Influencing Practice For Service Improvement In Primary Care Nursing Essay

Innovation and change are currently seen as an integral part of the NHS, and nurses have an increasing responsibility in the delivery of healthcare (DOH 2004). With the introduction of clinical governance many NHS Trusts are examining the standard of care being given and are implementing new initiatives to bring the care up to standard.

This essay will aim to discuss and explore the implementation of an initiative to change practice in a clinical area of a primary care setting within an NHS trust. The proposed change is that of an orientation pack for new staff. This change can be linked to one aspect of clinical governance, staff and staff management, as it was felt that this was an area that needed developing.

It will explore the reasoning for the change and the leadership style that was utilised for to implement a change. It will analyse the change theory developed by Kurt Lewin (1951) and how it will influence the implementation.

Key strategies for effective clinical governance involves effective teamwork, leadership, ownership, openness and, most importantly, communication. The additional recurring theme is that the public and patients need to be involved in all aspects of the planning, organisation and environment of care.

Since 1999, it has been at the top of the agenda for the NHS (Sale 2005). Scally and Donaldson (1998) define clinical governance as: 'A system through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish (p61). There are many key elements in clinical governance these have divided into seven pillars. The pillar that will be focussed on in this particular instance will be pillar 4: Staff and staff managing, it has many crucial elements essential to the structure of a trust, specifically workforce planning. Without planning there will be a lack of staff skills, knowledge and empowerment which could threaten the provision of quality clinical care (Sale 2005).

An orientation pack is vital in any organisation setting. It can be overwhelming when starting a new role, and people can experience many emotions therefore there needs to be a structure in place to aid with this transition. Ward (2009) explains an orientation pack may impact retention within the nursing profession as well as increasing self confidence it will also impact staff with greater productivity and sense of direction in the work group. This is due to new employees getting to know the alignment between their role and the organisation expectations of them (Brown 2000). The primary care trust was having difficulty in retaining their staff, and had been experiencing a high turnover; there had also been some difficulties in filling the vacancies. Recruitment is ongoing, and costly the official cost is 32% of nurse's annual salary, but including the building up of new staff and productivity deficit in the process it can be four times this (Foster cited by Agnew 2004). He goes on to explain in the first year if the new employee has a sense of belonging by being effectively bonded to the setting then this significantly reduces turnover. Despite these obvious advantages, it was found that there was only a general induction to the trust which every employee has within the first three months of their new employment; however no formal structure had been developed in the specific clinical area. By not having a formal orientation to the clinical area made it makes it difficult to establish the roles of the already existing team. The team is split into clusters; these clusters cover different general practices around the area, however trying to establish which cluster covered which practice was confusing. There was also found to be a lack of clarity when it came to the caseload, it was difficult to identify client groups and information was limited, this in turn was also putting possible risk to patient care. Furthermore there was no opportunity for new staff to identity their objectives and how to develop themselves within their role.

When an initiative is being introduced to staff, they need to be aware of the reasons for the implementation. To enable successful integration into a new work place there needs to be a structured form of induction to alleviate barriers in communication and to enable a smooth transition. The proposed idea of a staff orientation pack (appendix 1) was the result of planned change. Planned change is a deliberate application of knowledge and skills by a leader, to bring about a change requires the leader to have the skills of problem solving, decision making and interpersonal and communication skills (Marquis and Huston 2006). Warrilow (2009) and Oliver (2006) both recognise that transformational leadership is focussed on, and embraces change, as it involves both the leaders and followers engaging on a common aim. They also recognise the leader to be a key element of successful strategies for managing change. Transformational leadership would be the most appropriate style to utilise when introducing the orientation pack as 'the underlying goal of transformational leadership is to bring about some type of change' (Grimm, 2010, p76). The leaders who use this style are also regarded as change agents. A change agent should be a person skilled in the theory and implementation of planned change to be able to deal appropriately with the very real human emotions, including resistance that planned change can bring about (Marquis and Huston 2006). They can achieve this by using qualities such as charisma to motivate their followers to be able to achieve their goals, share visions and empower them (Grimm 2010).

Change can be an intricate process which can have barriers which can threaten a successful implementation (McCrery and Pearce 2002). Sullivan and Decker recognise that 'Nurse Leaders must initiate the changes they believe are necessary to strengthen nursing practice, provide quality care, and create a better system' (2005, p.217). In an organisation, to implement change they would need to follow a change theory.  There are many theorists who have developed processes of change, but Lewin's theory is perhaps the one that is most recognised, user friendly and uncomplicated. The aid of a change model can be beneficial in overcoming certain obstacles. 'His theory of change provides the structure for understanding nurses' behaviour during times of change and ways to improve the behaviour when introducing change into the workplace' (Bozak 2003 p83). The model encompasses a three strep process this can be found in appendix 2.

Lewin's normative model of change is based on team participation, including all staff that will be affected by this change. This then increases their approval and implementation of change through a bottom-up method (Murphy 2006), furthermore identifying that achieving durable and efficient change entails the collaboration and involvement of the whole team not isolated individuals.

Nevertheless, before any change is considered a plan is required that identifies the need. Baulcomb (2003) suggests 'guidance from Lewin's (1951) force field analysis (FFA) demonstrates the complexities of the change process and how driving and resisting forces were incorporated within the planning and implementation phases'(p275). It is pertinent that the driving and restraining forces must be analyzed before implementing a planned change. Cork (2005) further explains that when implementing any change there are a number of factors that help to achieve change, this would be the driving concept for example the aim to improve orientation to the work place. Conversely, a restraining factor could be unwillingness to change or poor staff morale. Change can then only occur when one force outweighs the other, ideally for positive change the drivers must outweigh the restraining forces. The FFA for the proposed change can be found in appendix 3.

The focus of the 'unfreeze' stage is to change the status quo of the existing practice. The change agent needs to prepare the staff by identifying and challenging the need for change. The identification is necessary because changing for the sake of changes sake can cause unnecessary stress and the feel of manipulation (Marquis and Huston 2006). Involvement of colleagues from the very beginning empowers staff and makes them feel more valued. Sale (2005) identifies that staff are empowered when an environment has been created which encourages them to be actively involved in the decision making processes. However it is inevitable that there will be resistance when trying to implement a change especially when involving humans. Emotions can run high and change can be held as threatening. Conflict can also arise as it is making something different to what was (Sullivan and Decker 2005). To be able to start to overcome resistance the change agent needs to start to utilise their qualities as a leader and focus on valuing creativity and innovation form their staff (Marquis and Huston 2006). Informal discussions took place with different members of staff at various levels to explain problem had been identified and that there was a need for change. This allowed for the change agent to find common ground and start having a sense of connection with the staff (Tyrrell 1994). Staff appeared quite unsatisfied with the current status quo, however it was found that time was a resisting factor due to busy workloads. An issue that the change agent could bring to the attention of the staff is that the in the current climate workloads would not improve if there is low retention in staff, which in turn can be caused by not feeling integrated into the team properly. Part of this stage may involve making people feel uncomfortable. Another factor that would need to be considered would be a possible cost implication and who would carry it, management may feel reluctant to participate in funding. In the clinical setting the change agent could start to communicate their desired change via email which all staff have access to. This can give the staff the opportunity to convey their opinions on the change, which can then be reinforced with a formal team meeting which will allow the change agent to convey their purpose for change and give the staff a sense of direction, and also allowed for them to be open and honest within the team (Grimm 2010). It can also give the change agent an idea of how change may be perceived by the whole team, and possible resistance. Once the need for change has been perceived by others and the status quo has been disrupted then the change agent can go on to the next stage in the change model (Marquis and Huston 2006).

Marquis and Huston (2006) states that 'In movement, the change agent identifies, plan and implements appropriate strategies, ensuring that driving forces exceed restraining forces' (p173). It also allows for problems to be undertaken and for goals and objectives to be set, and opportunity to scope out for alternative solutions. This stage can take time as there are many factors to take into account. In appendix 2 the FFA for the proposed change identifies that restraining forces appear to have an undercurrent of human behaviour. This can be extremely difficult to overcome especially when nurses' have always done something in a particular way and are reluctant to make change. As previously mentioned communication is the key to successful change and the change agent needs to keep an open line of communication when implementing the plan. A transformational leader uses effective communication to increase the motivation, morale and performance of their staff members as opposed to the usual command and control staff supervision style (Lorraine 2010). Trust is also a key issue; it arises from a mutual understanding that the change would not be detrimental to the staff (Hein 1995). Hence the change agent will require the ability to communicate effectively and encourage motivation amongst the staff. According to Clark (2009) a leader needs to develop a high degree of emotional intelligence. This allows for an understanding of the emotions of their staff and manages them in a positive way to achieve the best possible outcome. Hein (2007) then continues and says it enforces the problem solving and decision making skills of the change agent allowing for staff to become more relaxed, less stressed and more open for change. If there is a continuation of motivational struggles and unwillingness to change motivational interviewing would be a preference to over overcome this. This looks at encouraging and supporting people in adopting new behaviours. The change agent would support the staff member whom is struggling with ambivalence about change. Encouragement is used so that there is recognition of the alternatives to the 'status quo' (Bundy 2004). However, Bundy (2004) does go on to say this can be seen as quite challenging and can have elements of being confrontational. This process needs to be executed wisely.

For a successful implementation education would also be a key factor. The change agent would need to educate staff on the new pack and clarify the expectations of the staff for the pack to continually be used and developed. Spencer (2001) suggests that this will give staff the confidence that they are doing the right thing and that practice is successful and sustainable.

Once the plan has been established and implemented into practice, leaders need to ensure that there is maintained equilibrium. By including staff in the change, the change agent has invited them to become more attached to organisation, which leads to greater commitment, willingness and motivation (Hein 1995). Additionally it is imperative that continual support and guidance is given so that acknowledgments that all staff has embrace and understood it. Nevertheless no change should ever be frozen solid there needs to be scope for re-thawing to allow for continual changes to improve practice, however initially stabilization needs to occur for staff to reap the benefits. Refreezing actions include defining standards, documentation, training, processes and so on. The change agent would need to continue to monitor over a period of time as it can take three to six months for a change to be to be accepted (Marquis and Huston 2006). There will also be the need to make sure that people are not pulled back to the previous stage. Ways of doing this is removing any method by which people can return, so there is nothing to return to (Straker 2010). The change agent can try to do this is by making it part of everyday practice. Once a 'norm' is developed and there have been significant signs that it has had a positive impact such as greater staff retention then people are more inclined to use it.

If the change was found to be successful then a possible scope for development would be to start to look on a wider scale and try to implement the pack into other clinical practices within the PCT. Again there will be barriers to overcome, although from the experience that the change agent had encountered in the clinical area, these barriers could seem less daunting. There would have also been greater development in their leadership skills allowing for the growth of confidence in implementing change.

Change is an essential dynamic in positive growth and development; although some may be resistant to it others may embrace it and feel empowered. A recurrent theme that has appeared through the here may change process is that of communication. Excellent communication skills allow those affected by change to have their say, thus allowing barriers and resistance to be overcome. Although it may not be possible to fully eliminate barriers there may be ways to move the barriers to make them a positive. Saver (2009) also states that 'constant communication helps new and current staff feel valued' (p19).

In conclusion nurses in the present working climate have to accept necessary changes with an open mind and motivation arms. Not only should they accept changes as they take place, but should also be constantly reviewing working practices and being proactive in implementing changes as and when necessary. Change is not always welcomed, however it will allow for eradication of stagnation within the working environment (Ootim, 1997).

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Appendix 1

Proposed

Induction pack guidelines

Appendix 2

Kurt Lewin's Change theory

Unfreezing - reducing those forces which maintain behaviour in its present form, recognition of the need for change and improvement to occur

Movement - development of new attitudes or behaviour and the implementation of change

Refreeze - stabilising change at the new level and reinforcement through supporting mechanisms, for example policies, structures or norms

Mullins (2007 p736)