NSG 324 Unit 6 EBP model applied to a unit change example

Applying the Iowa Model to an Oral Care Protocol for Preventing Pneumonia in Non-Ventilated Patients on a Medical Unit

Student Name

Department of Nursing, Herzing University

NSG 324: Evidence Based Practice in Nursing

Instructor Name

February 25, 2026

Applying the Iowa Model to an Oral Care Protocol for Preventing Pneumonia in Non-Ventilated Patients on a Medical Unit

The Model and Why It Was Chosen

The Iowa Model of Evidence-Based Practice, revised in 2017, guides a team from a triggering issue through appraisal of evidence, a pilot, a decision about adoption, and steps to sustain and share the change. It includes three decision points at which the team must decide whether to continue: is the issue important enough to the organization, does the evidence justify acting, and should the tested change become standard (Iowa Model Collaborative, 2017). I chose it because its decision points match how change works on my composite 30-bed medical unit, where any practice change must win approval from the unit practice council and must survive a trial before it becomes policy. The model's steps serve as the headings below.

Step 1: Identify the Triggering Issue

Infection prevention's annual report identified seven cases of pneumonia acquired on the unit in 2025 in patients who were not on ventilators, about 0.7 per 1,000 patient days. Three of the seven patients were transferred to intensive care. In a one-week audit I conducted with the unit educator, oral care was documented on average 1.3 times a day for patients who needed help with it, and 11 of 20 dependent patients had no toothbrush in the room. The trigger is therefore both a clinical problem and a gap in basic care.

Step 2: State the Question

In adult patients on a medical unit who are not ventilated, does a structured oral care protocol, compared with current practice, reduce the incidence of hospital-acquired pneumonia?

Step 3: Is This a Priority? Where the Model Did Not Fit Easily

The third step tests organizational importance, and the honest answer at first was no. Unlike ventilator-associated pneumonia, pneumonia in non-ventilated patients is not a publicly reported measure at this hospital, and it did not appear in the hospital's quality goals. Rather than answering the step with a sentence claiming priority, the team made the case to the nursing quality committee: pneumonia in non-ventilated patients is common nationally, with incidence estimates suggesting it is among the most frequent hospital-acquired infections (Baker & Quinn, 2018); it is linked to intensive care transfers, which the hospital does track; and the proposed change costs little. The committee agreed to treat it as a unit-level priority, which was enough to proceed but meant the project would receive no additional funding.

Step 4: Form a Team

The team included two staff nurses, a nursing assistant, the unit educator, an infection preventionist, a speech-language pathologist to address patients with swallowing problems, and the purchasing department's representative for supplies. The nursing assistant was included because most oral care on the unit is done by assistants, and a protocol designed without them would likely fail.

Steps 5 and 6: Appraise the Evidence and Decide Whether It Is Sufficient

The team found a pre-post study in which a hospital introduced an oral care protocol with toothbrushing, and reported a substantial decrease in pneumonia in non-ventilated patients afterward (Quinn et al., 2014), and a cluster-randomized study on four units in which the units receiving an oral care intervention had lower rates than the comparison units (Giuliano et al., 2021). Most of the remaining evidence is from before-and-after designs, which cannot rule out other changes happening at the same time.

The team judged the evidence sufficient to pilot but not to adopt without testing. The reasoning was that the intervention carries little risk and little cost, the evidence consistently points in one direction, and a pilot with local data would show whether the benefit appears here.

The team appraised each study for the weaknesses that matter most here. In the pre-post studies, other changes, such as new hand hygiene campaigns or shifts in the patient mix, could explain part of the decline. Pneumonia in non-ventilated patients is also hard to define consistently, so a change in how cases were identified could look like a change in how many occurred. The cluster-randomized study reduces the first problem but involved only four units, so a difference between units unrelated to oral care could still affect the result. The speech-language pathologist added a clinical concern the studies did not address: patients with swallowing problems need oral care done with suction and upright positioning, or the care itself could cause aspiration. That concern shaped the protocol.

Step 7: Design and Pilot the Change

Protocol: toothbrushing with a soft toothbrush and toothpaste four times a day, after meals and at bedtime; for patients who cannot brush, assistance or a suction toothbrush; and denture care. Supplies: an oral care kit placed in every room at admission. Documentation: a single flowsheet row, completed each time. Training: 15-minute sessions at the unit huddle for all shifts, and a demonstration for assistants. The pilot ran for three months. Measures were oral care documented per patient per day, supplies present in rooms on weekly checks, and pneumonia cases in non-ventilated patients, recognizing that seven cases a year means three months cannot show a clear change in the outcome.

Step 8: Is the Change Appropriate for Adoption?

After three months, documented oral care rose from 1.3 to 3.1 times a day for dependent patients, and kits were present in 94% of rooms checked. One pneumonia case occurred during the pilot, too few to interpret. The team recommended adoption based on the process results, the external evidence, and staff feedback that the kits made the care easier. The council approved adoption as a unit standard.

Steps 9 and 10: Integrate, Sustain, and Disseminate

To sustain the change, kits are now part of the admission supply cart, oral care is on the assistant task list, and documentation is reviewed monthly by the educator. Pneumonia cases will be tracked for at least a year, the period needed for the numbers to mean anything. Results were shared with the nursing quality committee and two other medical units, which have asked about adopting the protocol.

References

Baker, D., & Quinn, B. (2018). Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States. American Journal of Infection Control, 46(1), 2-7. https://doi.org/10.1016/j.ajic.2017.08.036

Giuliano, K. K., Penoyer, D., Middleton, A., & Baker, D. (2021). Oral care as prevention for nonventilator hospital-acquired pneumonia: A four-unit cluster randomized study. American Journal of Nursing, 121(6), 24-33. https://doi.org/10.1097/01.NAJ.0000753468.99321.93

Iowa Model Collaborative. (2017). Iowa Model of Evidence-Based Practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223

Quinn, B., Baker, D. L., Cohen, S., Stewart, J. L., Lima, C. A., & Parise, C. (2014). Basic nursing care to prevent nonventilator hospital-acquired pneumonia. Journal of Nursing Scholarship, 46(1), 11-19. https://doi.org/10.1111/jnu.12050