recommendations from the guidance will then need to be identified. In the NICE guidance (2006) the recommendations around screening possibility of a nutritional tool for example MUST (2003), however the recommendation does suggest further research required due to the barriers of lack of evidence. However the end recommendation was passed on consensus.

Step 2-Identifying, Analyzing, and Engaging Your Stakeholders
“Individuals, groups, and/or organizations who may have a vested interest in your decision to implement CPGs, and who may attempt to influence your decisions and actions as you develop your implementation plans”(RNAO). The author identified both external and internal stake holders within the practice.
External Stakeholders Identified
GPs, dietician, pharmacy, patient and other district nursing teams.
Internal Stakeholders Identified
Team, patients, managers
In identifying the stakeholders who have the most interest the author can identify stakeholders’ threats and offer high support and interest (RNAO, 2005) Rogers’s theory also identifies these people as possible laggards in practice (2003).

Step 3- Assessing Your Environmental Readiness
Within this section of the toolkit, Alba Di Censo et al (2005) believes there has to be a particular blend of attributes to enable any change in practice to work. The author would translate this as setting the groundwork for change. In general the team will need to identify barriers to setting up a change such as workload, also ensure people can engage evidenced based change and communication of the change is managed and well planned. The author will also need to ensure management support is given to encourage success and most importantly the team are motivated to change.
Step 4-Deciding on Your Implementation Strategies
Once the previous steps have been successfully achieved, the concept needs to be put into practice using suggested different forms of strategies ( Di Censo 2005).These strategies could be in the form of interactive educational meetings, a more multi-faceted intervention such as audit/feedback, marketing and not forgetting informing patients and getting feedback from them. Within the tool kit, studies have been compiled to analyse effectiveness of these strategies (Thomas et al 1999).The results evaluated effectiveness but found the strategies lend themselves to the medical practice as opposed to nursing.

Step 5- Evaluating Your Success

Once the plan is in action, Di Censo (2005) expresses the need for measuring the out-come. There would need to be a trial period in order for an evaluation of results. In the au-thor’s micro-change, a trial of one month would be arranged and evaluated by the team after one month. The team would be able to analyse the good and bad points and come to a decision with an action plan. Unfortunately, it would be difficult to evaluate the outcome of malnutrition.

What About Your Resources?
If the plan is evaluated and confirmed as been valid the creation will need a budget. In the author’s micro-change, a budget will not be required as the paperwork is already in place and staff will have the clarification to use the tool. Persuasion of administrators’ will also not be required as the intervention does not change from the guidance. The author feels this again relates to organizational change.

Another planned change model

NICE have their own model of implementation which has six principles (2007). These principles relate very much with management hierarchy therefore supporting a change from the top level management. The description of the model clearly stated organization change. The author felt the model was inappropriate for use due to it’s out of reach prin-ciples.

In conclusion the author feels there are many similarities in the different models which were looked at and analysed. The RNAO Tool kit (2005) does have a very comprehensive systematic step by step tool which identifies all areas of concern. Step 1 highlights the importance of analysis of guidance which lends itself to more operational changes in practice. The tool kit’s origins are very evidence based and current within nursing practice.

The traditional classical theory is a more descriptive approach which lacks in the ability to change anything in practice. However the tool is usable when considering the author’s specific micro-change which isn’t particularly expecting to change anything but clarifies an existing guidance. Communication and team dynamics will make a massive difference in the result of the innovation working. Within small teams, there is still a need to discuss with stakeholders but when a clarification of guidance is only required, the innovator does not need to grade the guidance or ask for funding. The author without doubt believes in RNAO (2005) for use with organisational changes but not in this case study.

The NICE Guidance toolkit (2009) appears to be untouchable at ground level and would be best suited at high end management. Within any of the concepts there is a difficulty in measuring the outcome and quality of malnutrition due to no previous collection of data within the practice area.

3539 WORD COUNT

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