Running head: IMPLEMENTATION OF A PRACTICE CHANGE
Implementation of a Practice Change:
Acupuncture and Acupressure Therapy for Chemotherapy Symptom Management
Shelby DeLoach
University of South Florida
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IMPLEMENTATION OF A PRACTICE CHANGE
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Implementation of a Practice Change: Acupuncture and Acupressure Therapy for Chemotherapy
Symptom Management
According to Tipton et al. (2011) the management of nausea and vomiting in
chemotherapy patients persists to be an issue regardless of advances in medications.
Chemotherapy-Induced Nausea and Vomiting (CINV) has poor outcomes for patients including
lack of compliance, early termination of treatment, and poor quality of life (Rithirangsriroj,
Manchana, & Akkayagorn 2014). The implementation of acupuncture and acupressure in
addition to antiemetics will allow for better patient care and increased comfort. Current
guidelines for the management of chemotherapy-induced nausea and vomiting state that both
acupressure and acupuncture are likely to effective (Tipton et al., 2011).
PICOT Question
In patients undergoing chemotherapy, how does acupuncture and acupressure therapy and
medication compared to medication alone decrease the occurrence of nausea and vomiting,
during a three-month period of treatment?
Infrastructure to Support Practice Change
The infrastructure necessary to manage this project includes oncology staff nurses,
physicians, acupuncturist, and the unit nurse manager. Nurses are certified to administer
chemotherapy and document any patient reports of experiencing nausea or vomiting. Nurses will
administer patient’s regular and antiemetic medications. Physicians are responsible for
prescribing chemotherapy and order referrals for acupuncture therapy. Acupuncturist will
administer the acupuncture to patients. The unit nurse manager will supervise the nurses and
ensure that the study is running appropriately. They are the contact person for any staff that have
questions regarding the new implementation plan.
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Summary of Synthesized Literature Review of Best Practice
Literature Search
National Guideline Clearinghouse, PubMed, and CINAHL were approached to acquire
guidelines and randomized controlled trials regarding decreasing occurrence of nausea and
vomiting in patients undergoing chemotherapy. The key terms utilized were nausea, vomiting,
antiemetic, acupuncture, acupressure, cancer, and chemotherapy.
Synthesis
According the Rithirangsriroj et al. (2014), the utilization of acupuncture versus
ondanestron delayed the onset of nausea (P=0.04) and vomiting (P<0.001) as well as increased
the patient’s quality of life (P=0.004). Research produced by Tas, Uncu, Sendur, Koca, and
Zengin (2014), determined participants receiving the acupuncture experienced less nausea and
vomiting, pain, insomnia, and anxiety (p<0.001). According to the investigation conducted by
Yeh et al. (2012) patients who undergo either auricular pressure with standard care or sham
auricular acupuncture experience a decreased incidence of nausea and vomiting. Participants
who undergo auricular acupressure with standard care had a lower incidence of nausea
(p=0.0289) and vomiting (p=0.0024) than patients receiving standard care alone. Participants
undergoing sham auricular acupuncture experience a decreased incidence of nausea (p=0.1058)
and vomiting (p=0.0172) in comparison to only standard care. Tipton et al. (2011) recommends
the use of behavioral therapies and pharmacological interventions for the management of CINV.
The research produced indicates that acupuncture and acupressure both can be utilized to
reduce the occurrence of CINV. Tas et al. (2014) and Rithirangsriroj et al. (2014) included
sample sizes that were able to produce results that demonstrated the effectiveness of acupuncture
in reducing the side effects of nausea and vomiting. Yeh et al. (2012) included a sample size of
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ten patients, after six patients were excluded and 6 patients dropped out. The number of
participants affected the results of the study, as they were not able to determine if auricular
pressure with standard care or sham auricular acupuncture was more effective for reducing side
effects of nausea (p=0.2590) and vomiting (p=0.1775). However, it was determined that both
interventions independently did decrease the incidence of nausea and vomiting in participants.
The recommendation grade of the overall evidence provided would earn the
recommendation of a B. This recommendation is based on the need for further research. The
studies utilized do not confirm absolute effectiveness of acupuncture or acupressure for
managing nausea and vomiting in addition to antiemetics for all chemotherapy treatments. There
are several types of chemotherapy treatments and cancers that are not represented in these
studies.
Proposed Practice of Change
Administering acupuncture and acupressure therapies in additional to anitemetics during
rounds of chemotherapy treatments will reduce the occurrence of CINV in cancer patient. The
current guidelines by the Oncology Nursing Society indicate that the recommended practice for
managing the CINV is medication (Tipton et al., 2011). The guidelines also indicate that
behavioral therapies including both acupuncture and acupressure are likely to be effective as
well. The overall utilization of medication therapy combined with acupuncture or acupressure
will help improve patient outcomes and increase patient comfort and satisfaction.
Change Strategy
Promote Engagement
All staff members and any individual affected by the changed are encouraged to be
involved in the transition of practice. In order for an organization to be successful during periods
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of change, involvement by all leadership and staff members that will be directly affected by the
proposed change is vital (Melnyk & Fineout-Overholt, 2015). It is necessary during the transition
process that anyone person that has the potential to be affected is engaged in and aware of the
current changes of practice.
The Model for Evidence-Based Practice Change
All staff members involved must identify that acupuncture or acupressure combined with
antimetics is an evidenced based solution for managing CINV. Criteria will be determined to
ensure consistency of the care that is provided to patients as outlined by the current evidence
based practices. The Model for Evidence-Based Practice Change (Melnyk & Fineout-Overholt,
2015, p. 286-289) is being utilized to implement the EBP in a clinical setting.
Roll Out Plan
Steps
Definition
Timeframe For Rollout
Step 1
Assess The Need For Change
In Practice
 Collect internal data in
the current facility
regarding symptoms
of nausea and
vomiting on a scale of
zero to ten (baseline
data)
 Compare the internal
data to external data
from other facilities
 National Database of
Nursing Quality
Indicators may be
used to assess the need
for change in practice
regarding
management of CINV
 Identify the problem
in need for change in
Completed by May 25, 2015
IMPLEMENTATION OF A PRACTICE CHANGE
Step 2
Step 3
Step 4
Step 5
practice with
regarding to
management of CINV
Located the Best Evidence
 Review different types
of research sources
including randomized
controlled trials and
meta-analyses
 Plan research
including key terms
that will be utilized
 Conduct Research
regarding
management of CINV
Critically Analyze the
Evidence
 Analyze the data and
compare each source
for strengths,
weaknesses, and
relevance
 Select the best
evidence to be
synthesized
 Make sure that all
evidence used is valid
and contains
appropriate p-values
Design Practice Change
 Define the proposed
change for
management of CINV
 Determine what
sources from the
synthesis will be used
 Create an evaluation
plan that will utilized
in step 5
 Develop a description
of the new practice for
management of CINV
Implement and Evaluate
Change in Practice
 Implement the pilot
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Completed by June 7, 2015
Completed by June 27, 2015
Completed by July 17, 2015
Implement: July 31, 2015
Evaluate: October 31, 2015
IMPLEMENTATION OF A PRACTICE CHANGE
study
Collect post-pilot data
and compare to the
baseline data from
step 1 regarding
symptoms of nausea
and vomiting on a
scale of zero to ten
 Formulate conclusions
and recommendations
Step 6
Integrate and Maintain
Completed by December 31,
Change in Practice
2015
 Integrate into current
standards of practice
 Provide in-service
education to providers
and applicable
medical staff
 Continue to monitor
patient outcomes
monthly and
determine if the
change of practice is
causing a decrease in
the symptoms of
CINV
 Disseminate results of
the project
Model of evidence-based practice change (Melnyk & Fineout-Overholt, 2015, p. 286-289).

Project Evaluation
Effective December 1, 2015, all cancer patients receiving chemotherapy regimens will
follow new guidelines regarding the management of CINV. Patients will now be pre-medicated
with acupuncture and acupressure treatments the day before they receive any chemotherapy
treatments and a minimum of three days following treatments. Patients will still continue to be
pre-medicated using antiemetic medications. Antiemetics will also be available on an as needed
basis. Data collected on these patients will be compared to the data prior to the implementation.
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According the Rithirangsriroj et al. (2014), of the patients receiving acupuncture versus
ondanestron, 52.8% of the patients experienced complete control and experienced no nausea, no
vomiting, and no additional need for antiemetic drugs. Evaluations of this implementation will
be monitored monthly and will be observing for a 3-point reduction based on scoring the
symptoms of nausea and vomiting. Patients will be asked to score their symptoms of nausea and
vomiting on a scale of zero to ten, with zero being no symptoms and ten being uncontrollable or
unmanageable symptoms.
Dissemination of EBP
This implementation of practice can be encouraged in several ways. The main source of
encouragement will be through presentations at upcoming oncology conferences and emails to
local hospitals in the Tampa Bay area and throughout the state of Florida. Each of these emails
will include the power point presentations to be presented in an upcoming conference. The will
an outreach to Oncologist specifically at Moffitt Cancer Center as this facility would find this
new implementation useful.
As part of the dissemination of this practice change, the emails sent to all of the hospitals
will also include instructions for how to conduct an in-service on this topic. The email will also
include the answers to frequently asked questions, informational pamphlets, and sources for
those interested in participating in more evidence based research on this topic in addition to a
copy of the power point presentation. In addition, this material will be distributed regionally and
nationally through publishing this material in a peer reviewed journal(s). This entire process and
study will be published after it has been successfully implemented in a clinical setting.
Promoting the use of acupressure and acupuncture in addition to antiemetics for patients
undergoing chemotherapy can improve patient comfort and reduce the occurrence of CINV.
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References
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing &
Healthcare (3rd ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams & Williams.
Rithirangsriroj, K., Manchana, T., & Akkayagorn, L. (2014). Efficacy of acupuncture in
prevention of delayed chemotherapy induced nausea and vomiting in gynecologic cancer
patients. Gynecologic Oncology, 136, 82-86. doi:10.1016/j.ygyno.2014.10.025.
Tas, D., Uncu, D., Sendur, M.A., Koca, N., & Zengin, N. (2014). Acupuncture as a
complementary treatment for cancer patients receiving chemotherapy. Asian Pacific
Journal of Cancer Prevention, 15(7), 3139-3144. doi:10.7314/APJCP.2014.15.7.3139
Tipton, J., Mcdaniel, R., Barbour, L., Johnston, M., Kayne, M., Leroy, P., & Ripple, M. (2011).
Putting evidence into practice: Evidence-based interventions to prevent, manage, and
treat chemotherapy-induced nausea and vomiting. Clinical Journal of Oncology Nursing,
11(1), 69-78. doi:10.1188/07.CJON.69-78
Yeh, C., Chien, L., Chiang, Y., Lin, S., Huang, C., & Ren, D. (2012). Reduction in nausea and
vomiting in children undergoing cancer chemotherapy by either appropriate or sham
auricular acupuncture points with standard care. The Journal of Alternative and
Complementary Medicine, 18(40), 334-340. doi:10.1089/acm.2011.0102