Journal of Neonatal Nursing (2006) 12, 86e90

www.intl.elsevierhealth.com/journals/jneo

Implementing the change e Litmus paperto pH paper

Pauline Smith*

RGN ENB 405 & 998, Clinical Development Nurse, Neonatal Unit, Queens Medical Centre,Derby Road, Nottingham NG7 2UH, UK

Available online 11 May 2006

KEYWORDSNaso-gastric feeding;Neonate;pH paper;Litmus paper;Communication;Change;Cascade approach

Abstract This paper demonstrates the implementation of pH paper in to one neo-natal unit, following the guidelines issued by the National Patient Safety Agency(NPSA) in August 2005. It describes the process that was used, discusses the docu-mentation and reflects on the whole programme of events and with hindsight, whatcould have been improved. The change proved very challenging but was achievedsuccessfully with a large workforce, by use of a communication-driven cascadeapproach based around key trainers.ª 2006 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

Introduction

This paper demonstrates the implementation of pHpaper to assess the position of enteral feedingtubes in one neonatal unit at the end of 2005,following the directives for change from theNational Patient Safety Agency (NPSA). The pro-cess that was undertaken is described in somedetail in an attempt to share experiences and offersome guidance to other units.

Background

Traditionally, Neonatal Units used litmus paper totest the correct position of a naso/oro-gastric

* Tel.: þ44 115 924 9924x36242.E-mail address: pauline.m.smith@nuh.nhs.uk

1355-1841/$ - see front matter ª 2006 Neonatal Nurses Associatdoi:10.1016/j.jnn.2006.03.005

feeding tubes. For a number of years there hasbeen considerable debate around the use of pHpaper both in Paediatrics and Neonatology, con-cerning whether pH paper would offer a morereliable test for correct tube placement. Basedon the lack of evidence available at that time,regarding the use of pH paper in the neonatalpopulation, most neonatal units continued to uselitmus paper.

In April 2004, a coroner reported his concernsabout the placement of naso/oro-gastric tubesfollowing an investigation into the death of a child(MRHA, 2004). It was soon realised that this was notan isolated occurrence. It became evident that atleast 11 paediatric and adult patients had died asa result of misplaced naso-gastric tubes sinceDecember 2002. Following the initial advice givenby the NPSA in February 2005, a further 41 inci-dents were reported (NPSA, 2005). Of these, only

ion. Published by Elsevier Ltd. All rights reserved.

Implementing the change e Litmus paper to pH paper 87

3 were classed as causing serious harm. None of thereported incidents involved neonates. This led tothe NPSA investigating the practice in paediatricsand neonatology during the early months of 2005.

In August 2005, the NPSA, following discussionwith British Association Perinatal Medicine, Neo-natal Nurses Association and the Royal College ofPaediatrics and Child Health, issued an alertstating that ‘all staff and carers, caring forneonates with a naso-gastric tube in place shouldbe trained to assess the position of feeding tubesusing pH paper or indicator strips and that trainingmust be competency based’ (NPSA, 2005).

Not only was this a huge clinical change in a longstanding historical practice, but an enormouscultural change. For many years, staff had usedlitmus paper to assess the position of naso- or oro-gastric feeding tubes often as many times 6e8times a day. It had become very much a routinetask with often little thought for the practice, or itspossible consequences should something go wrong.

However, this publication from the NPSA broughtthe issue and safety issues surrounding it to theforefront of people’s attention. A number of unitshad already changed their practice and replacedlitmus paper with pH indicator strips, with minimalnegative impact (Bain, 2005). Other units werereporting difficulty working with the NPSA guid-ance. An audit conducted in Leicester showedthat a number of feeds had to be omitted becauseof high pH values (Foxon and Bohin, 2005). Thiswas a cause for concern, but with the directivesin place change was necessary.

Implementation of pH paper

Implementing change at work is often problem-atic, despite the wealth of theory available tosupport positive change. In the National HealthService change has an added dimension of publicscrutiny.

Nevertheless, change has to happen, and betackled with a broad understanding. Staff need toknow what the aim of the project is, why it isimportant, how it is to be achieved and whatimpact it will have on them and their dailyroutines. Communication needs to be at the centreof the change, since it is fundamental to goodpractice (Bond, 2003). This section describes thechange undertaken on our unit.

A Clinical Risk meeting was arranged for earlySeptember 2005 in order to discuss the implemen-tation of the pH paper with senior members of theNeonatal Team. Work and documentation alreadyprepared, including a competency document was

also discussed. The competency framework wasdevised with simplicity and most importantly,aimed to be a user-friendly document. It had tobe a resource for staff yet sufficiently concise to beincluded in their personal profiles. The documentfollowed a logical approach. The assessment wasone page so that it was not too daunting for staff toachieve. It followed the NPSA guidelines. Thedocument did not only focus on pH paper, but theknowledge and practical skills surrounding feedinginfants. A strategy on how this would be bestmanaged and achieved, feedback from discussionswith staff on Paediatric Intensive Care Unitregarding their practices and experiences withusing pH paper was shared at this meeting. Thisprovided a valuable resource on which to base ourstrategy. Fig. 1 shows the competency statements.

In light of all this information and taking intoaccount staffing issues and practicalities, it wasdecided that an implementation date of 1stDecember 2005 would be the target. At the timeit was daunting, as December is always a very busymonth and very worryingly, it would only give4 weeks, until the deadline of 1st January 2006,imposed by the NPSA to get the new practice run-ning and to iron out any problems that may arise.Up until this date litmus paper would continue tobe used, regardless of whether staff had beentrained and assessed as competent. This decisionwas made in order to maintain safe practice byonly having one system working at any one time.A lead nurse for the change was agreed.

Elsewhere in the hospital the paediatric unithad previously trailed a number of different pHtesting methods and agreed that pH indicatorstrips were the best choice. The Neonatal Unitadopted this method also (pH e Fix 0-6 Fish-erbrand; Fisher Scientific UK; Leicestershire UK).

At this stage some time was spent by the leadnurse for the project from the neonatal unitworking on PICU with staff that had alreadyimplemented the practice of using pH indicatorstrips to assess the position of the feeding tubes.Within the Paediatric Unit, posters were displayedinforming staff of the change. No systematic orstructured approach to their change was evident.However, each ward had a significantly lessamount of staff compared with the Neonatal Unitand their approach worked well for those smallergroups. On the Neonatal Unit, it needed to bemore structured if it was to succeed. With com-petence and confidence in the process, trainingcould begin for staff on the Neonatal IntensiveCare Unit (NICU).

With almost 100 staff to train before December1st 2005, the education programme needed to be

88 P. Smith

Competence Statement

Is able to demonstrate safe, effective and competent placement of a naso or oro-gastric tubeOn completion of this assessment the user will be able to:

Performance Criteria Evaluation Method Date Assessors

Signature

1. State the group of babies that would require a naso or orogastric tube

Discussion

2. Explain and demonstrate how you would pass a naso/oro-gastric tube

Discussion/DirectObservation

3. Explain the current and accepted methods that should beused to assess the position of a naso or oro-gastric tube andwhy

Discussion

4. Prepare equipment required. Direct observation5. Explain pH values to be used and the rationale behind theselimits

Discussion

6. Perform the test using pH paper Direct observation7.Identify what actions should be taken if insufficient gastricaspirate is obtained

Discussion

8. State what actions should be taken if aspirate pH is above 6 Discussion 9. Identify how each baby is individually risk assessed andwhere this is documented

Discussion

10. Demonstrate what needs to be documented and where Observation/Discussion

Figure 1 Competence statement for placement of naso- or oro-gastric tube.

planned meticulously. Evidence suggests that a sys-tematic approach to implementing change gives ita greater chance of success (Pemberton and Reid,2005). A minimum of 75% of staff were to betrained and competent to ensure the change overwould be safe and effective.

It was decided that a cascade or team approach(Curzon, 1990) would be the most effective way ofdisseminating such important information to somany people, across a variety of shift patterns. Ateam of seven members of staff were selected astrainers. Research has shown that an effectiveteam can accelerate change in a large organisa-tion, if the key team has the appropriate skills,knowledge and attitudes (Curzon, 1990). Thesepeople where members of staff who had eithertaught sessions in the past on local study days, orhad expressed a desire to be involved in teaching.They also had the excellent communication skillsthat would be vital to the success of the project(Hinchcliff, 1999). This gave a total of eight avail-able trainers. A small number in order to maintainthe accuracy of information during the initialtraining period (Quinn, 2000).

The seven trainers were invited to a trainingmeeting at the beginning of October. This wasarranged for 19:00, to take into account work andpersonal commitments. Each trainer was given a filecontaining everything needed to effectively trainmembers of a multidisciplinary team. Included was:

� A copy of the NPSA (2005) alert;� A copy of the MRHA (2004) alert;

� A copy of the teaching plan both a hard copyand an electronic version;� A copy of the competency document;� A pre printed care plan with an area to docu-

ment each babies individual risk assessment;� A packet of pH indicator strips;� A list of all the staff that required teaching &

assessing.

The teaching session commenced with the back-ground surrounding the need for change (NPSA,2005). A discussion took place around the compe-tency document. They were shown how to use thepH indicator strips, how to document their findingsand what should be documented and where. It wasdecided that following the training and assessmentof staff, the trainers would report names to a cen-tral person, in order to keep a list of all staff whohad been trained and assessed as competent.Once the trainers were confident in their own prac-tice and what was expected of them, training com-menced for the remainder of the team.

All this documentation was forwarded to thePractice Development Nurses within the network,so a standardised approach could be used for allstaff, carers and infants throughout the area.

Staff were taught in small informal groups, inorder to allow them time to contribute and askquestions (Quinn, 2000). Assessments took placeon an individual basis when the member of stafffelt confident that they had understood all theinformation surrounding the change. Staff mem-bers were then taken through the formal process

Implementing the change e Litmus paper to pH paper 89

of completing the competency document. Anyproblems or questions were dealt with at thetime. A copy of the completed document waskept in their personal files for reference and theoriginal kept by each member of staff for theirportfolio.

As1stDecemberdrewcloser, ‘target’ lists of thosewho still needed to be trained were made for eachtrainer, based on their forth-coming shift pattern.

A bright, colourful display in a prominent positionjust near the main doors of the unit, helped keepthe change alive. It included all relevant documen-tation, publications and deadlines for implementa-tion. Weekly updates entitled ‘The story sofar..’, kept staff informed as to what washappening, how it was going and graphs showingthe percentage of the team who had undergone andsuccessfully completed the course. This encouragedstaff that had not yet tackled the process toapproach one of the trainers. Peer support helpedstaff comeforward for training,as theypreferrednotto be amongst those who had not attended a teach-ing session or had not been assessed as competent.

By midnight on 30th November 86% had receivedtraining and had been assessed as competent inusing pH indicator strips. At midnight a formalchanging over process took place. All litmus paperand any ungraduated tubes were removed fromthe unit. Each baby was given their own box ofindicator strips, labelled with their name.

Over the following week, guidance and supportwas constantly available. The eight trainers hadorganised there off duty so that there was alwaysat least one of them available on every shift incase there were any problems or queries.

From 1st December 2005, parents and carerswere taught by competent members of staff to alsouse the indicator strips when feeding their baby.

Evaluation

The change of practice from testing enteral feed-ing tubes with litmus paper to pH indicator stripswas an enormous success. Staff embraced thechange with enthusiasm and interest.

The systematic approach described was the key.Each member of staff knew what the aim of theproject was, why it was so important, how it wasto be achieved and the impact it would have onthem and the infants in their care. Also key wasthe commitment and excellent communicationskills of the eight trainers. Everyone having thesame information and teaching material wasessential, and the trainers commented favourablyon the packs provided. The process was stressful

and time consuming taking up much of the clinicaldevelopment nurses time over this period.

New staff have the competency package intheir induction folder when their employmentcommences and are asked to complete it withintheir first six weeks of low dependency experienceduring their supervised practice.

Conclusion

This paper has focused on the practical steps thatwere needed to implement a fundamental changein practice on a large neonatal unit. While changewas accomplished successfully, this was notinevitable. Making change happen is dependenton some key factors, and these are pulled togetherin the recommendations below.

Of central importance, however, was the cas-cade approach. While this depends on clear lead-ership and committed coordination, it also ensuresthat responsibility is shared and that the task is nottoo onerous for any individual. It was also impor-tant that staff where open to embracing thechange. Change cannot be accomplished withoutthe active support of the people whose practice isbeing modified, and that this change was madewith relatively little pain reflects on the commit-ment of the whole team.

Recommendations

� Optimise the number of trainers, so that youhave enough to get the training done.� Some protected non-clinical time is required,

at least for the lead trainer to get the projectstarted and for ongoing coordination.� Anticipating deadlines for change avoids last-

minute panics and allows a planned approach.� Communication is key. Everybody that is

involved needs to understand why the changeis taking place and how it will affect them.Use personal approaches as well as visualdisplays.� The change needs to be conducted in a system-

atic way in order to maintain compliance ofstaff and credibility of the process.� Competency assessment is a helpful tool for

assuring compliance with change.

Acknowledgements

I am very grateful to the seven trainers who helpedimplement this project: Lorraine Collins, Liz Davis,Jenny Machell, Alison Nield, Mary Palframan, SianWoodhouse, and Louise Wright.

90 P. Smith

References

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Bond, P., 2003. Best Practice in naso-gastric & gastrostomyfeeding in children. Nursing Times 99 (33), 28e30.

Curzon, L.B., 1990. Teaching in Further Education. An Outlineof Principles and Practice Cassell, fourth ed.

Foxon, J., Bohin, S., 2005. The Implications of Using pH Paper asan Indicator of Correct Naso-gastric Tube Placement in Neo-nates. Presented at: British Association of Perinatal Medi-cine, Annual Scientific Meeting, Belfast.

Hinchcliff, S., 1999. The Practitioner as Teacher, second ed.Balliere Tindall.

MRHA, 2004. Medical Device Alert e Enteral Feeding Tubes Med-icines and Healthcare Products Regulatory Agency.

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Quinn, F.M., 2000. Principles and Practice of Nurse Education,fourth ed. Nelson Thornes.