Prevention of Deep Vein Thrombosis (Dvt) Development

Abstract

This clinical change proposal seeks to introduce an exercise leaflet to prevent deep vein thrombosis (DVT) amongst the elderly and immobile patients that have been admitted to a hospital. In light of this, the proposal endeavors to place emphasis on the targeted patients, so that they may take responsibility for preventing the development of DVT. As such, the proposal attempts to initiate a behavioral process on the part of the patient, as a way of preventing DVT development. The level of mobility of an individual has been seen to reduce with an increase in age (Aldrich & Hunt, 2004), and this acts as a precursor for the development of deep vein thrombosis (DVT). As such, this clinical change proposal hopes to introduce an exercise regimen that shall enhance the mobility of the elderly patients and consequently, prevent the development of DVT.

The planned program of change involves first an identification of the patients to take part in the change process, an identification of a change agent, and a consequent introduction of the exercise regimen, such as neck and calf stretches, toe/foot circling, and brisk walking, amongst others. Moreover, a measurement, monitoring and evaluation of the outcome of the change process shall also be assessed. There are issues that are anticipated to either influence, or hinder the anticipated change process, and these shall also be explored. Moreover, the human and material resources that the hospital has set aside for the implementation of the clinical change process will also be evaluated. The role of a change agent is fundamental in such a process and for this reason, the characteristics of an agent of change shall also be explored.

Introduction

This research proposal is concerned with the introduction of a clinical change, targeting the elderly and the immobilized patients admitted to a hospital. As such, this proposal is more of a clinical behavioral change initiative, whose aim is to encourage such a group of elderly patients to take responsibility for their lives, when it comes to the issue of preventing the development of DVT. It is important to note that with an increase in age, the level of mobility also tends to reduce, with the result that the flow of blood in the vein may slow down (Wells et al 2006), in effect causing the development of blood clots and consequently, DVT. In this case, the proposal seeks to introduce an exercise leaflet for such patients, with w view to preventing the development of deep vein thrombosis (DVT) amongst the elderly and immobile patients.

It is the intention of this researcher to place emphasis on the patients so targeted, so that they may take responsibility for preventing DVTs. There is a need to initiate a clinical change, whose aim is to alter the behavior of the immobile elderly patients, so that they can be more responsible with their lives, as far as the issue of preventing the development of deep vein thrombosis is concerned. There is an association between increased immobility on the one hand, and a rise in the risk For DVT development, on the other hand. When you factor in age, the elderly tend to be at an increasingly higher risk of DVT development and consequently, pulmonary embolism as a complication (Wells et al 2006).

Elderly patients have reduced immunity (Hughes 2006), and by creating awareness to them as regards the development of DVT, what this means is that in essence, we are helping to improve the quality of their lives, by alleviating a potential source of discomfort, morbidity and by extension, mortality. Moreover, such a research study would also assist in the establishment of a rich body of knowledge when it comes to the creation of awareness as regards the development and propagation of deep vein thrombosis, in addition to an assessment of the associated risk factors, and potential signs and symptoms. This way, the target group, in this case, the immobile and elderly shall be better able to take charge of their lives in preventing the development of this venous condition.

If at all the elderly patients that this research proposal seeks to target are to benefit from it, there is a need to enlighten them on the venous condition that is deep vein thrombosis, the associated signs and symptoms, the risk factors that they could be faced with, its pathophysiology, the frequency of occurrence, and the management of DVT through exercise.

On the other hand, there is a need to point out that for the elderly, the exercise regimen to which they may be exposed would often differ significantly from that of young patients, on the basis of their age and the associated health complications. Therefore, it is important to identify an ideal level of exercising that shall ensure that the elderly are able to prevent the occurrence of DVT, and at the same time also ensure that no complications come about due to exercising.

The literature review chapter of this dissertation proposal shall document the planned program for the anticipated change. Moreover, a theoretical framework, with respect to change management shall also be explored, coupled with a justification for the utilized change theories. Furthermore, the aims and objectives of this change proposal shall also be explored in this section, followed by a timetable for the various phases of the proposed change. Besides, there are also potential issues that may obstruct or enhance the anticipated implementation of this change proposal, and these will be clearly outlined in this section. Moreover, it is also important to document the necessary resources for the effective implementation of the change proposal.

In the third chapter of the change proposal, measuring, monitoring and evaluation steps shall be clearly articulated, with respect to the anticipated change. Furthermore, the desirable skills for a change agent to be in possession of will also be explored, in addition to recommendations on implementation, as well as practice issues of the clinical change.

Literature review

Background

This proposal dissertation endeavors to introduce an exercise leaflet whose aim shall be the prevention of DVT. In this case, the focus shall be laid upon the elderly and immobile patients, possibly those who have undergone or are undergoing surgery, as well as those in intensive care. The intention, therefore, is to emphasize the need for exercising by such patients, as a way to reduce the risks for the development of DVT. There is a need, therefore, to ensure that the introduction of a leaflet on DVT to the elderly and immobile patient takes into account the detection and diagnosis of DVT, along with the associated risk factors such as age, family history, cancer, and surgical operations. This is for purposes of ensuring that the patients so targeted are best placed to take full responsibility for preventing the development of DVT, through an exploration of the option that is open to them.

The level of incidence for deep vein thrombosis (DVT) development has aged as one of its risk factors. In this case, therefore, the elderly, and more so those who are above the age of 60 years, are seen to be at an increasingly higher risk of developing DVT (Trujillo-Santos et al 2006) when compared with their younger counterparts. In a bid to prevent the development of DVT amongst elderly patients with reduced mobility, research findings have revealed that physical exercise does play a significant role in as far as the reduction of potential risks for DVT development are concerned (for example, Brown & Lie, 2008).

Even then, there are also conflicting research findings that appear to suggest that such strenuous exercises as jogging, may end up elevating the risks for DVT development amongst the elderly and otherwise immobile patients (Wells et al 2006), relative to their peers who are immobile. On the basis of such conflicting research findings, would it be in order then, to subject the elderly to an exercise regimen, while still being aware of possible risk factors? Arriving at an exercise regimen that would be whose benefits would by far out-way the associated risks, remains a challenge.

Amongst patients that have been hospitalized, DVT prevalence has been seen to be exceedingly higher, oftentimes varying between 20 and 70 percent. Venous insufficiency, along with venous ulceration, both of which afflicts the lower leg, are usually DVT complications that are long-term, and these impact approximately 0.5 percent of the individuals to be found in the whole populace (Kolbach et al 2003). Between patients of Caucasian descent who have had a hip fracture, deep vein thrombosis has been found to be a common occurrence. In this case, the cumulative DVT incidence, in the absence of prophylaxis is estimated to range from 35 and 52 percent.

Patients that are obese could be faced with difficulty when it comes to a proper dissolving of the clots that could form in the blood (Brown & Lie 2008), in essence elevating chances of them developing DVT, after a surgical procedure. The new have the issue of those patients whose clotting disorder is in-born. For example, those patients in possession of Factor V Leiden have been implicated with a higher risk with regard to DVT development. It has been noted that approximately 60 percent of those patients that are hospitalized with leg fractures eventually end up also developing clot fragments. In turn, such clot fragments act to block pulmonary circulation, an action that in itself has been seen to be quite extremely fatal.

Those women that are either under hormone replacement therapy or oral contraceptives have been shown to have a higher chance of DVT development (Horne & McCloskey 2006) when compared with their counterparts who are not taking these. Geerts and others (2004) contend that those patients that have not been admitted to a health facility, but who have nevertheless presented with classical symptoms for DVT, in addition to a single risk factor for DVT development, have been shown to have a probability level of 85 percent, in as far as being diagnosed with DVT is concerned.

On the other hand, patients presenting with atypical features and at the same time also lacking risk factors that may be identified, have been shown to have a low probability for the development of DVT, at 5 percent (Wells et al, 2006). There is also the issue of trying to convince the elderly to change their behaviors, such as a sedentary lifestyle, even at a time when they may be recuperating from other illnesses, albeit to prevent the development of DVT.

Obesity, diabetes and hypertension are some of the risk factors that have been linked with an increase in the cases of DVT amongst the elderly (Tsai et al 2002). These conditions, amongst others, have been shown to be manageable by way of physical exercises. Therefore, another challenge would be the creation of awareness amongst the elderly patients who have already been diagnosed with either of these conditions, as a way of preventing the development of DVT, following episodes of immobility for such patients.

Virchow’s triad has attempted to associate the risk factors for the development of deep vein thrombosis (DVT) with their common causes. To start with, changes in the flow of blood within the veins has been noted to be a risk factor for DVT (Scarvelis & Wells 2006), with this being tied to states, usually associated with paralysis, prolonged immobility, heart failure, as well as varicose veins, not to mention an observed rise in terms of the viscosity of the blood.

Then there is the issue of alterations within the walls of the blood vessels. A cause of this, according to Virchow’s triad, could be atherosclerosis, usually resulting in either a rupture or even the formation of plaque on the wall of blood vessels. Due to this, thrombogenic materials get exposed, with the result that the platelets are activated, with a resultant cascading of a coagulation process of these (Trujillo-Santos et al 2006).

With respect to alterations in the ability of blood to undergo through the coagulation process, this could come about as a result of a burn, trauma, as well as surgical injuries due to the damage of tissue, having tissue factors being released onto the bloodstream, and having the coagulation pathway being activated (Trujillo-Santos et al 2006). Moreover, cancer development has also been implicated with alterations in blood coagulability. This is because when cancer develops, there is a resultant reduction of fibrinolytic activity. In addition, malignant tissue is thought to aid in the coagulation process.

Preventing the development of DVT amongst the elderly through exercise

Reduced levels of exercise, coupled with immobility have been noted to be some of the risk factors that play a significant role in the development of a patient with DVT (Brown & Lie 2008). In the event that an individual is less active, what this means is that the rate at which the flow of blood within the veins shall also be less, and this has the potential to enhance the formation of blood clots within such inactive veins.

Perhaps a question that we ought to ask ourselves here is whether or not it would be okay for a patient to exercise in the event that they have just received a positive diagnosis for DVT and is at the time the recipients of a treatment regime. Previously, those patients that were being diagnosed as having developed DVT would often be advised by their physicians to strictly remain in bed (Brown & Lie 2008), with a majority of these bind admitted to hospitals for between 7 and 10 days. The reason behind this is that at the time, the assumption was that any form of a movement that such a patient would make, had the potential to result in clotting of the blood (oftentimes in the leg).

In addition, such a clot had the chance to get dislodged into the bloodstream, finding its way into the lungs of a patient, with the result that a pulmonary embolism could very well result (Horne & McCloskeym, 2006). Currently, however, we have overwhelming evidence to support claims that early mobility for patients that are otherwise immobile or have limited mobility, is capable of curtailing the development of DVT symptoms, in addition to aiding in a fast recovery. Could this, therefore, be taken to mean that early mobility for patients is safer?

According to a number of research findings that have sought to investigate early mobility following the development and a consequent diagnosis of DVT amongst in-patients (for example, Tveit, 2002), a number of selected patients were started on walking exercises under supervision. This was either accomplished immediately following a diagnosis for DVT, and such patients were then placed under compression (that is, stockings and bandages) and anticoagulants therapy, or this was started two days following the commencement of treatment.

The observation was that such patients had a lower chance of pulmonary embolism development within the successive months when compared with those patients that had been advised to remain quite immobile, in bed from the very first time they were diagnosed with DVT (Tveit, 2002). Furthermore, swelling and pain amongst those patients that had been encouraged by their physician to remain mobile were also seen to be somewhat clear in a relatively quicker manner (Brown & Lie 2008). Moreover, the well-being of such patients was also seen to improve, by and large. This is in addition to the observed quality of life associated with DVT that was also seen to improve.

There is a widely held theory that mobility has the potential to avert relentless symptoms of the calf following the development of DVT (Wein et al 2007), further aiding in a reduction of the risk that is associated with DVT, by way of enhancing circulation within the limb that has been affected. Prevention is still touted as the very best defense possible when it comes to the development of DVTs. The activity of identifying those individuals that have a higher chance of developing DVT, coupled with a consequent application of preventive measures that are preventive in nature still remains one of the best strategies when it comes to a reduction of the risks that result in the development of DVT.

It is important to note here that even as little as a single hour immobility or inactivity may very well reduce the flow of blood within the deep veins, such as in the calf of the legs, thereby enhancing the associated risks for the development of DVT. Patients that have been bedridden, in addition to those who have already undergone surgery, are usually encouraged to start walking immediately after they are capable of moving out of bed. As such, increased levels of immobility have been seen to enhance the chances of a patient developing DVT (Well et al 2006) and consequently, PE.

Even as it is recommended that elderly and immobile patients ought to exercise with a view to keeping at bay the development of DVT, nevertheless such exercises should be gradually and at the same time mild, with a close supervision of such patients by the health care practitioner concerned. Brown and Lie, in their 2008 Medscape article titled: ”Unexpected Increase in Thrombosis Risk Seen With Strenuous Exercise in Elderly”, opines that those elderly individuals that normally involves themselves in such strenuous exercises as jogging, could be faced with a higher risk when it comes to the development of DVT, relative to their counterparts who have assumed a sedentary lifestyle.

Nevertheless, it is the assertions of these authors that the ensuing benefits that often accompany either strenuous or moderate exercises amongst the elderly persons have a high likelihood of overshadowing the associated risks (Brown & Lie 2008). Preceding observational research findings have tended to provide results that are rather conflicting, with respect to the impact that exercise has when it comes to the development of DVT. This is as per a March 2009 report that featured on the Geriatrics Society Journal for America.

On the other hand, the principle studies that were exploring the issue of strenuous exercise leading to an increased risk for DVT development failed to yield a detailed assessment of exercise, as well as a through management of those confounding factors that have the potential to cause DVT. At the moment, Dr. Susan Heckbert, a scholar at the Seattle-based University of Washington, along with other researchers, has sought to explore the clinical data of a total of 5534 subjects, all of whom are over the age of 65 years, and who have no preceding history for DVT (Brown & Lie 2008). These subjects had gotten themselves enrolled in a study for cardiovascular health, and had been under scrutiny for an average of about 11.6 years.

During the follow-up for these subjects, between two and three assessment for self-reported exercise was undertaken. A total of 171 subjects were seen to develop DVT during the time over which the researchers followed them. Following an adjustment for age, self-reported health, gender, race, as well as body mass index (BMI), the level of exercise that a patient engaged in, at baseline, appeared to be less of a significant predictor, when it came to the issue of DVT development (Brown & Lie 2008).

On the other hand, when the investigators sought to model exercise on the basis of an exposure in which time was varied, there resulted evidence to suggest that the patient in question had increased risk fro DVT development. Additional analysis indicated inferior drop with respect to thrombosis risk (Brown & Lie 2008), when exercise regimen of mild intensity was introduced to the subjects. In this case, mild exercising includes such activities as walking in which the hazard ratio first had to be adjusted to a figure of 0.75.

On the contrary, jogging, in addition to additional taxing excises were seen to enhance in a significant way the risk for thromboembolism, when the hazard ratio had been adjusted to 1.75, in comparison to a situation whereby a patient may not have been subject to any from of exercise by any means. In spite of the aforementioned findings, nevertheless, Heckbert and colleagues have arrived at a conclusion, that “The overall benefits of exercise likely outweigh the possible higher risks of venous thrombosis or injuries, but more research is needed to investigate this unexpected higher risk of venous thrombosis in elderly people associated with strenuous-intensity exercise.” (Brown & Lie 2008).

Some of the tips that have been offered by health care professionals to prevent the development of deep vein thrombosis (DVT). These includes the wearing of clothes that are loose, with a view to ensuring that the flow of blood within the veins is unrestricted (Wein et al 2007), the avoidance by individuals of alcohol and cigarettes, in addition to ensuring that a person drinks fluids in plentiful amounts. Moreover individuals, and especially patients, are usually encouraged to ensure that they move about on a regular basis.

The performance of both foot and leg stretches has also been noted to help in the prevention of DVTs. Anyone that has been immobilised for a long time is usually at an increasingly higher risk for the development of DVT (Wells et al 2006). In the case of hospital patients, these are usually encouraged to participate in moderate forms of exercises, for between 4 and 5 times on a daily basis. Such exercises as stretching could then be carried out while the patients are in their beds, seated on a chair. Alternatively, the patients could also perform these exercises while standing. Some of the more common exercises include foot circles, toe/heel lift, calf stretch, neck stretch, and knee rises.

Benefits of the change process to the organisation and stakeholders

For the elderly patients that have been hospitalised, the proposed clinical change would serve as a preventive measure, when it comes to the risk factors for deep vein thrombosis (DVT). Through the introduction of the leaflet, it will be easier for the patients to get to know about the risk factors for the development of DVT. Through the introduction of an exercise regimen, the patients shall also get to experience increased level of mobility.

Other than that, the leaflet shall enlighten such patients on the complications that would often accompany a venous disease like deep vein thrombosis (DVT), suck as pulmonary embolism, which is quite fatal. That way, the participants will appreciate that it is important for them to appreciate the suggested behavioural change by this proposal, if at all they wish to take charge of their wellbeing. On the other hand, the hospital shall be endeavouring to improve the quality of life of the patients, in a bid to reduce potential complications for their elderly patients.

Additionally, there shall also be a reduction in the incidence rates as well as the prevalence of deep vein thrombosis (DVT) amongst the elderly and immobile patients. For the professional practitioners, the aspects of measuring, monitoring and evaluating the outcome of the change process will go a long way into enlightening these professionals on the aspect of implementation of change. Furthermore, this is also a chance for them to enhance their project planning and implementation techniques. Moreover, this is also an opportunity for the agent of change to exercise their skills and more importantly, try to explore the change process from the perspective of the various stakeholders involved, such as the patient, the hospital staff, and the management.

Implication of a clinical change to the policy and strategy of a hospital

By embracing a clinical change with the aim of preventing the development of deep vein thrombosis (DVT) amongst its elderly and immobile patients, such a gesture by the hospital may at best, be viewed as an act of Corporate Social Responsibility (CSR). What this means is that the policy of the hospital shall have been altered, albeit to a certain degree, in order to create room for this new initiative.

In addition, there will also be the added need for human and material resources fro purposes of managing the new project. In addition, the hospital authority may wish to have a sustainable project, in the long-run, meaning that now, the strategies of management may have to be revised, to incorporate this new clinical change.

A planned program of change

The first activity that this clinical change proposal shall take into account shall be the identification of the participants to the clinical change practice. It is important to select a specified number of participants, in order to integrate well with the resources that have been allocated. In addition, the size of the participants to a study is also important, for purposes of effective measurement of the outcomes, an implementation of the laid-down plans, and also the evaluation of the outcomes.

If at all the planned program of change is to succeed, there is a need to have an agent of change. In this case, the change agent shall be charged with the responsibility of getting the participants to the clinical change (the elderly and immobile patients) actively involved in the project at hand. It is important that the change agent is able to obtain the commitment and support of the participants to a change process. As such, this calls for such agents of change to be highly competent in what they do.

Communication skills are therefore a necessity, in addition to the fact that it is important for a change agent to fully comprehend the doubts and opinions that the patients could be harbouring. There are a number of forces and factors that are at play when we want to implement change projects. These kinds of factors have the potential to compromise the objectives and the reasons behinds the anticipated change, in addition to the beliefs, values and routines that the participants involved in this change proposal are used to. In this case, the onus shall be on the change agent to ensure that he/she exercises diplomacy in dealing with the participants.

Obtaining consent from the patients for purposes of participating in this planned change shall also be important. Even as the planned clinical change agent is poised to be of benefit to the elderly and immobile patients, by assisting them to prevent the development of DVT, nevertheless it would be quite unethical to enrol such patients in a program without first obtaining their consent. There are those patients who may want to be excluded from such an exercise, its enormous benefits notwithstanding.

In addition, there are also other patients who would wish to take part in a clinical change program, but at the same time also ensure that their views and opinions as regards the programs remains anonymous. As such, it is important to respect the wishes of such patients.

Following the obtaining of the consent of the patients, and once the number of the patients that shall be taking part in this clinical change study has been established, it wills then become necessary for such patients to work hand-in-hand with the change agent, in order to realise the goals and objectives of the program.

At this point, the creation of awareness of the associated risk factors for deep vein thrombosis (DVT) within the context of the elderly and immobile patients will then be communicated by the change agent to the participants. The introduction of an exercise regimen for the patients shall then be laid out. Such would include neck and calf stretches, toe/foot circling, and brisk walking, amongst others. These kinds of exercises shall be under the supervision of a change agent, for purposes of assessing the progress of the patient, in addition to recording improvements in terms of progress.

Utilization of theoretical frameworks in change management

Previously, there have been endeavors by a number of researchers and scholars alike (for example, Lazenbatt 2002; Martin, 2003), to marry the various aspect of a change theory. For instance, a model that has been developed by Grol for the implementation of change entails cyclical and a stepwise process that takes into account the identification of possible obstacles that could stand in the way of a change initiative, in addition to a connection of potential interventions towards these kinds of obstacles. We also have a number of doctors who have sought to explore the process of affecting the change of behavior within a clinical setting.

One of the theories that have found application within the realm of clinical change is the diffusion theory of innovation. As Patton (2002) has noted, this theory is a derivative of the theory of communication, and it seeks to explore the communication of an innovation process via a number of challenges to individuals within a social system, over time. In this case, an innovation is taken to mean a practice, idea, or even an object that is often viewed as being new. It is important to note that the diffusion theory of innovation holds in high regard on the various functions of an agent of change.

In the case of the clinical change at hand, the agent of change shall be charged with the responsibility of ensuring that the patients are able to embrace the behavioural changes, such has the adoption of an exercise regimen, for purposes of preventing the development of DVT. Since this is a new concept fro both the patients and the health care practitioners at the hospital, it may therefore be regarded as an innovation. As such, the agent of change here will require influencing the decisions of the patients; in as far as the adoption of this novel idea is concerned.

According to Martin (2003), an agent of change requires to be fully acquainted with, and entirely identify with, the various concerns that a target groups could be harbouring. Still on the issue of behavior change, the transtheoretical model has received wide recognition, based on the fact that this model conceptualizes in broader terms, the various factors that have the capability to influence change, at a clinical setting. Following a testing of this model, what emerges is that it is both an effective and reliable means of enhancing the practice of clinical change.

McSherry and Bassett (2002) opine that behavioral change as a process that is continuous consists of five fundamental stages. To start with, there is the pre-contemplation stage, then the contemplation stage. After these, we have a preparation stage, after which action and maintenance follows. The journey through the five stages entails changes with regards to the attitudes and knowledge of the participants, something that is expected for the participants of this clinical change as well.

Before the actions stage may be attained, it will be expected that the elderly and immobile hospitalized patients that are a target for this particular change proposal, shall have undergone through positive beliefs as regards their self efficacy for embracing the change, an emotional process, as well as their developing and embracing of the much-needed skills to cope with this kind of clinical change (McSherry & Bassett, 2002).

In order to ensure the progression of this clinical change, the staff members and the change agents involved shall be called upon to restructure the hospital environment, so that the behavioral change may take place in a manner that is quite conducive. Moreover, the provision of social support to the participants shall also be a necessity.

Aims and objectives

The purpose of this research proposal is to introduce an exercise leaflet with a view to preventing the development of deep vein thrombosis (DVT) amongst immobile elderly patients. As such, this proposal is more of a clinical behavioral change initiative, whose aim is to encourage such a group of elderly patients to take responsibility of their lives, when it comes to the issue of preventing the development of DVT’s. It is important to note that with an increase in age, the level of mobility also tends to reduce, with the result that the flow of blood in the vein may slow down (Wells et al 2006), in effect causing the development of blood clots and consequently, DVT.

If at all the elderly patients that this research proposal seek to target are to benefit from it, there is a need to enlighten this target group on the venous condition that is deep vein thrombosis, the associated signs and symptoms, the risk factors that they could be faced with, its pathophysiology, the frequency of occurrence, and the management of DVT through exercise.

On the other hand, there is a need to point out that for the elderly, the exercise regimen to which they may be exposed to would often differ significantly from that of young patients, on the basis of their age and the associated health complications. Therefore, it is important to identify an ideal level of exercising that shall ensure that the elderly are able to prevent the occurrence of DVT, and at the same time also ensure that no complications comes about due to exercising.

Objectives

• To introduce a clinical change exercise leaflet to prevent deep vein thrombosis (DVT) amongst elderly patients
• To create awareness to elderly patients on the risk factors for deep vein thrombosis (DVT) development
• To enable the elderly patients to take responsibility of their health, with a view to preventing an escalation of the risk factors for DVT development.

Proposed phases of the clinical change

Below is a diagrammatical representation of a timeframe for the steps to be followed in implementing the proposed clinical change.

Table 1: a timetable for the various stages of proposed change implementation

Issue influencing clinical change proposal

Lately, we have had a number of authors underscore the significance of assessing the various aspects of a change process that could either influence it positively, or be an obstruction to it. Obstacles to a change process therefore require to be identified beforehand, even before possible strategies for intervention are arrived at (Hughes, 2006). Some of the obstacles that this proposal anticipates are from both the hospital as an institution, along with the associated human and capital resources, as well as from the individual patients taking part in the process of change.

From the point of view of the patients, it is expected that their habits, skills, knowledge-levels and attitudes shall differ significantly, and this could be a challenge to the hospital staff and the agent of change alike, to try and identify these variations. Moreover, the reaction from the colleagues of the patients as regards their participation in the change process could impact on the participants.

With regard to the hospital as an organisation, the expectation is that the availability of resources for this particular project could be somewhat limited, thereby interfering with the implementation of the clinical change. During the implementation process, there is the possibility of a further cropping up of a number of problems. For instance, the groups that this change proposal has targeted could fail to keep up with the sequential progression of the different stages of the change, meaning that the staff and the change agent could have to work extra hard to ensure that such patients do not lag behind.

When it comes to the issue of adopting this change proposal, resistance could also be anticipated from the participants, some of whom could view it as being too complex fro them to master, or due to the fact that it is a break from their usual routine. During the actual implementation step of the change, limited resources, in addition to the possibility that some of the participants may relapse to their former routines, is another anticipated obstacle. Moreover, there is a chance that some of the participants may very well fail to get satisfied by the progress that they make in embracing the proposed change.

Resources analysis for effective change management

In order that the change may be managed in an effective manner, there is a need to ensure that the processes of planning and analysis for such change process are executed well, as Bartunek (2003) notes. In terms of analysis, the organisation that is executing such a change needs to be assessed beforehand, for its readiness to take part ion the foreseen change. In this case, the sharing of financial information towards the implementation of the change should be done, with all the various stakeholders involved.

The outlook of the stakeholders to the change process requires to be explored, in order to assess whether the environment is conducive for the change to be effected. The timeline and overall plan for the change should ideally be a pointer to the objectives of the proposed changes this is important (Batavia, 2001), so that the possible barriers along the way can be evaluated in advance and if possible, avoided or mitigated. The timeline from the execution to final stage of evaluating the outcome for the change proposal is anticipated to take a maximum of 4 months. An extended timeline results in extra utilisation of resources, and thus may hinder progress.

Characteristics of an effective change agent

There are quite a number of characteristics that have been provided on an effective agent of change. To start with, a change agent requires to be focused on the goals or outcome of the anticipated change (Bartunek, 2003). In other words, a change agent is more like a roadmap for the change process being implemented. As such, an agent of change needs to be well aware of the expectations of individuals and an organisation, once the desired outcome has been attained.

Moreover, it is the responsibility of a change agent to anticipate how different the participants or the organisation shall be, due to the implementation of the desirable change. In addition, a change agent needs to consider the various benefits that the various stakeholders to a change process stand to gain. It is also important that an agent of change is able to harbour a belief that the change that they are campaigning for is possible (Bartunek, 2003). In other words, an agent of change needs to firth believe in the change, before convincing others about the same.

In the absence of a possibility in change, an agent of change may then expect to meet with a blockage of their creativity, in addition to a possible resistance of the change by the beneficiaries (Bartunek, 2003). Then there is the issue of motivation. An agent of change recognises that change is often times a tough undertaking and so if at all they fail to become highly motivated, getting stuck is a possibility.

Motivation is a necessity for the maintenance of momentum, even in the face of adversities (Bartunek, 2003). Another characteristic often deemed as being essential to an agent of change is commitment. This is because the commitment levels of an individual usually influences their behaviour and by extension, the results that may be expected. There is a need also to have an agent of change with a high level of creativity. This is important, because no two processes of change may be the same.

For this reason, an agent of change requires to seek novel solutions, as well as new techniques of encountering the challenges that they could anticipate along the way. When it comes to the issue of planning, an agent of requires being highly flexible, since in the absence of an effective plan, change may be hard to attain (Bartunek, 2003). To those change agents that have attained certain levels of success, that have since come to the realization that it takes time and patience to obtain the desired change. The desirable change outcome calls for patience and persistence.

Flexibility for a change agent is very important so that they can easily adapt to circumstances as they change. Empathy is yet another desirable characteristic of an agent of change (Bartunek, 2003). In this case, high empathy levels are required, so that an agent of change may perceive the change from the point of view of the various stakeholders involved and if possible, make the necessary amendments.

Measuring clinical change

In order to determine whether the anticipated behavioral change for the elderly and immobile patients at risk of developing DVTs has been successfully been implemented, In this case, the clinical changes amongst the individual patients shall be undertaken on the basis of the observed differences amongst the groups of patient. As such, the intervals at which patients shall be undertaking a common and identified physical exercise, such as walking, shall be computed for each individual patient, along with the duration of their participation.

Such measurements shall then be compared with the average figure for this group of elderly patients so examined, to determine the patients that fall below the established threshold. In addition, such other physical exercises as the circling of the foot by a patient, knee raise, calf and neck stretches, as well as toe/heel lift, shall also be assessed in a similar manner. It would be important to point out here that a regular recording of these activities would be necessary so that the progress- or lack of it- that an elderly patient is able to make over the time during which the anticipated clinical behavioral change is being assessed.

Monitoring

Clinical monitoring is a term that is used in reference to the administrative and oversight efforts that are directed at monitoring the health of a participant in a given clinical change plan (Prandoni et al, 2004). It is the responsibility of health care personnel, such as nurses, to ensure that safety measures have been put in place to safeguard the participants (Batavia 2001). In this particular clinical change, the elderly and immobile patients that are at risk of developing DVT shall be under the supervision of a nurse as they undergo through the various chosen exercises regimen, for purposes of reducing their risks.

Furthermore, it shall also be necessary that the patients are periodically assessed to see whether they are taking the initiative to take charge of their lives, in as far as changing their behaviour to prevent DVT development is concerned. According to Batavia (2001), the frequency with which the monitoring exercise of a clinical change is carried out is of significant value. In this case, the patients shall be under the watch of a supervisor as they undergo through their physical excises, such as moderate walking, and calf and neck stretches. This is important, so that they may not overdo it, resulting in drastic complications.

Evaluation

Research on evaluation is usually carried out with a view to assessing the effectiveness of number elemental practices, like a policy or a project. What this means is that first, objectives are identified, followed by an assessment of the progress that such a project has undertaken, in a bid to achieves the set objectives (Patton 2002).

Currently, evaluation research appears to be more focused on solutions, and often times takes into account possible recommendations for a project, with a view to improving the outcomes. The positivist theory of evaluation supports hypothesis development, followed by quantitative data collection. It is this data that is then used for purposes of hypothesis testing, and a consequent evolving of a theory. On the other hand, the constructivist theory places more emphasis on the experiences of individuals, meaning that as opposed to the positivist theory, the main focus here is qualitative data. In addition, the evolving of a theory followed a sequential collection of data.

For this particular research study, use shall be made of the constructivist theory, in a bid to evaluate the outcome of the research study. As such, the experiences of the participants, in terms of being confronted with behavioural change as a way of preventing the development of DVT, shall be employed. A valuable tool that shall come in handy in evaluating the productivity of the change agent to the participant, is the administering of a semi-structured questionnaire, that shall target both the patients, as well as the staff of the hospital to which they are admitted. In this case, the questionnaire shall be qualitative in nature, as it will seek to address the experiences of both the patients and the medical staff alike, with regard to the effectiveness of the change implementations process.

During the evaluation process of the data pertaining to the participants for this research study, it is expected that some of the elderly patients may opt to drop out of the exercise, and this shall impact on the final outcome of the study. In addition, difficulties are also anticipated in terms of changing the behavior of the elderly patients, such as their lifestyle, to now take an active role in physical exercises.

On the positive side however, this research study anticipates the patients so targeted to embrace this clinical change, given that it is an initiative that is geared towards preventing the development of a venous disorder; DVT. Given that age is a risk factor to the development of DVT, the expectations is that such elderly patients shall be more than willing to take an active role in as far as the embracing of the clinical change is concerned.

Role of a change agent

The role of a change agent is quite significant; in as far as the issue of change implementation is concerned. For purposes of this particular clinical change, a change agent shall therefore occupy a central role. Specifically, he or she shall act as a guide to the participants, to help them with the implementation of change, such as behavioral change, as well as the various physical exercises that the immobile and elderly patients will be subjected to.

In addition, a change agent also assumes the role of an educator (Bartunek 2003), imparting knowledge to his/her subjects. As such, the change agent from this particular research study shall see to it that the participants are aware of the risk factors for DVT, and the role of physical exercises as a way of minimizing the risks associated with its development.

Moreover, it will also be the responsibility of such a change agent to educate the participants on complications that are associated with DVT, and so the need to institute preventive measures beforehand. Facilitation is yet another responsibility for a change agent (Bartunek 2003). As such, a change agent for this study shall ensure that the anticipated behavioral change, and the creation of awareness about DVT to the elderly and immobile patients that this research targets, happen.

Conclusion

The aim of this research proposal is to introduce a leaflet that shall assist the elderly and immobile patients to prevent the development of deep vein thrombosis (DVT). in this case, the leaflet is perceived to be more of an informative document that will both educate and offer advice to the elderly patients that have been immobilized in their hospital beds either as a result of having undergone a surgical operation or because they are awaiting one. In this case, there is a need to mention that immobility, and a resultant lack of exercise has been implicated with predisposing one to the development of deep vein thrombosis (DVT) (Wells et al 2006).

When you factor in the issue of age, what emerges then is that the elderly patients, who are also more likely to be less mobile, are six times as much at risk of the development of DVT when compared with their youthful counterparts. The intention of this leaflet, therefore, is to create awareness to the elderly and immobile patients of the potential risk that they could be faced with.

Less active individuals, like in the case of the elderly and immobile patients, shall often experience a reduced flow rate of blood in their veins (Brown & Lie 2008), and this has the potential to enhance the formation of blood clots within such inactive veins. Previously, those patients that were being diagnosed as having developed DVT would often be advised by their physicians to strictly remain in bed (Wein et al 2007), with a majority of these bind admitted to hospitals for between 7 and 10 days. On the other hand, physical exercises have been noted to be quite beneficial to these patients, and doctors are changing their stance on this. It is from such a perspective, therefore, that this research proposal wishes to explore the possibility of introducing a leaflet that promotes exercise as a way of preventing the development of DVT amongst the elderly and otherwise immobile patients.

A number of researchers contend that even a mild form of exercising like brisk walking could greatly reduce the risk of the development of DVT (Partsch 2001). However, we also have researches that have reported contrasting findings, with reports indicating that exercising could predispose a patient to potential risks; as far as their overall quality of health is concerned. On the basis of such findings, there is a need to ensure that a leaflet so produced is able to take into account such issue, although by and large, the argument is that the ensuing benefits that accompany moderate forms of exercising by far exceed potential risks. There is also the need to take into account the age bracket of the elderly patients, in this case, beyond the age of 60 years. As such, any form of exercise regimen that could be arrived at requires being at best, modest.

Recommendations

• It is important that the full consent of the participants be sought, prior to the commencement of the research study.
• A reliable and valid yardstick should be incorporated so that the performance of the participants with respect to the implementation of change may be effectively measured.
• The physical exercises are so chosen should take into account the age bracket of the participants, to avoid possible complications
• There is a need to have the participants implement the change under the supervision of a health practitioner.

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