A Staff Nurse as Change Agent: Bringing a Nurse-Driven Urinary Catheter Removal Protocol to a Medical Unit
[Student Name]
University of Phoenix
NSG/451: Professional Nursing Leadership Perspectives
Week 4 Assignment
[Instructor Name]
[Date]
The unit, staff and data are a composite written for a model paper.
Catheter-associated urinary tract infections (CAUTIs) are among the most common health care-associated infections, and most of them share one risk factor that nurses control every shift: the catheter stays in longer than it needs to. On a composite 30-bed medical unit, a staff nurse noticed during a month of chart reviews for her BSN coursework that more than a third of patients with indwelling catheters no longer met any accepted reason to have one, and that removal usually waited for a physician to write an order during morning rounds. The evidence for removing unneeded catheters has been settled for years; what the unit lacked was someone willing to carry that evidence into its daily routine. This paper describes how a staff nurse can act as a change agent to bring a nurse-driven catheter removal protocol to that unit, using Lewin's model of change.
The Case for the Change
National guidance recommends that indwelling catheters be used only for appropriate indications and removed as soon as they are no longer needed (Gould et al., 2010). Pooling studies of ways to cut catheter use that is not needed, Meddings et al. (2014) found that reminder and stop-order strategies, including protocols that allow nurses to remove catheters without a new physician order, reduced catheter use and CAUTI rates. A national program that combined technical steps such as nurse-driven removal with attention to unit culture was associated with lower catheter use and fewer infections on non-intensive care units across hundreds of hospitals (Saint et al., 2016).
The unit's own data made the national evidence local. Over four weeks the nurse found 41 patients with catheters, 15 of whom met none of the appropriate indications on the day she reviewed them. Their catheters had been in place a median of two extra days. That finding became the problem statement for the change: catheters on this unit stay in after their reason is gone because removal depends on an order that arrives once a day.
Why a Staff Nurse Can Lead This Change
Change agents are often pictured as managers or educators, but the role depends more on credibility than on position. The nurse in this case had worked on the unit for six years, precepted several of its newer nurses and was known for accurate charting, which gave her what Marquis and Huston (2021) call referent and expert power: influence that comes from being trusted and from knowing the work. She lacked legitimate authority to change a medical practice, so her first strategic choice was to borrow it. She met with the nurse manager before presenting anything to staff, asked the infection preventionist to check her audit method, and asked the hospitalist lead whether the medical staff would support a standing protocol. By the time the idea reached the whole unit, three people with formal authority had already agreed that the problem was real. That sequence is itself a leadership skill; a good idea presented to a staff meeting without sponsors often dies of polite agreement.
Lewin's Model Applied Stage by Stage
Lewin (1947) described change as moving through three stages: unfreezing the current state, moving to a new state and refreezing so the new state holds. He also described the driving and restraining forces that keep a group's behavior in balance, which is a useful way to see why a practice persists even when most people agree it should change.
Unfreezing
The nurse's first task was to make the current practice visibly uncomfortable without blaming anyone for it. She presented her audit at the unit practice council as a picture of the unit, not of individual nurses, and she brought one composite patient story: an older adult whose catheter stayed in for three extra days, who developed a urinary tract infection and delirium and whose discharge was delayed. She then listed the forces on each side. Driving forces included the audit, the hospital's CAUTI target, patient discomfort and nurses' own frustration with waiting for orders. Restraining forces included worry about retention after removal, uncertainty about who was responsible if a patient had to be recatheterized, and the habit of waiting for rounds.
Moving
The nurse did not write the protocol alone. With the manager's support she formed a small group that included two staff nurses from nights, the unit's hospitalist lead and the infection preventionist. They adapted the hospital's existing indication list into a protocol that allowed a registered nurse to remove a catheter when none of the listed indications applied, followed by a bladder scan protocol for patients who did not void within six hours. The hospitalist lead took the protocol to the medical executive committee, which approved it as a standing order. Education was short and practical: a ten-minute huddle on each shift, a one-page algorithm at every workstation and two nurses on each shift designated as resources during the first month.
Refreezing
To make the change hold, the group added a catheter indication prompt to the nursing shift assessment in the electronic record, so that every nurse answered the question once a shift. The manager added catheter days to the unit's monthly quality board, and the practice council agreed to review every recatheterization for the first three months to catch problems early.
Meeting Resistance
Resistance appeared where the restraining forces predicted. Some night nurses worried that removing catheters at night would leave them managing retention with fewer resources. The group responded by recommending morning removal for most patients and by adding the bladder scan steps to the algorithm, which answered a real concern instead of dismissing it. Two physicians initially objected to nurses removing catheters without an order; the hospitalist lead's sponsorship and the standing order approved by the medical committee settled the authority question. Resistance in this case was information about what the protocol lacked, and treating it that way improved the protocol.
Knowing Whether the Change Stuck
The group chose three measures. The process measure was the percentage of catheters with a documented indication on each shift assessment, audited weekly for the first two months and monthly after. The intermediate measure was catheter utilization, catheter days divided by patient days. The outcome measure was the unit's CAUTI rate per 1,000 catheter days, which moves slowly on a single unit and would need at least a year of data to interpret. A balancing measure, the recatheterization rate, guarded against the risk that nurses were removing catheters too early.
The group also agreed in advance what would count as success at three months: at least 90% of catheters with a documented indication, a 25% drop in catheter utilization from the baseline month and no rise in recatheterizations. Setting the targets before the data arrived kept the evaluation honest, because it prevented the group from deciding afterward that whatever happened was good enough. The nurse presented the three-month results at the practice council in the same format as her original audit, which let staff compare the before and after pictures directly. Where the unit fell short, the group planned a second, smaller cycle rather than declaring the change finished, since refreezing in the sense Lewin (1947) intended means the new routine survives staff turnover and busy weeks, not only the first month of attention.
Conclusion
Nurses are well placed to act as change agents because they see the gap between evidence and routine every shift. In this composite case a staff nurse used a small audit to make the problem local, followed Lewin's stages from unfreezing through refreezing, built the protocol with the people whose support it needed, treated resistance as feedback and chose measures that would show whether the change held. None of those steps required a title. They required evidence, allies and persistence.
References
Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & Healthcare Infection Control Practices Advisory Committee. (2010). Guideline for prevention of catheter-associated urinary tract infections 2009. Infection Control & Hospital Epidemiology, 31(4), 319-326. https://doi.org/10.1086/651091
Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social change. Human Relations, 1(1), 5-41. https://doi.org/10.1177/001872674700100103
Marquis, B. L., & Huston, C. J. (2021). Leadership roles and management functions in nursing: Theory and application (10th ed.). Wolters Kluwer.
Meddings, J., Rogers, M. A. M., Krein, S. L., Fakih, M. G., Olmsted, R. N., & Saint, S. (2014). Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: An integrative review. BMJ Quality & Safety, 23(4), 277-289. https://doi.org/10.1136/bmjqs-2012-001774
Saint, S., Greene, M. T., Krein, S. L., Rogers, M. A. M., Ratz, D., Fowler, K. E., Edson, B. S., Watson, S. R., Meyer-Lucas, B., Masuga, M., Faulkner, K., Gould, C. V., Battles, J., & Fakih, M. G. (2016). A program to prevent catheter-associated urinary tract infection in acute care. New England Journal of Medicine, 374(22), 2111-2119. https://doi.org/10.1056/NEJMoa1504906
How this NSG 451 Week 4 example is structured
The University of Phoenix library guide for NSG/451 lists Week 4 as Nurses as Change Agents. The paper makes the case for the change first, with evidence, because a change agent has to show why before anyone asks how. It then applies one change model stage by stage to the same unit, so the model does real work instead of sitting in a definitions paragraph. Resistance gets its own section because the rubric in most leadership courses rewards a writer who expects it, and the evaluation section closes the loop with measures that fit the stage the change is in. Students search this week as NSG 451 Week 4, NSG451 Wk 4 or NSG/451 Wk 4; all three are the same assignment.
NSG/451 Week 4 questions, answered
What does NSG/451 Week 4 usually ask for?
The course's library guide lists Week 4 as nurses as change agents. Many sections ask for a paper, sometimes with a presentation, that proposes a practice change and applies a change theory such as Lewin, Kotter or Rogers to leading it. Your instructions and rubric set which model and how much detail.
Do I have to be a manager to write this paper?
No. The sample is written from a staff nurse's position on purpose, because most practice changes on a unit are started by nurses without titles. What matters is showing how you would gain support from the people who do hold authority, such as the manager, the physicians and the infection preventionist.
Which change model is best for this assignment?
Any model your course names will work if you apply it stage by stage to a real change. Lewin's three stages are compact enough for a short paper; Kotter's eight steps suit a larger organizational change; Rogers's diffusion theory helps explain why some staff adopt early and others late.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official University of Phoenix document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.