Management and Implementation of Change in Nursing

                                                   Introduction : 

 Nursing as a profession is ever evolving and changing in order to meet the needs and demands of our healthcare system. Revision of practice in the field often comes about due to economic reasons with cost reduction being the main driving force. Budget cuts in recent years have led to targets and outcomes taking precedence over the expansion of knowledge in our practitioners (Cliff 2018, Andrews et al ,1993).  Maintenance of best practice and provision of quality healthcare should however remain at the forefront of nursing practice. Every nurse is the accountable for the care they provide and therefore they must strive to continually improve their own standards of practice by moving with the technological advances in modern medicine, (page, 2004).  The ability to adapt practice or seek out opportunities for change is influenced by the recognition that we all have a part to play in service quality improvement , (Kerridge, 2012).

 Quality and change are two terms synonymous with one another when it comes to nursing practice , the ability to provide quality evidence based care requires a willingness to continually adapt practices as denoted by the literature.  In stark contrast to change, defining quality in healthcare has posed many issues.  A large portion of the literature has described it as being so complex a clear definition has proven extremely difficult , (Thompson et al, 2003). The most widely cited definition was developed by the US based Institute of Medicine, which states quality as being the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990 PG4). Brady et al (2010) capture the essence of quality in nursing when they describe it as doing the “right thing”.  According to Redfern et al (1990) quality nursing healthcare should be underpinned by the following attributes: effectiveness, efficiency, accessibility and appropriateness.

  The change proposed for the purpose of this paper is with regards to the introduction of  new end catheter hub system in a dialysis outpatient unit. One of the most common complications associated with  long-term dialysis is the risk of developing a  Catheter related blood stream infection (CRBI).  The current data highlights CRBIs as being  the second leading cause of death in  the chronic kidney patient population (Soi et al , 2016, Brunelli et al , 2018).  A study carried out by the Renal association of the United States (2011) showed that roughly 300 per 1000 dialysis patients developed catheter related bactermia in 2011. Research by the National healthcare safety network showed that  over 29,516 bloodstream infections were reported in dialysis units in 2014 (Shugart et al,2014). A retrospective study by Brunelli et al (2014) which looked at the use of the Tego needle-free end hub system, showed and overall reduction of between 10-12%  in CRBS versus the use of standard end hubs. This according to their research was due to minimization of end hub manipulation.  The clear-guard end hub anti-microbial device also showed positive results when compared with standard end hubs. According to a prospective multi-unit randomized cluster trial by Hymes et al (2017), the use of the clear guard system showed a 43% reduction in CRBIs over a 12month period.

 In this assignment the research surrounding the benefits of such systems will be reviewed and conclusions drawn as to the benefits of their implementation in the clinical dialysis setting. Current research on the management and implementation of change will be draw upon in order to provide a basis on which the change could be successfully implemented in the clinical setting.

                                                            Main body :

    In the introduction of this assignment the concepts of quality and change where briefly touch upon. The next few paragraphs will provide more in-depth analysis of a model for change, leadership and its role in quality control. Currently a vast depth of depth of knowledge and models exist in the literature in terms of change implementation. The literature highlights the Kotter model (1996) as one of the leading clinical models with regards to change management (Burden et al, 2016). This model highlights eight key steps to implementing change in nursing  practice and therefore will be drawn upon for the purpose of change in this assignment.

   Step one of the model involves creating a sense of urgency.  This essentially means highlighting to staff why there is a need for change in their practice and what needs to changed , ( Campbell, 2008).  In order for the  implementation of new practices to be successful all parties involved must understand firstly: why there is a need for change , what needs to be changed and how it can be changed , ( fisher et al , 1985). Step one would involve highlighting the current data available regarding the prevalence of CRBIs due to end hub manipulation.  The second aspect of this step would be how the introduction of a new safety hub system may help to tackle this issue. Summarised findings from the current literature have been detailed below and will provide the basis of information upon which the need for the change in practice will be highlighted.  A bullet point summary of the data may prove beneficial at this point in the  process as the initial setting should be informal. The idea in this  step is to plant a seed for change in practice. An ideal time within the dialysis setting would be at morning safety pause as this is an allocated time slot to highlight concerns and ideas.

   The biggest challenge currently facing end stage renal patients world-wide is the early establishment of access. Although arterio-venous fistulas are considered the gold standard in terms of renal access therapy, a series of challenges face their implementation (mcCann et al, 2010). These challenges include patient reluctance, anatomical issues and the requirement for ready to use access points in particular in the case of  Aki’s , (Soi et al , 2016, Leapman et al 1996).  Due to these predisposing issues , indwelling catheters have become the main choice for long-term dialysis use with up to 80% Of American initiating treatment with cuffed catheters (USRDS, 2011) . Within 24hrs of insertion micro-organisms are present in all indwelling catheters (Raid et al,1993). The main source of these micro-organisms is through end hub manipulation. The ineffective handling of the lumens can lead to the introduction of bacteria which travels into the patient’s bloodstream. End hub mishandling has shown to be the most important factor in the contribution of intraluminal microbial colonisation. (Marr et al ,1997, O’grady et al ,2011).  Much of the literature surrounding dialysis is teamed at tackling CRBIs within our catheter patient populations with reduction and or prevention being the main aim. The CDC ( 2011) established a set of recommendations regarding handling of our catheters with a large focus being on how we handle our hub sites. The effective scrubbing of our end hubs and  the maintenance of  strict asepsis when manipulating them were seen as playing a vital role in infection reduction.

   A recent study carried out by Macafee et al (2010) on infection rates in the pediatric dialysis population. Showed that the introduction of the tego system in this particular cohort of patient between (2005-2006), lead to  an overall reduction from 7.8% to 3.9% regarding the incidence of catheter associated infections.  Brunelli et al (2014) also looked at the incidence of CRBIs when the tego needle free system was implemented versus the use of standard hubs. Their data showed an overall  reduction of up to 5% in positive blood cultures and an 8% reduction for the need for antibiotic therapy. Hymes et al (2017) also found very positive results in their study of the clear-guard antimicrobial system which showed an overall reduction of up-to 43% in infection rates . Interestingly  a repeat study by Brunelli et al (2018) which contrasted both systems against one another found the clear -guard system to be the superior of the two. 

The main issue that arose when an in-depth search of the literature was conducted was that although a more effective end hub system needs to be established, current data surrounding such systems is very limited. The lack of evidence is the main threat represented by the attempted implementation of such a system. Resistance to such an idea may stem from the lack of data, making staff unwilling to let go of current routines and practices . Staff may feel a distrust or indifference to such a system being introduced, ( Salam & Algamedi, 2016). The early recognition of barriers and resistance to the proposed system will be pivotal in order to progress to the next step of the model.

  The second step in the process involves the formation of a powerful coalition , (Kotter, 1995).  This step involves building a core team, who will guide others through the process of implementing the change. The team members need to be key stakeholders within the organization, there must be a focus not only on those in positions of power but on all levels of the workforce within the organisation (Kerridge, 2012). This is key as to creating an atmosphere for transformational type leadership to flourish .  Transformational leaders are those who are intellectual, charismatic, inspire others and have an ability to individualise tasks, (bass, 1985).  Understanding this style of leadership and its role in change, is essential in the formation of a powerful coalition. Bolden (2011) defines leading as the responsibility of everyone and not just one particular individual. Those with high levels of expertise in the area play a pivotal role in this step of the process,(Kanter et al 2003). The key members will involve : the unit manager,  the vascular access nurse specialist, the consultant nephrologist, the infection control nurse , a representative from the finance dept, a healthcare attendant and a leading member of the nursing staff who will act as a team nurse champion for the change . The nurse champion will play a vital role in the day to day managing of the change  process and should be someone who regularly displays an ability to lead.  Frances (2013, p:105) states how leaders are those within an organization who “consistently reinforce standards of patient care”. Effective leadership in this incidence will require good communication , interpersonal skills, an ability to act in a supportive way and lastly empower other staff members (Junymin et al ,2016). The team may also include a representative of the company who produces the end hub system. This would help to facilitate the collection and compiling of  data as to the benefits of the system. A comprehensive  in-depth evaluation of the system would provide a basis for future initiatives.

    The creation of  a strategic vision and initiative provides the foundation of step three.  Initiatives are focused clearly defined goals which if set out correctly help to ensure the teams vision becomes a reality , (Burden et al, 2016).  This step involves creating a focus on why we are changing our current practices and why doing so will benefit not only our patients but also staff.  The references and studies mentioned in the above paragraphs offer support for step three of the process. Audit data surrounding catheter related infections and there prevalence in our unit should be drawn upon also to provide an effective basis on which to shape the vision.

    The fourth step in the change process involves a focus on communication. Spillane (2006) highlights how adapting a distributive leadership style may prove beneficial  in this stage of the process due its focus on interaction rather than just action. The main focus of distributive type leadership is on the sharing of activities and functions through effective and timely  communication, (Spillane ,2006). Although effective and efficient communication is key to each step of the process, during this phase clear communication is essential. As healthcare providers nurses often feel they are strong communicators and see it as a skill they employ in every aspect of their work. It is extremely important however to be aware when implementing a new practice how different types of communication barriers may arise. According to Hill (2013) these barriers can be cultural, generational, due to differences in values and beliefs or simply due to linguistics.

     The main idea behind step five is the recognition that change is not only going to impact the facility in which its being implemented but also on the lives of those work within that area , (campbell,2008). In order to successfully implement a change one must recognise the barriers to its implementation and work to remove them or  over-come them, (Calegeri et al, 2015). Kotters model believes in the use of the analyse-think-change mindset in order to overcome change barriers (Kotter, 1996). The main barriers that will need to be overcome for the purpose of this change are : fear due to lack of understanding and or information and secondly workload burden, ( Maslach & leiter, 2016). The recognition of both fear and embarrassment as being two of the key reasons why changes aren’t successful is essential to the process ( Salam & Alghamadi 2016).  . In the instance of the end hub system the provision of pre:educational sessions would be essential. These sessions would look at the current data surrounding infection rates but also provide in-depth background information on the chosen hub system. The sessions could be carried out using power-point presentations with an opportunity for staff  to ask and learn from experts within the team. The use of bar charts, histograms and other forms of data collection would help highlight clearly the available figures.  Education sessions should also encompass the  patients as lack of information may lead to fear and reluctance to accept the change and hinder staff patient relationships, (Jack et al, 2013)

  The creation of short term incentives is a positive way to reinforce change (Kotter & Cohen, 2002). The use of rewards and recognition along the process helps to increase motivation within staff as they feel they are being rewarded for work well done , (Calegeri et al,2015). Regular meeting slots to discuss progression and highlight employees work would be beneficial to this change. Staff who feel valued and recognised are more likely to accept the change long-term.  Reduction in infection rates would benefit the staff as well as the patients, due to reduction in staff labour and time as well as increased job satisfaction by creating an environment for happier healthier cohort of patients. The benefits may also have a ripple effect and extend  beyond the bounds of the unit benefiting other areas such as : the finance dept, the infection control team and potentially other dialysis units nationwide.  A collective leadership type  approach would be key at this stage as its surrounds the concept of creating  clear goals while promoting continuous learning . This style of leadership mainly focuses on small achievable goals combined with timely feedback (Eckert et al, 2016).

   The last stages in Kotter’s change model involve consolidating gains, producing more change and anchoring new approaches in the culture( Burden et al 2016). These last two phases of the  model are the most important to the long-term effectiveness of the change. Employees often revert back to old habits or practices post implementation.   The key to preventing this is not allowing complacency , (Kanter et al,2003). Prevention of complacency is achieved by executing micro and macro level of  plans. (Kotter,2018)  Macro level planning would involve the key team members effectively communicating the completion of each stage of the needle free hub change and on a micro-level improving standards as the new system is  being implemented, i.e being open to adapting their approach along the way.  The final two step of the model have been drawn together in the same paragraph  as essentially they both involve making the change the “status quo” of the unit. The change in order to stick must become ingrained in every aspect of the unit , the team and the patients (Kotter, & Cohen 2002).

                                              Conclusion:

   Evaluation of the change here is extremely important as although current studies into end hub systems have proven very beneficial they are also limited . Therefore regarding this change there is a need for strict collection and analysis of outcomes pre and post implementation. This data is extremely important as it may help to shape future practice in all dialysis settings if the outcomes are as positive as those of brunelli et al (2013) , Hymes (2017) and Macafee  (2010). It’s extremely clear from the literature that implementing change in practice although necessary poses many issues, difficulties and barriers. The application of a change model provides a good understanding of leadership and quality in the process and is crucial to successful implementation of a change in practice.  Although many  different models exist the model used for the purpose of this assignment was deemed the most appropriate. Regarding the use of a new end hub system it’s clear that  this type of change could help to drive forward more positive patient outcomes in the future.  A current  lack of more distinguishable research however makes the introduction of these type of systems extremely difficult in the clinical setting . Resistance is a huge threat due to  many feeling it’s not worth the risk or increased workload burden. The data however does highlight the need for us as practitioners and healthcare providers to strive to improve our quality of care by looking for new methods and practices to tackle CRBIs once and for all . We as practitioners must strive to continuously improve our quality of care by adapting practices and implementing new guidelines aimed at reducing mortality rates and infection associated complications .  A more in-depth analysis will need to carried out on both systems before implementing one within the chosen dialysis unit . This is in order to ensure the best evidence based practice is being adhered too.

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