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This essay is a summary of five articles and critique of two articles in relation to Lewin's theory. The power of Lewin's theory lies in his ability to come up with models of various that draws attention to the right type of variables that needed to be observed and conceptualized. Of all the most powerful is the model of the process of change in systems of human beings. This model is fundamental in explanation of various phenomena as it allows itself very well to elaboration and refinement. The discussion in this essay will be about change management in relation to the Lewin theory.
Effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers
This is the title to the first article. Pressure ulcers are basically ulcers on the skin caused by friction or shearing at weight bearing points of the body especially in immobilized persons. Pressure ulcers pose serious complications of hospitalization that should be prevented at all costs. Damage to the skin is usually caused by pressure and shearing forces that can be avoided by effective preventive measures. Pressure relieving cushions, mattresses, and postures reduce the magnitude of pressure and the shearing forces. Alternating pressure air mattresses and repositioning help in the reduction of pressure and shearing forces. These mattresses usually generate alternating high and low border pressure between a patient's body and the support by alternating deflation and inflation of air filled cells. The main purpose of this study was to determine whether alternating pressure air mattresses are more effective than the other conventional preventive methods. Randomized controlled trial was preferred as the appropriate design to asses this effectiveness (Vander wee K. et al. 2010 p266).
Randomized controlled trials were carried out in several hospitals on patients who were picked basing on their age, duration of hospital stay, body weight, and patient's need for preventive measures. This need was measured using the Braden Scale and the presence of a grade 1 pressure ulcer, which defines a patient's risk status. Patients were then exposed to these two conditions and monitored for some time. A daily assessment of the occurrence of ulcers was done by ward nurses and some patients were randomly sampled and observed at unexpected times and results recorded. At the end of it all, it was observed that despite carrying out all the required preventive measures, a substantial number of patients who had been identified as being at risk, went ahead to develop pressure ulcers. The incidence of these ulcers was compared in patients both in the use of alternating pressure air mattresses and the standard method. It emerged that those using alternating pressure air mattresses developed severe pressure ulcers than those in the control group. It was also discovered that constant low pressure is more damaging than the alternating one (Vander wee K. et al. 2010 p266).
Systematic reviews of wound care management.
This is the second article on the summary list. The prevalence of chronic wounds such as leg ulcers and pressure ulcers is high in many health care settings. Many strategies are involved in their treatment like the use of pressure relieving mattresses and cushions to prevent and treat pressure ulcers, and compression therapy to treat leg ulcers. The article looked at the clinical effectiveness and cost effectiveness of pressure relieving mattresses and cushions. Information was sourced from electronic data bases and controlled trials register, journals and conference proceedings. The study used randomized control trials which evaluated the outcome measures of the incidence of ulcers and rate of healing. 45 random controlled trials were done whereby 40 looked at the different mattresses and mattresses overlays, only two trials looked at cushions. Studies were small and the quality of methodology was also poor. However it was clear that foam alternatives to the common standard hospital foam mattresses greatly reduce incidences of pressure ulcers in those patients at risk as well as pressure overlays on operating tables. It also emerged that air fluidized therapy increases the healing rates of pressure ulcers (Cullum, 2001 p1).
Alternating pressure air cushions
The third article is titled alternating pressure air cushions. Alternating pressure cushions that are available commercially are used for the prevention and treatment of pressure sores. They are said to increase tissue perfusion by decreasing and increasing the pressure that the body applies on the sitting area. There has been an improvement in the sitting systems following the increased interest in the subject. Allegations have been there that the hammock seat and the back of the conventional wheel chairs do not provide enough support to a patient's pelvis and the spine. This calls for necessary measures to be taken so that a comfortable and functional posture is achieved; making sure that there is minimal risk that can cause the development of deformities and pressure ulcers. This will enable wheelchair users to achieve their full potential in their endeavors. The many support surfaces that are used reduce the concentration of pressure on local areas by distributing it over a large area. These surfaces include foam, gel, and gastric air cushions. But the alternating pressure air cushions achieve pressure relieve through a system of cells that deflate and inflate alternately bringing about a low pressure interface that ensures an adequate tissue perfusion level (Attard 1997, p1).
The function of alternating pressure air cushions depend on time and therefore one should factor in time because the effectiveness of pressure relieve is strongly related to the period of time in which the interface pressure remains below the closure pressure of the capillary. This study looked at the effectiveness of four alternating pressure air cushions. A sample of volunteers was picked a subjected to observation using the four types of alternating pressure air cushions. These included the Alpha Trancell-Active Pressure Relief Seat Cushion, Bellows Air Support Equipment (BASE)-Sequential Seating System, Care Chair- Dynamic Posture System, and the Pro-active Seating System. For each chairs subjects were observed in comparison with a standard chair and results recorded. The maximum, minimum, and mean interface pressure together with the cushion's air pressure were recorded for each cushion. Characteristics of pressure relief were also obtained as a percentage of the time the interface pressure took to remain below the particular threshold for a cycle. It was then converted to pressure relief per hour. Results showed that the Alpha Trancell gave better pressure than the others. The BASE and Pro-active cushions were not able to give enough pressure relief as the other two. It was also observed that body weight affected the extent of magnitude interface pressure between the body and the surface. It was noted that it is not enough just to look at support surface in terms of pressure interface. Other factors such as age, level of activity, and an individual's motivation should be considered (Attard 1997, p1).
Pressure relieving mobility aids
The forth article is on pressure relieving mobility aids. Pressure ulcers are damaged skin parts that usually affect the bonny parts of the body which if not treated can lead to body complications and even death. They come about if a person stays in the same position for a long time without moving. This is mostly in the helpless members of the community such as the elderly and the sick. That is why pressure relieve is important. Pressure relieving mattresses and cushions are used for this purpose. These devices have supportive or memory foam base that helps in the reduction of pressure. Some mattresses ae flexible making them suitable for the electric adjustable mobility beds. Foam and fiber mattress overlays allow air to circulate between the mattress and the patient's body reducing moisture build up that may bring ulcers. Alternating pressure devices vary pressure mechanically and are therefore said not to be suitable to patients with fractures. For those who sit in one place for a considerable amount of time, they should be provided with pressure relieving cushions to reduce the risk of ulcer development. Common cushions include the ring cushions which are usually round and inflatable and the waffle ones which have ventilation holes and can also be inflated to allow air circulation. Cushions are very important especially when considering buying a wheel chair for a patient. Pressure relieving devices are therefore important in making sure that development of pressure ulcers does not happen and that patients remain comfortable although regular change of position is the best way to prevent and treat ulcers (Pressure 2006, p1).
Pressure ulcer prevention and management: Using mattresses and cushions
The last article on the summary list is titled pressure ulcer prevention and management. There is no doubt that pressure ulcers cause a lot pain and suffering to many people and also cost hospitals a lot of money. That is why pressure relieving equipments are important. Deciding on which equipment to use depends on the cost, the patient's needs and the knowledge of use by the patient's care giver. All care givers should know that pressure relieving equipments are not sufficient but should be supplemented by other measures like regular repositioning of the patient. Staff should be trained on how to use pressure relieving equipment so that patients are not left vulnerable and staff frustrated for their inability to use equipment. The use of pressure relieving mattresses or cushions is to reduce pressure, shear, and friction. These support surfaces redistribute pressure preventing its damaging effects, and providing a surface that is comfortable for the patient to lie on. The difference between pressure reducing mattresses and those that relieve pressure is determined by the interface pressure which varies form individual to another. If patients are not repositioned, there is risk of high interface pressure and therefore development of pressure ulcers. Patients at high risk of developing ulcers, or those with severe ulcers should be nursed on low air loss mattresses. Air-fluidized mattresses are mostly used in critical settings. Pressure relieving mattresses include the alternating pressure air mattresses that are mechanically operated to change interface pressure periodically according to the patient's condition. The comfort of the patient should be considered before selecting a pressure relieving mattress. Patients using pressure relieving mattresses should also use pressure relieving cushions especially when sitting out of the bed. The type of cushion used will depend on the type of mattress the patient is being nursed on, although this can change with the patient's changing condition. High risk patients or those already with ulcers, usually use dynamic cushions. A good pressure reducing equipment will definitely minimize pressure ulcer development (Beldon 2007, p 98).
This section is a critique of two articles on the topic of the essay.
Alternating pressure air mattresses as a prevention for pressure ulcers
This study made use literature review to examine the issue of preventing pressure ulcers. Specifically the objective of the this study was to examine the and make a synthesis of the literature which analyses the use of alternating pressure air mattresses (APAMs) as a way of preventing pressure ulcers. The design used by this study was that of literature review. The study made use of credible sources for literature review which included Cinahl, PubMed, Medlin and Embase. The sources were used to search and identify relevant and original articles. This design and sources of data chosen was quite appropriate which makes the study quite credible. The study examined a total of thirty five studies.
Many articles were reviewed in this study whereby any material that addressed the comparison between alternating pressure air mattresses and other mattresses was included. The factors that were looked at included; comfort, effectiveness, mechanical reliability, contact interface pressure and blood perfusion, and the costs of the device. It involved randomized control trials in various patients and experimental laboratory studies in healthy persons were also done. There was comparison of the alternating air mattresses and the other mattresses. A number of methods were used in the study to assess the effectiveness, these included; incidence of pressure ulcers, blood perfusion, and constant interface pressure. Comfort was assessed using questionnaires or sometimes visual analogue scales. Power calculation, reporting of randomization method and also baseline comparability were used to assess the validity of the randomized control trials. The grouping of the studies was based on outcome and the design of the study which were then combined in a narrative synthesis while data was given in form of tables. Of the 35 studies done, 20 were randomized control trials, experimental studies were 13, one prospective study and retrospective study. The sample size ranged from 10 to 2000 patients. When looking at quality, 18 of the randomized control trials had insufficient power o did not just estimate the sample size that was required, 11 of them had unclear or inadequate randomization, and four did not report baseline compatibility of the treatment categories (Vanderwee, Grypdonck & Defloor 2008, p 799).
In the assessing of the effectiveness of randomized control trials, there was a lower incidence of pressure ulcers that was associated with alternating pressure air overlays in one trial as compared to the standard hospital mattress. Ten of them showed that there was a big difference between these two pressure devices. Three trials showed that the alternating devices were more effective than the constant pressure devices. One retrospective study showed that alternating pressure air replacements were more effective than the standard hospital mattresses. There was no significant difference in the degree of comfort in either of the mattresses although this was inconsistent due to the use of different mattresses and also mechanical reliability and user errors. It was evident that alternating pressure air overlays are more cost effective than the standard hospital mattresses in pressure ulcer prevention. It is also evident that they are more effective in their use although the degree of comfort was not conclusively determined. Health organization should see to it that their nurses are properly trained so that the correctly use the different alternating pressure air mattresses. High quality randomized control trials are needed to evaluate the effectiveness of the alternating pressure air mattresses, and also there is need to come up with and validate more measures of comfort that will be appropriate (Vanderwee, Grypdonck & Defloor 2008, p 799).
Support surfaces for pressure ulcer prevention
This is a research carried out on support surface for pressure ulcer prevention. The study is a systematic review which was carried out with the objectives of finding out to what extent pressure relieving materials actually do reduce the incidences of pressure ulcers when compared to the standard support surfaces. The study also was to find out how effective different pressure relieving surfaces when compared to one another. The selection criterion for this study was randomised controlled trials (RCTs). The selection of the study was carried out by three authors, two who worked independently and the thirdd who resolved uncertainty. The RCTs which were included were only those that reported an objective clinical outcome measure. The study omitted the studies that reported proxy outcome measures. The study collected data through trial data which were extracted by one researcher and then checked out by another research. This article uses simple language which makes communicated simple to understand.
Occurrence of pressure ulcers is a common phenomenon with studies showing a prevalence of between 4.4% in one unit in a community to 37% in mitigative care. A prevalence of 4.7% in hospitals to 33% in spinal cases in the community is reported in the USA and Canada. These pressure ulcers are costly in their treatment costing large sums of money to many countries. The main aim of the prevention strategies for pressure ulcers is to reduce the magnitude and duration that pressure takes between the support surface and a patient, commonly referred to as the interface pressure. This can be achieved through regular repositioning or through the use of pressure relieving surfaces like mattresses, overlays, and cushions. These equipments work by either molding around a patient's shape to distribute his or her weight over a large area, or varying the pressure beneath the patient mechanically, reducing the duration of the applied pressure in the process. Questions are always asked as to what extent these pressure relieving equipments reduce incidences of pressure ulcers when compared to the standard support surfaces, and also how effective are the different pressure relieving surfaces when compared to each other in their prevention of pressure ulcers. Randomized control trials were used in comparing beds, mattresses and cushions in which the incidence of new pressure ulcers was measured. Those who participated in the study were patients who were receiving health care and seen as being at risk of developing pressure ulcers in any particular setting. Equipments used included a variety of mattresses. Other support surfaces included turning beds or frames, operating table overlays, wheelchair cushions, and limb protectors (McInnes 2010, p1).
Most of the evaluations only measured pressure on different parts of the body that are in contact with the support surface. It is important to understand that interface pressure is a surrogate or intermediate outcome measure which has limitations as an alternate for clinical outcome. This is because the processes through which pressure ulcers develop involve the complex interplay of many factors. But because it is simpler, cheap, and fast to measure, many of the evaluations only look at the interface pressure. For instance, in this study only trials reporting clinical outcome measure of the incidence of pressure ulcers were considered. In some cases, differentiation between people developing grade 1 ulcers and those developing severe ulcers, were not done. There are a number of pressure ulcer grading systems that are used in pressure ulcer trials. These includes; grade 1- this shows persistent discoloration of the skin, grade 2-which shows partial thickness skin loss that involves the epidermis and the dermis, grade 3-full thickness skin loss, and grade 4- where there is full thickness skin loss with extensive destruction and tissue necrosis. Other outcomes considered were; the cost, durability, reliability, acceptability of the devices, and the patient's comfort. All said and done, one thing is sure, that having foam alternatives to the standard foam mattresses in hospitals can greatly reduce incidences of pressure ulcers in patients at risk, although the merits of constant low pressure devices and the alternating ones remains unclear. High quality studies have found out that there are no major differences alternating pressure cushions and alternating pressure mattresses, the only difference being that alternating pressure mattresses are cost saving. Firm conclusions can not be confidently made from these trials because many of them are of poor quality, there was lack of replication of many comparisons, and there was no clear definition of a standard mattress. They vary with hospital, country and over time. In future trials this should be looked into so that clear trial conclusions are made. More research should be done to find valid and reliable methods in which early skin damage that brings about ulcers is detected. There should be true randomization of patients, there should be sufficient trial size so that clinical trial differences are detected, and there should be clear criteria for measuring outcomes (McInnes 2010, p1).
Lewin come up with a three stage theory of change that is commonly referred to Unfreeze, Change, and Freeze. Using this theory individuals or organizations can prepare for what is a head and make plans to manage the transition so that unnecessary chaos and turmoil is avoided. For any care giving organization or group to have any successful change process, they should start by first understanding why the change must take place. Like in this case, they should first understand why prevention of ulcer development is important. Generation of motivation for the change should be made before the change takes place. Nurses should be made to see the need to prevent the loss of life and resources that is brought about by pressure ulcers. Common assumptions about ulcers should be reexamined. This is the unfreezing stage that triggers the change (DeVos 2006, p.1).
When the uncertainty created in the unfreeze stage has settled, the change stage takes over. The need to solve people's lives will be understood and therefore new ways to do things will be sort. When medical practitioners realize that use of pressure relieving devices will save on costs, they actively support the change. The management should give its employees time and communicate the change to them so that they feel that they are part of the change. This can be in form of coaching, training, and mistakes should be expected and corrected (Brucetyson 2010, p 1).
When everyone has learned and embraced the change, the organization should now put in place mechanism that will establish the change, mechanism that will put down the roots of the change. It is usually very hard for any change to pick up smoothly. For instance there are those who will claim that the pressure relieving surfaces are too costly and therefore resist their use, but slowly, with encouragement they will come to realize their benefits and embrace them. This is what Lewin calls freezing or refreezing. The new methods, procedures, patterns of thought and new devices are firmly cemented into place. Steps should be taken that will ensure that people do not regress away from the just implemented change (Brucetyson 2010, p 1).
Basing on Lewin's theory, one will not understand the importance of prevent the development of pressure ulcers if he or she does not change the existing systems. The standard mattresses and cushions should be supplemented with the most effective pressure relieving mattresses and cushions. In doing this, differences in the two will be seen and hence an understanding that pressure relieving devices are effective will be reached. Patients will then embrace their use and save lives and costs. It is therefore wise, as Lewin suggests, intervening in order to learn the important dynamics of the system. The information gain from the intervention when balanced with the risk involved will help come up with better ways of implementing the use of pressure relieving devices. Lewin shows us that the recognition of these three stages of change, an implementation plan of the required change can be easily made. Starting with the motivation to change what he called unfreezing, and then move through the process of change, this involves promotion of effective communication and empowering others to embrace the change, and finally returning the organization to a sense of stability that is refreezing (Schein n.d, p1).