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Change Management Contents Introduction……………………………………………………………. 3 Evidence Based Practice………………………………………………. 4 Clinical Governance…………………………………………………… 5-6 Findings from the literature……………………………………………6-7 Implementing the change………………………………………………7-9 Leadership……………………………………………………………. 9-10 The Un-freezing Stage………………………………………………10-11 The Moving Stage…………………………………………………… 11-13 The Re-freezing Stage………………………………………………. 13-15 Resistance and barriers to change…………………………………… 15-16 Conclusion………………………………………………………….. 16-17 References………………………………………………………….. 18-24 Appendices…………………………………………………………. 5-26 Introduction This is essay is being written to identify and promote change in clinical practice in relation to nursing and evidence based practice. This will be done in relation to nursing and will include supporting references. The literature review investigated nurses’ knowledge of pain management, finding that nurses’ had different ideas of what pain management is. Therefore the aim of the essay is to change practice by increasing nurses’ awareness of what exactly pain management is and from this how it can improve postoperative pain management in the clinical area.
This essay commences with a description of both clinical governance and evidence based practice (EBP) and the association between them, describing how this will assist achievement of clinical effectiveness. From this there will be a synopsis of the findings from a recent literature review of “Nurse Assessment and Management of Postoperative Pain” including a recommendation that was found from the evidence of this review and how this will have an impact for a change in practice. An analysis of different theories of change will be made, looking at several models and theorists.
The chosen model for change will be used to bring the findings from the review into practice and what resources will be needed for the implementation of change and any barriers that may occur during the change process. All names and locations will be changed to maintain confidentiality in accordance with the Nursing and Midwifery Council (NMC) Code of Conduct (2008). Evidence Based Practice Evidence-based practice has been described as a systematic process of ‘finding, appraising and using research findings as the basis for clinical decisions’ (Long and Harrison, 1996 cited in McSherry et al, 2002, p7).
However there are many other definitions the most widely used is Sackett et al (1996) “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. ” However there are some problems with this definition especially with regards to nursing. This definition does not include what the patient wants from the care given.
Morton and Morton (2003) agree that patients should be involved in decisions about their care. Therefore there is an alternate definition more suited to nursing that states “an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits the patient best” (Muir Gray, 1997). Simmons (2002) supports this view and states that for research to be of benefit it needs to be individualised to the patient.
According to Morton and Morton (2003) this definition highlights that the nurse should integrate the patients preferences and their wish to avoid risk associated with some interventions and using the best available evidence for said interventions. More recently, Gerrish et al (2010) suggests that for nurses to give the best possible care to patients they need to research the evidence available and apply it to their decision-making in clinical practice. Clinical Governance Clinical Governance is an umbrella term that covers activities that help sustain and improve high standards of patient care.
It is how health services are held accountable for the safety, quality and effectiveness of clinical care delivered to patients (NHS Scotland, 2007) Clinical Governance was introduced in response to public concerns over poor standards of care provided by the National Health Service (NHS) (Wright and Hill, 2003). There are seven pillars of Clinical Governance including 1. Risk Assessment 2. Clinical Effectiveness 3. Education, Training and Continuing Personal Development 4. Use of Information 5. Staffing and Staff Management 6. Clinical Audit 7. Patient/Service User and Public Involvement
To monitor standards of clinical governance the government established the National Institute for Clinical Excellence (NICE) and commission for Health Improvement (CHI) (Department of Health, 1998). The purpose of clinical effectiveness is using the best available knowledge through research, clinical expertise and patient choice, applied to patient care. This can be achieved through training, education and change management (Muir Gray, 2001); evaluated through clinical guidelines and provision of evidence-based practice (Royal College of Nursing, 1996). Clinical effectiveness is the cornerstone of evidence-based practice’ (Reagan, 1998 p245) Links between evidence based practice and clinical effectiveness are outlined by Dawson (2001). He suggests that evidence based practice cannot be achieved independently of clinical effectiveness. McSherry et al (2002) considered that the two are interdependent of each other with evidence being used to improve practice and enhance effectiveness of care. Findings from the literature The findings from the literature review suggest that pain management is not being implemented as well as it should be in the postoperative setting.
Nurses’ should be working within the NHS Enhanced Recovery Programme (2008). However findings from the review have proven that assessments are not good enough or consistent throughout wards in the same hospitals. The evidence proves that self-reporting of pain was not seen as a vital part of assessment. Carlson (2009) shows that only 59% of registered nurses accepted patients report as valid assessment of pain although it is Gold Standard for pain assessment (Melzack and Katz 1994). Another study (Rejeh et al 2008) showed that nurses are too busy with such a large workload to be able to do full pain assessments on their patients.
Young et al (2006) believes that a good assessment tool will help efficiently assess pain. According to The World health Organisation (Delphi, 2007) nurses can first evaluate the pain and can recommend to the treating doctor whether the use of pain relief medication is appropriate. However Cordts et al (2011) suggest that doctors are not listening to nurses’ assessments of the patient and this can lead to the patient not moving up a step on the WHO Pain Ladder. Medication is not given efficiently enough when a patient complains about pain. Doctors can be slow to prescribe, as they do not see it as urgency.
Doctors then need to understand that analgesics need to be given promptly as to stop any further discomfort for the patient. All of the above findings lead to the main theme that was evident throughout the literature – A lack of nurse knowledge and pain education. Carlson 2009, Chung et al 2003, Coll and Ameen 2006 all show that there is a high awareness of pain from registered nurses but there is a low level of consistent implementation of evidence based practice when it comes to pain management. Carlson (2009) results showed that nurses were not transferring their knowledge into clinical practice.
Nurses deliver the majority of patient care (WHO, 2007) and have an ethical and moral responsibility to ensure that best care is provided by incorporating Evidence Based Practice into clinical practice (NMC, 2011) Therefore in this assignment the proposed change will concentrate on the improvement of nurses’ knowledge of post-operative pain management in accordance with the NHS Institute for Innovation and Improvement Enhanced Recovery Programme (2008, See Appendix A). This will be guided by an educational session to implement this change.
Implementing the change According to Sale (2005) change needs to occur to improve patient care. However change is best if it is planned. Cork suggests that if it is to be successful it needs to be planned, focused and inclusive. Pearce (2007) McAuliffe and Vaerenbergh (2006), Craig et al (2008), Upton (2005) all agree that barriers will arise if a change is unplanned, or if nurses are unaware of it. Change needs to be well communicated and organised with everyone who will be involved (Upton, 2005). To enable change, the type of change needs to be recognised.
Planned change is considered and put into practice by a well-informed agent and triggered by the need to respond to new challenges, opportunities or potential complications (Thornhill et al, 2000) McSherry and Pearce (pg. 128, 2007) suggest that Change is complex and that barriers are inevitable therefore threatening the successful implementation of clinical governance. It is suggested then that utilising a change model can help guide the process and hopefully reduce the obstacles, which may be encountered. There are a number of questions that need to be looked at before a change can commence (Craig et al 2008).
Firstly, will the patient benefit from the proposed change? For the proposal of an educational programme to improve nurse knowledge then yes, the patient will benefit. As they will be treated in accordance with NHS evidence based guidelines. The next step is choosing a change management theory to follow stage by stage. There are many change theories, some of which are easier to follow than others (Sale, 2005). It is important that the correct theory is chosen because if the wrong one is picked it can lead to negative outcomes for the proposed change. (Craig et al, 2008).
The change theories that will be discussed are Lewin’s Force Field theory (1953) and Lippitt et al (1958). Lewin’s theory has three steps; Un-freezing which allows existing processes to change. Movement allows adoption of new practices and Re-freezing, which involves re-stabilisation; ensuring practices remain in the organisation (Gopee and Galloway 2009 and Mullins 2010). His theory also 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 forces (Baulcomb, 2003).
When driving forces exceed restraining forces, the move towards change is facilitated (Reid, 2002). Lippitt’s (1958) is an extension of Lewin’s (1951) Force Field theory. It is a seven-step theory, where information is constantly exchanged. This is advantageous as communication is key if a change is to be made in clinical practice (Mcsherry and Pierce, 2007). However, the focal point of this theory is the role and responsibility of the change agent. Although this is important there is not an emphasis on the progression of change that Lewin’s 1951) theory has. Lewin’s (1951) force field analysis will enable participants in this change process to identify factors that are driving the change and those causing resistance (Gopee and Galloway, 2009) Lewin’s theory (1951) will be implemented as this helps to understand planned change processes within organisations. The three steps should be followed to create and embed change. Leadership To bring about change in the clinical area it is important to have good leadership. According to Allen (2000) having a good leader will improve patient care.
Lewin (1951) says that it is necessary to have a change agent in order for the change process to be effective. A change agent is a person who is organises and holds the day-to-day responsibilities of the change (Craig et al, 2008). McSherry and Pierce (2007) believe that the change agent needs to have certain characteristics to be an effective leader. They need to have self-belief, self-awareness, drive for improvement and personal integrity. Another key component of a successful change agent is one who has excellent communication skills.
McSherry and Pierce (2007) discuss that communication can be enhanced in the clinical environment by sharing goals, information, learning and responsibilities so that everyone feels included in the change. Baulcomb (2003) agrees with this stating that the change agent needs to empower the staff giving them a chance to enhance their skills. However on the other hand Cherry et al (2005) believes that the change agent needs to be original, be able to analyse the evidence-based practice and collect and implement the change along with possession of a positive outlook.
This would improve nurses’ pain management knowledge with the implementation of the NHS Enhanced Recovery Programme (2008). For this change to come about the change agent needs to have as many of positive characteristics stated above. The more of them that they have the more likely it will be that the change will be implemented with fewer barriers in the process. (McSherry and Pierce, 2007). The change agent for this project will need to be able to communicate with theatre, recovery and ward managers. Bass (1985) extended on the work of Burns (1973) about transformational leadership.
He suggests that the followers of a transformational leader feel trust, admiration and loyalty for them. They make them feel this by inspiring them and give them their own identity (Kotlyar and Karakowsky, 2007). Using such an approach will reduce the resistant forces by bringing about change slowly to clinical practice (Sale, 2005). The Unfreezing Stage Lewin’s first stage in the change process is Unfreezing. Recognition that change needs to be made is the initial step. From this the right conditions for change to occur are developed and the forces maintaining behaviour reduced (Gopee and Galloway, 2009 and Mullins, 2010).
The literature review states that nurses were unclear about what pain management was and how any knowledge they had of it could be brought into practice (Carlson 2009, Chung et al 2003, Coll and Ameen 2006). Nurses need to be educated on the importance of pain, good communication and assessment skills to a more in depth level than what is taught during university. For nurses to use the NHS Enhanced Recovery Programme, forces are needed to direct the behaviour away from the original situation and drive them towards the proposed change (Robbins 2003).
To achieve this change in practice the change agent would need to have posters and leaflets produced so that staff know that there is a proposed change. This way when initial meetings are called they will not be surprised and they will have already formed opinions and hopefully ideas to bring to the table. Within the leaflets there will be evidence from the literature review of what needs to be changed how the change will be implemented. The posters will include a diagram of the tool that is to be introduced and how this will improve care for post-operative patients.
During this stage the change agent will need to communicate with all the stakeholders this includes the nurses at ward level but also the ward manager, as she/he will hopefully be able to fund any expenses. Printing and photocopying charges will apply as well as a room within the hospital will need to organised at this stage, to ensure that it will be vacant. Resistance will begin to show at this stage. Sullivan (1992) states that it is then the change agents’ responsibility to earn the resistors trust and respect by the use of effective communication and understanding.
Robin (2003) states that the percentage of driving forces needs to be higher than those opposing the change in order to unfreeze the current state. The nurses on the post-operative ward will now be able to trial use the enhanced recovery programme (2008) and put forward their opinions to the change agent, be it ideas to improve the proposed change or reasons why they do not want or like it. The Moving Stage The second stage identified by Lewin’s change process is Movement. This is the transition from the present to stage to the chosen stage (Lewin, 1951). It requires bringing equilibrium back, which has been broken in the unfreezing stage.
Sale (2005) states that if the change agent has been effective in preparing for the change in the first stage nurses should begin to accept it. Sale (2005) also explains that this stage identifies the roles and responsibilities within the change to the nursing team, which is needed for the change to take place. The leaflets that will be circulated will include definitions of clinical terms including “What is pain management”, information about the Pain Ladder and the Enhanced Recovery Programme (2008). There will be opportunities during handovers if anyone does not fully understand anything within the leaflet.
Stakeholders will be required to sign to say that the booklet has been read and understood. National Institute for Clinical Excellence (NICE) suggests that printed materials are low cost aids to raise awareness of a desired change, and most importantly are very effective in changing behaviour especially when combined with other methods. After all the signatures have been collected informal teaching sessions of half an hour will commence and will be facilitated by the change agent to re-educate and influence the stakeholders targeted in the change process.
This will be achieved using a normative re-educative approach. This approach addresses group norms, personal values and common goals. The stakeholders internalises the change rather than imposing change through authority and coercion. However these sessions will be made compulsory by authorities in order to promote best practice. The idea of these sessions is to aid in clearing any confusion about what has been read in the leaflets, increasing nurses’ knowledge and allowing stakeholders an understanding of the merits of change (Dawson 2001). It would be helpful to have the pain specialist nurse attend he sessions, it would hopefully make the staff aware of how important the change will make to the patients. Dowsett (2001) states that professional development is a key element to provision of clinical government. Learning not only provides nurses with knowledge and skills, it improves competence and reduces threat to change (Chapman and Howkins, 2001). It is vital that the change agent considers available resources. A lack of resources is a barrier to the implementation of evidence-based practice and therefore the implementation of clinical effectiveness (Polit and Beck, 2001).
Appendix B summarises the time, cost and resource requirements for each activity, for the implementation of the educational package. This will assist nurses in the improvement of post-operative pain management using best evidence. The table in Appendix B provides a brief summary of the activities required to bring about change, the time it takes to start activity, how long it will take to implement action, cost and resources required to ensure implementation of change and change management. The cost and timelines are an estimation, which needs to be taken into consideration.
The prices of stationary that have been included are given at institutional rates. The venue for the half hour re-education session will be allowed in the day room on the ward as management has made arrangements for this. The change agent will need to clarify that the Health Board would give 100% funding to the proposed change. Training is compulsory for practitioners in order to meet statutory obligations. According Aneurin Bevan Health Board (2010) training designated as mandatory meets the needs of the service. The Re-freezing Stage
The final stage identified by lewin’s (1951) change process is re-freezing, which comes with proper implementation of the change. According to Gopee and Galloway (2009) the change agent will need to maintain motivation throughout implementation and ensure that change is integrated and assimilated by the organisation and stakeholders. Gopee and Galloway (2009) also agree with Bednash (2003) state change is needed within the nursing profession to provide quality care. Nurses need to monitor quality of care given by recognising problems and from this implement best practice (Grol and Grimshaw, 2003).
If this stage is not done then there is a high chance that nurses will revert back to the original state (Robbin, 2003). It is in this stage that it necessary to bring in formalities such as guidelines and policies. This will ensure that Lewin’s (1951) Re-freezing stage is implemented. This stage also ensures that the stakeholders approve of the change. McSherry and Pierce (2007) explain that once the stakeholders have accepted the introduction of the Enhanced Recovery Programme (2008) there will be no more resistance or barriers and the stakeholders will have accepted the new change.
To evaluate the effectiveness of the change, the next step would be to introduce clinical audit to compare with previous outcomes of post-operative pain management or, more importantly how to keep preventing poor pain management. NICE (2002) states that an audit is a quality improvement process, aiming for enhancement of patient care, during an assessment of care. This will be introduced in another session based on the ward, three months after the change. A questionnaire would be introduced to get feedback from practice (NICE, 2007). The results from this would be anonymous as to not compromise levels of knowledge.
Bell and Duffy (2009) state that clinical audit are used as a way to improve assessment and management of pain and to assure that best practice is applied in clinical practice. The department of health (1989) explains that audit helps to underline variation in practice, giving opportunity practitioners to reflect and evaluate the success of implementation. Three months after the first another audit will be carried out to ensure that the change has become frozen and that it is making the improvements that were needed within clinical practice.
The change agent will need to release the results of clinical audit of the Enhanced Recovery Programme (2008) to all involved and to other wards so that the change can be implemented else where if requested (Murphey, 2006). Any new evidence that develops that will improve best practice will be highlighted in yearly update teaching sessions. Resistance and Barriers to Change NICE (2007) states that in order to develop a successful strategy for change; the change agent needs to understand barriers faced within health care organisations.
Gopee and Galloway (2009) suggest that change can cause anxiety; resistance to change can succeed as a result of fear of the unknown: lack of confidence of knowledge or skills to carry out the change. However parkin (2009) states that change can be disturbing to those involved therefore resulting in increasing resistance to the implementation of a change. It is therefore the change agent’s responsibility to foresee any resistance, act and over come these barriers. Habits are hard to break, people become familiar with particular practices; it is therefore vital that the change agent adopts a “bottom up” approach.
All stakeholders will then have an active part in the change. Nurses’ who feel they lack the knowledge and are not happy about the change will be able to receive extra support from the ward manager, pain nurse or change agent. The implementation of the proposed change would mean that there would be a shortage of staff on the floor. Although the sessions are based on the ward they would still need to be carried out with minimal interruptions. This is a barrier to change. To overcome this barrier, the change agent can chose to have the sessions in the afternoon when both morning and afternoon staff are on the ward.
As the session is only half an hour this would not cause too much disruption. Two sessions could be carried out so to see as many staff as possible. The achievement of this change will be shown by better results in patient care but also an improvement in ward team work which all leads to cost effective practice. This will be achieved, as patient recovery time will be reduced. Conclusion Change is indispensible in nursing practice for the improvement and transformation of health services, and is crucial in maintaining sound judgement together with effectiveness of best practice (Gopee and Galloway, 2009).
Clinical effectiveness can be translated into clinical governance however for this to happen clinical practice must combine with the best available knowledge through research, clinical expertise and patient choice. This can be accomplished through training education and change management (Muir-Gray, 2001). This essay showed that the change needed for nurses was to introduce the NHS Enhanced Recovery programme (2008) into practice. For this to happen they would need to have short informal ward based training sessions to improve knowledge of pain and its management.
The literature review showed that there was evidence there was a gap between nurse knowledge and how this affected the care patients were receiving. The change was implemented using lewin’s (1951) Force Field Analysis. The three stages showed driving and restraining forces but by the Re-freezing stage restraining forces had been limited so that there was equilibrium. Resistance and barriers to change were discussed including money, resources, time and how the change agent would overcome these.
Once the Re-freezing stage had been implemented and therefore the change being successful it is important that the change is periodically evaluated to ensure that it does not slip back to the original state. References Allen, D. (2000) ‘The NHS is in need of strong leadership. ‘ Nursing Standard. Volume: 14, (Issue: 25) p. 25 Aneurin Bevan Health Board (2010) Education and Development. Available at : http://www. wales. nhs. uk/sitesplus/866/page/40 (accessed October 16th 2011) Baulcomb, J. (2003). ‘Management of Change Through Force Field Analysis’. Journal of Nursing Management. Volume: 11, (Issue: 4), p. 275-280.
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Clinical-terms booklet|One month|Active/regularly|Ink+paper (50) leaflets+(50) questionnaires+time of printing= ? 100 |Expert practitioner, printing| Courses aimed at re-education for the improvement of pain management |Will know when the manager gives change agent time, date and room for all stakeholders to participate. |Twice a year|Varies on band of stakeholder. Approx ? 3500 for 50 participants +extra time of change agent to plan change. |Change agent to decide (will key stake holders assist in the process of change. | Constant communication|immediately|indefinite|? 100. 00|Information/notice boards| Source-Made by essay author