Vasospasm after subarachnoid hemorrhage (VSAH) refers to delayed ischemic complications associated with the narrowing of major intracranial arteries following SAH. There are four different major clinical definitions for vasospasm, depending on how it is diagnosed. Symptomatic vasospasm is a clinical syndrome, defined as a clinical deterioration deemed secondary to vasospasm after other causes were eliminated. Delayed cerebral ischemia (DCI) includes both symptomatic vasospasm and infarction on CT attributable to vasospasm. Angiographic spasm is diagnosed by digital subtraction angiography. Transcranial Doppler (TCD) spasms are those that are diagnosed based on a mean flow velocity >120 cm/sec. There are currently no guidelines for early identification of clinical risk predictors and/or early warning signs of VSAH. This means that rather than taking proactive measures to prevent VSAH, the standard procedure is to react to VSAH after its occurrence has been diagnosed. Although vasospasm can be treated and potentially reversed in its early stages, optimally it would be prevented from developing. Therefore, as a change management strategy, it is proposed that a checklist be developed for nurses to use in the monitoring of all SAH patients. The checklist would indicate any further diagnostic tests that would be indicated by the presence of one of the indicators on the checklist, along with any potential medical interventions to be recommended and the evidence supporting those interventions. The current model is top-down, with doctors ordering diagnostic or monitoring tests. Nurses follow these instructions and inform doctors when there is a sign of VSAH occurring, and doctors give orders on what diagnostic tests and therapeutic interventions must then be given to mitigate the damage once the vasospasm has begun. The new model is bottom-up, placing more responsibility on nurses for proactive action to prevent vasospasm before it occurs. With the help of the proposed checklist, nurses would be alert for risk factors and symptoms and advise doctors on recommended preventative action.
Kurt Lewin's change management theory is a theory of planned change that has been useful in planning organizational change in nursing. It consists of three major stages: unfreeze, change, and refreeze. Each of these stages will be considered in turn to produce a plan for instituting the proposed change.
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Unfreezing involves recognizing that a current model is counterproductive and instilling a desire to change that pattern, thereby making it possible for people to psychologically accept a new way of working (Kaminski, 2011, p.1). This requires an analysis of the situation to identify the forces that maintain the current behavior. To promote unfreezing, the organization may conduct transformative activities such as workshops where colleagues can discuss the situation, brainstorm, and team-build. It is therefore suggested that interprofessional workshops, including both nurses and doctors, be conducted as a first step in developing the checklist.
The process of change involves a shift in the thoughts, feelings, and behaviors that maintained the old model (Kaminski, 2011, p.2). Nurses and doctors must be convinced that the new model is more effective than the old one. This is the most time-consuming stage, but also the most productive. This will involve presenting evidence of how the use of the checklist will be beneficial to patients, instituting the use of the checklist, monitoring the use of the checklist, and getting feedback from nurses and doctors on how the checklist is working, revising accordingly. For example, at regularly scheduled developmental workshops there should be a review of whether the checklist was used, what the results were, barriers to following the checklist, and what changes should be made to make the checklist more useful.
Freezing involves the establishment of new changes as operating procedures (Kaminski, 2011, p.3). Some methods of ensuring personnel do not fall into the old pattern include rewards, ongoing support, and leadership that consistently orients personnel toward the old procedure. For example, leadership can point out cases in which nurses brought early warning signs to the attention of doctors and the result was prevention of vasospasm.
Force field analysis involves the identification of the driving forces promoting change in addition to the restraining forces that hinder change (Kaminski, 2011, p.4). To disrupt equilibrium or status quo, the driving forces must exceed the restraining forces. The restraining forces on the nursing ward may include routine, dislike of change, and hesitancy to speak up to doctors. The driving forces include the desire for the best possible outcome for patients and the empowerment of taking on a leadership role. To magnify the strength of the driving forces, nurses and doctors alike must be presented with strong evidence for the potential benefits to patients, as well as highlight the positive outcomes that occur on the ward following the change.
A checklist of early signs, symptoms, and risk factors for VSAH has the potential to prevent VSAH from occurring. The fundamental change of working from top-down doctor-led to bottom-up nurse-led has been discussed in this essay in the light of change management theory. The proposed checklist is a change that is both possible and necessary for the prevention of VSAH.
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