NR 528 Week 7 Barrier Mitigation Brief Example

Barrier Mitigation Brief: Six Objections to the Head-of-Bed Practice We Can Already See Coming, Each Turned Into a Step With an Owner, a Date or a Purchase

Student Name

College of Nursing, Chamberlain University

NR 528: Leading and Managing Evidence-Based Change in Nursing

Instructor Name

Month Day, Year

Barrier Mitigation Brief: Six Objections to the Head-of-Bed Practice We Can Already See Coming, Each Turned Into a Step With an Owner, a Date or a Purchase

Purpose

This brief addresses the objections staff have raised, or are likely to raise, about keeping continuously tube-fed patients raised between 30 and 45 degrees on our progressive care unit. An objection answered with an argument is still an objection; a nurse told why the practice matters will still lower the bed if a patient keeps sliding down. Each barrier below is therefore turned into something concrete: a step with an owner, a changed date, a person freed for a period or an item purchased. The barriers came from a ten-minute discussion at each shift's huddle and from the wound care nurse.

Barrier 1: Patients Slide Down the Bed

The objection. At 30 degrees or higher, patients slide toward the foot of the bed within an hour, end up hunched with their chin on their chest, and ask to be lowered. Pulling them up takes two staff members.

The step. Raise the knee section of the bed slightly before raising the head, which reduces sliding, and keep friction-reducing slide sheets in every tube-fed patient's room. The wound care nurse will teach the knee-first technique in the nursing assistant huddle in week 7. The charge nurse will stock one slide sheet per tube-fed room; the unit has eight, so the manager has approved purchasing 20 more, due in week 6.

Barrier 2: Pressure on the Sacrum and Heels

The objection. Higher angles increase pressure and shear on the sacrum, and the wound care nurse is concerned about pressure injuries in patients who may be at 30 degrees for days.

The step. Any patient expected to be on continuous feeding for more than 72 hours will be placed on a pressure-redistribution mattress, requested through bed management at admission; the wound care nurse owns this rule and will review each such patient's skin twice weekly for the first month. Heels will be offloaded with pillows or boots. The measurement plan counts new sacral and heel injuries monthly, so a rise will be seen.

Barrier 3: Night Baths and Linen Changes

The objection. Night shift bathes most patients between 0300 and 0500, which means lowering the bed, and at that hour nurses forget to raise it again before restarting the feeding.

The step. Move bathing for tube-fed patients to the day shift where patient condition allows, a change owned by the day and night charge nurses and starting at go-live. For patients who must be bathed at night, the pause-and-restart rule applies, and a reminder label reading "Head up to 30 before restart" will be placed on every feeding pump in week 6 by the project lead.

Barrier 4: Float and Agency Nurses Do Not Know the Practice

The objection. Staff who were not at the teaching sessions will not know the practice, and they cover several shifts a week.

The step. A one-page card describing the practice will be added to the float and agency orientation packet in week 7, owned by the unit educator. The charge nurse will tell every float or agency nurse assigned a tube-fed patient at the start of the shift.

Barrier 5: Transport and Imaging Lower the Bed

The objection. Patients return from radiology or procedures flat, and the bed is not raised until someone notices.

The step. The transport team's return checklist will include "head of bed to 30 degrees for tube-fed patients," requested from the transport supervisor in week 3. Until it is added, the receiving nurse checks the angle on every return.

Barrier 6: No Order When the Head Must Stay Down

The objection. Some patients cannot have the head raised, but there is no standard way to document that, so nurses guess.

The step. A standard contraindication order will be added to the order set through the forms committee in week 4, with the flowsheet field going live in week 6. Until then, the charge nurse asks the provider to write a note in the chart.

Barriers Not Yet Solved

Two objections have no satisfying answer yet, and the brief says so. First, some patients simply find 30 degrees uncomfortable for sleep and ask to be lowered. The practice allows no exception for comfort alone, but nurses will face a patient with capacity who refuses. The plan is to explain the reason, offer pillows and repositioning, and, if the patient still declines, pause the feeding while the bed is lowered and document the refusal; the unit's practice council will review how often this happens after two months. Second, the unit has two older beds whose head sections drift down over several hours. Biomedical engineering has been asked to inspect them, but replacement may take months, and until then patients on continuous feeding will not be placed in those beds when others are free.

How New Barriers Will Be Handled

More objections will appear once the practice goes live. Any staff member can write a barrier on the sheet posted in the break room. Each Monday, the project lead will review the sheet with a charge nurse and assign each new barrier an owner and a step, or record why it cannot be addressed yet. Barriers and their steps will be shared at the next huddle, so that staff see their objections turning into changes rather than disappearing.

Why These Steps Are Worth Their Cost

The steps cost money, 20 slide sheets and a few mattress rentals, and time, including the wound care nurse's reviews and the educator's orientation card. Each is small compared with the cost of an aspiration event. Two sources anchor the practice: a nutrition support guideline placing high-risk enterally fed adults at 30 to 45 degrees (McClave et al., 2016), and a critical care nursing alert setting 30 degrees as the floor unless contraindicated (American Association of Critical-Care Nurses, 2016). In one tested protocol, close to nine of every ten patients were kept at or above 30 degrees (Metheny et al., 2010), which suggests the barriers can be overcome when they are addressed directly.

A Note on Tone

Every objection in this brief came from someone who cares about patients. A nurse who worries about sacral skin, or about a patient sliding down the bed, is raising a real clinical concern, not resisting for its own sake. The responses above are written to be said aloud at huddle to colleagues, not handed down to them.

References

American Association of Critical-Care Nurses. (2016). Prevention of aspiration in adults [Practice alert]. Critical Care Nurse, 36(1), e20-e24. https://doi.org/10.4037/ccn2016831

McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., McCarthy, M. S., Davanos, E., Rice, T. W., Cresci, G. A., Gervasio, J. M., Sacks, G. S., Roberts, P. R., & Compher, C. (2016). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211. https://doi.org/10.1177/0148607115621863

Metheny, N. A., Davis-Jackson, J., & Stewart, B. J. (2010). Effectiveness of an aspiration risk-reduction protocol. Nursing Research, 59(1), 18-25. https://doi.org/10.1097/NNR.0b013e3181c3ba05