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The primary purpose of this paper is to provide an overview of Lewin’s change theory in introduction of modified role of Registered Nurses in ambulatory care. In particular, discussion will focus on role change from coordinating role to clinical role while utilising Lewin’s theory of transitional change.
Lewin’s theory of change was implemented to bring innovations in traditional roles of nurses at ambulatory care by introducing an ambulatory care nursing conceptual framework adopted by AAACN/ANA in 1998. Three main roles were introduced, clinical role, professional role and organization/system role. Nurses’ capacity buildings by professional and clinical education, empowerment and role and assignment modifications were key strategies to achieve this change.
The change process is greatly enhanced by the application of a logical process through the identification of a problem, development of an implementation plan and clear monitoring and evaluation at all stages. The choice of a suitable change model/theory aided the course of development of role of ambulatory care RNs, which was visibly noted in the project with use of Lewin’s (1951) theory of transitional change.
Developing the role of Registered Nurses in ambulatory care setting: A change management project
The primary purpose of this paper is to provide an overview of change process implementation in lieu of Lewin’s theory of transitional change to implement new roles of RNs in ambulatory care setting.
The concept of change may simply be defined as ‘to make or become different’ (Mc Leod and Hanks, 1982, p. 72). Change is an inevitable phenomenon of the universe. For evolutionary purpose as well nothing remains constant. Change brings new life and energy in the existing systems which otherwise can be redundant over period of time. Baulcomb (2003) said that planned change represents an intentional attempt to improve operational and managerial effectiveness.
The transition of changing from one practice to another is never easy. The literature stresses that the effective management of change includes empowering the people involved in the change and not utilizing an autocratic or top-down approach (Crotty 1996, Baileff 2000). However, it has been a common observation that usually change projects are forced from higher management to the employees which many time results either in unsuccessful project outcome or dissatisfaction of the employees. Ulrich, et al (2002) said that “two thirds of quality projects fail because of the prevailing culture and the resistance of the people to change”. (p. 211). Therefore, any successful change project requires honest commitment from leadership which leads the team with courage and motivation. Schifalacqua and Costello (2009) said:
“It is important that management practices are aligned to support and reinforce the change, such as clinical systems, staffing, and rewards. The changing of systems and structures are vital to lasting change.” (p. 27).
Today’s healthcare is very different from what it was a just a decade ago. It has taken a shape of an industry/business which is growing at an incredible speed. This fast paced growth keeps the healthcare managers on toe to meet the challenges of rapidly changing world around them. Ferrara-Love (1997) said:
“Health care is not immune from the impact of change, and is still in its infancy of downsizing, mergers, and corporate buyoutsâ€¦ The changes health care is experiencing are not unique, but are reflective of changes in society.” (p. 12).
This can explicitly be seen today where everyone wants to have cost containment due to which institutional level changes are made at a rapid pace. Healthcare industry is not an exclusion from this change phenomenon, which many times put the employees at stress that may affect their work performance as well. Factors that can affect change also include: the attitudes of people, lack of perceived support during the change process, worker reluctance or resistance to change, lack of consideration of attitudes and beliefs of staff, fear, anxiety, uncertainty and loss of control (Crotty 1996, Telles 1996, Willmot 1998, Baileff 2000, Carney 2000, Tingle 2002).
Any change process requires utilization of resources in terms of human, finance, and material; hence the change process needs frequent monitoring and evaluation for its applicability and effectiveness. Schifalacqua and Costello (2009) said “the transition of moving from one practice change to another is never easy, and the people side of change is a dominant aspect that needs to be incorporated into the overall implementation plan.” (p. 27). This can be seen in daily routines as people get accustomed to the practices over a period of time and usually it is difficult to change the practice which they ingrain in their daily lives. Hence, the successful change implementation depends upon the communication and shared values between the team members responsible for the change.
Therefore, one should not expect a successful change to be implemented overnight. This requires thorough planning, critical thinking and engagement of relevant stakeholders which requires energy, dedication, time commitment and mutual respect between two parties that is the change agent and the client.
Smith-Bla and Bradle (1999) said:
“Although health care organizational change is a constant phenomenon, little is understood as to how staff experiences this change. Unsuccessful change efforts have suggested the possible important relationship between understanding staff’s experience and improved results”. (p.340)
This is a vital consideration to be taken into account by change management leaders as healthcare is growing at an incredible pace; the demand and supply ratio needs to be balanced by implementing innovative change strategies which should be cost effective as well as user friendly. If the clients’ input is not considered then the leaders might not be able to have a successful outcome from a change process which they might desire.
The subject of change is not new. Poggenpoel (1992) affirms that change may lead to real innovation, providing abundant opportunities for creating a better way forward. This is particularly true in healthcare setting. Today’s evidence based medicine and evidence based nursing practices primarily bring innovation and change in the field of health sciences which ultimately help in improving quality of life whether of patients in specific or society in general. However, the process of leading successful change requires effective communication, wide participation, facilitation and manipulating different interests towards the agreed goal (McLaren and Ross, 2000). Successful change cannot be a one man show and needs team effort which cannot occur without effective communication between team members who need to work with mutual understanding towards shared vision.
The ambulatory clinics are an integral part of any hospital; clinics are the bridge between the hospital and the community, and are utilized as a pre-hospitalization center. Null and Bonser (1997) stressed:
“The outpatient /ambulatory services can be a vital stage in many patient journeys. It may be a patient’s only place in the hospital setting where they visit on continuous basis. So far this has been a department staffed by nurses who have no proficiency in any clinical specialty. Hence, they gain experience in several and expertise in none.” (p. 325).
The affirmation above was very true for staff nurses working at ambulatory care setting in my organization. Role of Registered Nurses (RNs) at ambulatory clinics had been a real discussion at my organization due to a general perception that there is no active clinical role of registered nurses in clinics thus they are underutilized. In addition due to cost containment projects, highly paid employees efficiency was also closely monitored therefore registered nurses being highly paid among other staff categories were objected for being underutilized at outpatient clinics. Out of 215 staff in ambulatory care setting, 75 (34.8%) are RNs who cover all the specialties. These registered nurses have gone through general nursing training in their graduating school of nursing. They develop clinic based competencies during their competency based orientation conducted in the unit within first three months of their job. This on-job training is supervised by Clinical Nurse Instructor (CNI) and Clinical Nurse Specialist (CNS) of ambulatory care services.
Haas (1998) said:
“Ambulatory care nursing is a unique realm of nursing practice. It is characterized by rapid, focused assessments of patients, long-term nurse/patient/family relationships, and teaching and translating prescriptions for care into doable activities for patients and their caregivers.” (p. 16).
However, at my institution this role was limited to initial assessment and giving some very basic education to patient like on diet and medication. While reflecting the factual nursing roles and practices at ambulatory care services of our setting in the light of definition by AAACN/ANA, a big room for improvement and innovation was seen to re-conceptualize RNs roles and practices. The existing roles and responsibilities carried out by clinic RNs were much more general than the efficient clinical roles which they should have been playing. It was now the responsibility of nursing management of ambulatory care services to relook at the roles and re-assign tasks so that the true need of registered nurses and their proper utilization could be justified.
Literature search on RNs’ roles in outpatient clinics revealed that internationally there are RN-managed clinics, telephone medicated care by RNs, specialty based nurse educators, practitioner, consultants, and clinical nurse experts such as pre-operative nurse, oncology nurse, wound specialist nurse etc (Hamner, 2005). American Academy of Ambulatory Care Nursing (AAACN, 1995) categorized roles of ambulatory care nurses as clinical, management, educational, and researcher roles.
The goal of the management plan was to address the issue of strengthening the role of registered nurses at ambulatory care services, to justify their need in outpatient services; Lewin’s three stage model was chosen to introduce the change in RN’s role. Lewin’s model has intuitive appeal and became an enduring influence because it was taken up as one of the foundation stones of the organizational development (OD) movement during the 1960s-1980s (Burnes 2000, Cummings & Worley 2001).The reason behind choosing Lewin’s change theory was its easy and simple implementation and efficacy in bringing modification in existing practices by analyzing driving forces, restraining forces, and by targeting new innovations and implementation. The literature supports the effective use of said theory in various organizational change management projects (Mrayyan et al, 2007; Huber, 2006; Marquisand Huston, 2005). Fetherston et.al (2009) emphasized the importance of major change and endorsed that:
“Where a major change … is implemented, models such as Lewin’s (1951) model of unfreezing, changing and refreezing can be a useful guide …” (p. 2586).
As the alteration of RNs role at ambulatory clinic was a significant major change Lewin’s model proved to be a useful and effective guide for system modification. The system perspective of the Kurt Lewin’s theory suggests that the process of change occurs in three stages: unfreezing, moving and refreezing. For change to occur, a motivational factor should arise in order to break the ice. Baulcomb (2003) states that “
“This theory places emphasis on the driving and resisting forces associated with any change, and to achieve success the importance lies with ensuring that driving forces outweigh resisting forcesâ€¦The intention is to reach a state of equilibrium.” (p. 277).
Green (1983) stated “within every change situation forces exist either to push the system toward changing (pro-change forces), or push it away from changing (anti-change forces).”
(p.1623).” Pro-change forces act to alter the status quo and are considered important aspects of change motivation. Anti-change forces, on the other hand, work toward maintaining equilibrium and are usually manifested as habits, rituals or policies. Unfreezing occurs when the driving forces (pro-change) become stronger than the restraining forces (anti-change). Stage 1: The unfreezing phase-becoming motivated to change:
Schifalacqua and Costello (2009) said:
“Communication is vital to any change process. If the change is on the unit level, a question-and-answer format on the impact on patient care and/or the caregivers is very effective.” (p.29).
The key to this phase was to answer following questions:
What is the problem which needs to be addresses by the change management project?
Who needs to be involved in the change process?
What will be the post change benefits to the organization?
What would be the likely cost of the change?
Huber (2006) asserted that “the first stage is cognitive exposure to the change idea, diagnosis of the problem, and work to generate alternative solutions”. (p.811). Discussion with the in charge nurse and staff nurses of ambulatory care services was held in which desired change and of role modification was highlighted. Majority was in consensus of the need of this change as they were also dissatisfied due to people’s perception of their role and lack of clinical utilization of them in their workplace. It was also shared that changing the nurses’ role would be potentially stressful for those taking the new role as well as for those with whom they work. Fetherston et.al (2009) stated that:
“When change is managed in systematic steps with adequate evaluation and communication throughout the process, it is more likely to result in successful outcomes”. (p. 2582)
From a broader perspective there was an impulsion for developing RNs to meet the need of multispecialty tasks at outpatient setting, with a need to demonstrate the effectiveness of any new roles created. This multispecialty tasking required RNs to gain competency in multispecialty.
Miller, Flynn, & Umadac (1998) said:
“Competency is the assessment of the employee’s ability to perform the skills and tasks of his or her position as defined in his or her job description. A competent staff member has the knowledge, skills, ability, and behaviors to perform required tasks correctly.” (p. 10).
Hence, in order to evaluate the competence of ambulatory care RNs baseline knowledge and practice assessment was done for 40 RNs to assess their insight related to clinical, professional and system roles in ambulatory work setting (please refer appendix A). Audit results showed only 41% involvement of nurses in clinical related knowledge and patient care tasks. Cork, A (2005) said:
“When examining the introduction of competencies in relation to force-field analysis it can be seen that one of the main drivers would be an improvement in nurses’ practice and a defined level of achieved competence for individual nurses. In addition, the projected benefit to patient care, through the acquisition and application of knowledge, would be a major driver.” (p.40)
The audit proved to be very useful in identifying gaps in the required standards of nursing knowledge and practice of RNs working in the clinic setting. Hence, it ultimately helped in planning and implementing educational strategies to overcome the identified gaps.
Stage 2: The moving phase-change- what needs to be changed?
Once mutual agreement for a desire for role modification was obtained, ambulatory care nursing conceptual framework by Haas, S.A. (2006) was searched from literature (please refer appendix B). The framework was liked by higher authorities and approved to be incorporated and introduced in the ambulatory care nursing model.
Flannigan (1995) states,
“If you can define an ideal culture in terms of your strategy and leadership, particularly how the culture would be different from the way it is currently, then you have the basis for changing the culture.” (p. 60).
In order to gain shared vision for proposed changed culture the model was introduced to all ambulatory services RNs to obtain their feedback and open discussions were held through meetings with nursing management, ambulatory care nurses and medical colleagues. On this occasion, information concerning the change was provided through a discussion and presentation of research findings regarding development of outpatient nurses’ specialty based practices. Indeed, this increased knowledge about specialty based roles created dissatisfaction with the current system. Tross and Cavanagh (1996) claim that dissatisfaction with the status quo is the most influential factor in the initiation of change. However, rather than being an education issue, four nurses argued that it was an experiential issue and subsequently suggested that it may cause the difficulties in implementing specialty based roles. Being mindful of the normative re-educative strategy that was employed in the change process, provision was made to appreciate the resistors’ feelings. Nevertheless, it was asserted that if nurses did not have the theoretical knowledge, which underpins the specialty skills, they would be unlikely to be competent practically in this area (Reece and Walker, 1997). Accordingly, the resistors’ argument was diluted by providing them with abundant amounts of evidence to support the introduction of the project. A consensus was then reached and actions were prioritized for the change initiative in specialty based training.
Smale (1998) highlights the benefits of actively involving staff that are closest to the problems, by explaining that they are closest to the solution. Consequently, Rigorous training sessions were arranged for nurses for clinical concepts such as triage, health assessments, specialty based diseases and case presentations, specialty based skills assistance, patient and family education and counseling techniques etc.
Applicability of RN roles taken from the framework:
Within pre-admission assessment, the aim was to develop the RN role so that s/he could get the patient’s medical history, and perform pre-consultation assessment accordingly. Nurse-led pre-admission assessment has shown to be effective and safe (Whiteley et al. 1997). The issue of developing advanced assessment skills was resolved through special courses by clinical nurse specialist. There is an evidence to suggest that developing the role of the nurse specialist or practitioner can increase the continuity of care whilst still maintaining clinical standards; examples include nurse-led rheumatology follow-up (Hill 1997) and breast care follow-up (Earnshaw 1997). Such a development not only enhanced stability but also free up consultant’s time within their clinic to see patients with more complex needs and to potentially increase the number of new patients that could be seen.
A group of seven senior RNs was formed from different sections of ambulatory care, to be included in a review of ambulatory care related policies, protocols and work instructions.
This group was also trained for supervisory skills to cater evening shifts and weekends in absence of head nurses of respective units. This role proved to be productive and satisfactory for nurses as well.
Stage3: The refreezing phase-making the change permanent:
The introduction of role changes were well appreciated by the consultants, management and RNs. Enhanced patient safety, patients and nurses satisfaction and most of all effective time utilization was evident. To fix these changes, slight modification in RNs job descriptions (JDs) was done to introduce these role aspects in their JDs. Furthermore, their schedules and assignments were fixed for three months period and then rotations were pre-planned.
In this instance, Lewin’s (1951) force-field analysis also served as an assessment of the driving and restraining forces that impacted on the implementation of this change process. Driving forces facilitate change because they push employees in the desired direction (Kritsonis, 2004). These were RNs motivation and enthusiasm, pressure from higher management and doctor’s acceptance, patient’s safety and satisfaction.
There was little resistance to change in first three months of the project. Those who????????closely working with RNs in out-patient setting were supportive of the project and worked with the team for achievement of goals. In fact, the slower than anticipated development meant that key stakeholders such as consultants did not feel threatened by the pace of the change.
The outcome of the strategies through implementation of conceptual framework as a change agent was assessed through measurement audits. Audit of the nurses’ practices was carried out concurrently, while the patients’ experiences were being surveyed. The literature contends that change is not consolidated without continuous monitoring and observation (Smale, 1998). Furthermore, Dale (1994) asserts that internal auditing, scrutiny of records and objective observation help discover what is currently taking place. An audit tool was developed with 19 criteria, 80% nurses were evaluated on conceptual framework through this audit tool, 74.2% compliance was observed for knowledge and new role implementation.
50% of ambulatory nurses were trained for health assessment, performing health assessment of patients with clinical emergencies as a daily clinical task.
100% patients with clinical emergencies were identified by RNs of assigned clinics and received timely interventions and transfer to appropriate care facilities. 80% patients received education on disease, treatment plan and lifestyle modification from nurse educators in specialty based clinics.
Other gains were safe and complex patient care delivery, evident by no clinical errors and incidences in that period. Increased patient satisfaction indicated by no clinical complaints reported by patients. Consequently nurses’ satisfaction was largely enhanced, assessed by subjective verbalization of nurses in open forums and meetings. Formal surveys for nurses and patient satisfaction need to be conducted to evaluate objectivity of these outcomes.
The change process was greatly enhanced by the application of a logical process through the identification of a problem, development of an implementation plan and clear monitoring and evaluation at all stages. Furthermore, the selection of an appropriate change model aided this process, something clearly demonstrated in this project with use of Lewin’s (1951) theory of transitional change. It also discovered some very hopeful aspects with regard to professional development and team working. However, it was also experienced that change is not easy, sometimes filled with unwary troubles and sometimes intimidating.
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