NR 446 Week 7 Daily Weights Change Project Proposal Example

Weighing Before Breakfast: A Change Project Proposal to Reduce Missed Daily Weights on a Cardiac Telemetry Unit

Student Name

College of Nursing, Chamberlain University

NR 446: Collaborative Healthcare

Instructor Name

Month Day, Year

Weighing Before Breakfast: A Change Project Proposal to Reduce Missed Daily Weights on a Cardiac Telemetry Unit

The Problem, Sized Locally

On a composite 30-bed cardiac telemetry unit, most patients admitted with heart failure, and many receiving intravenous diuretics for other reasons, have an order for a daily weight. The weight is the number the cardiology team uses each morning to decide whether to continue, increase or stop a diuretic. The unit already tracks daily weight completion on its quality board: over the last eight weeks, 64 of every 100 ordered daily weights were documented before 0800 rounds, 19 were documented later in the day, and 17 were not documented at all. Of the weights that were documented, a spot check of 30 found that 11 were taken on a bed scale and 19 on the standing scale, with the method recorded in only 9. A weight taken on a different scale from yesterday's, at a different time and after breakfast, can differ by a kilogram or more for reasons unrelated to fluid, which makes it useless for the decision it exists to support.

The Change, in Operational Terms

The change is to one routine. Every patient with a daily weight order will be weighed between 0500 and 0600, after voiding and before breakfast, on the standing scale if they can stand safely for 30 seconds and on the same bed scale each day if they cannot, in a hospital gown with no shoes. The nursing assistant assigned to the patient takes the weight during the 0500 vital signs round and records it in the flowsheet with the scale used, which will become a required field. If the weight differs from the previous day by more than 1 kilogram, the nursing assistant tells the registered nurse, who rechecks it before 0630 and notes the recheck. A laminated card on each scale will list the steps. Nothing else about the patient's care changes.

The Change Model Behind the Plan

The plan follows Lewin's three stages of planned change, unfreezing, moving and refreezing (Lewin, 1951), and the stages appear in the order of the steps rather than as a label. Unfreezing comes first: at two staff meetings, the unit will see its own completion data and a single example of a patient whose diuretic was held because a bed-scale weight taken after lunch looked like a two-kilogram loss. Moving comes next: a two-week pilot on one hallway of ten rooms, with the laminated cards and the required scale field, and a daily five-minute check at the 0700 huddle. Refreezing follows: the routine becomes the unit standard, the scale field stays required, and completion before 0800 becomes a line on the monthly quality board reviewed by the nurse manager. Shirey (2013) notes that the refreezing stage is where most unit changes fail, because the new behavior is never anchored in a system, and the required field and the quality board line are the anchors here.

Stakeholders and Their Real Reasons

Nursing assistants carry most of the change, and their interest cuts both ways: they want fewer end-of-shift arguments about missing weights, but 0500 is already their busiest hour, and adding a walk to the standing scale for eight patients takes time. Their concern is legitimate, and the pilot will measure how long the 0500 round takes before and after. Night registered nurses gain reliable data at morning report but will have to recheck outliers at the busiest point of their shift. The cardiology team gains a trustworthy number for diuretic decisions and has supported the change; the cardiology nurse practitioner has agreed to speak at the first staff meeting. Physical therapy has a real concern that some patients are unsafe to stand at 0500 when orthostatic; the plan answers it by allowing the same bed scale daily for anyone who cannot stand safely, rather than pushing every patient onto the standing scale. Patients themselves may resist being woken at 0500, and the plan does not pretend otherwise; the weight is paired with vital signs that already wake them, so it adds a step but not a new interruption.

One Measure and Its Baseline

The measure is the percentage of ordered daily weights documented between 0500 and 0800 with the scale type recorded. The baseline, from the eight weeks before the pilot, is 64 of every 100 for timing and fewer than a third for scale type. The measure will be read weekly during the two-week pilot on the pilot hallway, then monthly for three months on the whole unit. The target is 90 of every 100 weights documented on time with the scale recorded by the end of the third month. A balancing measure, the average time the nursing assistant 0500 round takes, will be timed on three mornings before and three mornings after the pilot begins, so that the unit can see what the change costs. Weekly and monthly values will be plotted on a run chart rather than compared as two averages, because a run chart shows whether a change holds over time or only appeared during the weeks when everyone was paying attention (Provost & Murray, 2011).

Barriers Named, Not Solved on Paper

Three barriers are likely, and the proposal does not pretend to solve them in advance. The unit has one standing scale for 30 beds, so on mornings with many patients who can stand, the nursing assistants will queue at the scale; the pilot will show whether a second scale is needed, which would be a purchase request for the manager. Patients on fluid restrictions sometimes drink water from their bedside cup before 0500, and nothing in this plan prevents that. And the required scale field depends on an informatics request that may take weeks. Each barrier will be recorded during the pilot, and the unit practice council will decide what to do about each one with pilot data in hand rather than with guesses.

What I Can Start Alone and What Needs Approval

Some of this I can start next week without anyone's permission. I can weigh my own patients at 0500 on the same scale, record the scale, and bring the unit's completion data to the next staff meeting. I can also make the laminated cards. The rest needs approval. The two-week pilot needs the nurse manager's agreement and the night charge nurse's support. The required scale field needs the nursing informatics team, and adding the measure to the quality board needs the manager. I will ask for the pilot at the next staff meeting, with the baseline data and the cardiology nurse practitioner present, and I will not claim that the change is unit practice until the manager has approved it.

References

Lewin, K. (1951). Field theory in social science: Selected theoretical papers (D. Cartwright, Ed.). Harper & Row.

Provost, L. P., & Murray, S. K. (2011). The health care data guide: Learning from data for improvement. Jossey-Bass.

Shirey, M. R. (2013). Lewin's theory of planned change as a strategic resource. Journal of Nursing Administration, 43(2), 69-72. https://doi.org/10.1097/NNA.0b013e31827f20a9