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Changing practice to improve care: nursing leadership is as much about influencing change at ward/unit level, as it is about influencing change at hospital or national level. One nurse shares how she introduced a change in practice.

I have worked in the neonatal specialty area for more than 20 years and am passionate about the care of neonates. Sometimes nurses experience frustration when their attempts to provide good nursing care appear to be causing harm. When faced with such situations, it is important to look for possible alternatives and not just accept current practice simply because it is what has always been done.

In the special care baby unit (SCBU) where I work, one of the requirements for babies born at 32 weeks' gestation or less, is to have an eye examination for retinopathy of prematurity (ROP). This has been described as "inappropriate and excessive growth of retinal vessels which may lead to blindness". (1)

Babies who fit the criteria must have their eyes examined by an opthalmologist at four to six weeks of age. These examinations usually occur more than once. A component of the eye check is to administer eye drops for dilation of the pupil, so the retina can be examined.

My SCBU colleagues and I observed that the side effects of these eye drops could be quite significant for some of these babies. The drops we use are Cyclopentolate (0.5 per cent) and Phenylephrine (2.5 per cent). Mims New Ethicals lists a number of side effects; (2) the most relevant to the babies we care for are tachycardia, decreased gut mobility, stinging and arrhythmia. Researchers have suggested that systemic absorption of the drops is unavoidable to some extent. (3)

The person administering the drops is advised to apply pressure to the tear duct for one minute during and following administration. (2) This technique assists in avoiding the absorption of the drops via the lachrymal duct. It is also important to wipe away any drops expelled from the eye, as they can be absorbed by the skin.

The SCBU protocol for administration was one drop of each medication in each eye, and this was repeated 15 minutes later. What I observed was that babies treated under this protocol experienced an increase in feed intolerance, along with increasing events of apnoea and bradycardia. This was particularly evident in smaller babies.

Because of the slower gut motility, feeds were taking longer to move from the stomach into the intestine, leading to increased spilling, as the stomach became over full. This also increased oesophageal reflux and, consequently, led to more apnoea and bradycardia. The risk of aspiration was also increased. Not only was this detrimental to the baby, but it was also discouraging for the family, who were experiencing what appeared to be a setback in their baby's health, with monitor alarms going off more frequently.

I felt these responses were a significant problem and decided to look for a solution. In discussion with a colleague who had worked in another SCBU, I learnt that other units' eye drop protocol was different. Through research, I discovered there were other options with fewer side effects. To bring about a change in the eye medications and protocol, we had to work through the process of change. Firstly, a new standing order was required. Then staff involved needed to be informed of the change and the guidelines for ROP eye checks needed to be updated. Finally, everything was in place and the new procedure began.

Under the new procedure, one drop each of Cyclopentolate and Phenylephrine is instilled into both eyes of the baby and pressure is applied to the tear duct for one minute following instillation, minimising absorption of the medication through the nasolacrimal system. A second drop of the medication is given only if the baby's eyes are not dilated after 20 minutes.

The new procedure has been in place for some time and has been reviewed. It has certainly made a difference. We are seeing fewer side effects and babies' eyes are dilating well with only one set of drops. It is most gratifying to see that a combination of factors--research, good communication within the multidisciplinary team and a willingness to embrace a practice change--has resulted in better care for babies.

On reflection, I realise someone needed to take responsibility for an issue the nursing staff had identified. Good communication is an essential part of team work--the ophthalmologist was not aware of the problems the babies and nursing staff were experiencing, because of the side effects of the medication.

Best practice is changing and it is important to review current research to ensure we are providing the best care. Nurses need to communicate with each other and share their experiences, so we can all learn. We all need to be open to change that will improve the care we provide.

Leadership is a role we can all achieve, if we are prepared to make the time and effort to seek answers and pursue best practice. As nurses, ethics and standards of practice require that we seek best practice for our clients. By investigating and pursuing change to ensure best practice, I have made a difference and improved the care we provide for our neonatal clients. It is very satisfying to have done so.


(1) Lissaurer, T. & Fanaroff, A. (2006) Neonatology At A Glance. Oxford: Blackwell Publishers.

(2) Mims New Ethicals (2009) Issue 10. LMP Medical: New Zealand.

(3) Kenner, C. & Lott, J.W. (2007) Comprehensive Neonatal Care An Interdisciplinary Approach (4th Edition). Saunders Elsevier: Missouri.
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Title Annotation:EXEMPLAR
Author:Rhodes, Lynley
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Jun 1, 2012
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