How a Nurse Can Manage Change in Order to Deliver Effective Patient Care - Essay Example

I. Introduction The rapid development of all life’s sectors has led to the recognition of the importance of change in all particular human activities. More specifically, change is considered today as connected with all aspects of human life from the personal to the professional life and for this reason an extended research and study both in theory and in practice has been taken place in all scientific areas. Current paper examines the behaviour of nurse towards the change as appeared in the daily activities taken place in a healthcare institution. Furthermore, the above interaction is examined as of its influence to the nurse – patient relationship and the level and quality of care provided to the latter. The presentation of current conditions regarding the above issue is also followed with views of literature on the specific subject with an effort to choose and evaluate the most appropriate model for the presentation of the nurse-patient relationship as been formulated under the influence of change in the internal and the external organizational environment. II. Change – definition and implications Change management is the process [1] of developing ‘a planned approach to change in an organization’. In this context it can be assumed that its main objective is ‘to maximize the collective benefits for all people involved in the change and minimize the risk of failure of implementing the change’. For the above reasons, it has been found that the discipline of change management ‘deals primarily with the human aspect of change, and is therefore related to pure and industrial psychology’. There are several theories referring to the role and the structure of change management, the most known of which is that of Lewin. Lewin’s theory of force field analysis (Lewin 1951) is widely used in change management and can be used to help understand most change processes in organisations. Figure 1 – Force field analysis (Lewin, 1951) In force field analysis change, is characterised as ‘a state of imbalance between driving forces (e.g. new personnel, changing markets, new technology) and restraining forces (e.g. individuals fear of failure, organisational inertia)’. Moreover, in order to achieve change ‘towards a goal or vision three steps are required: First, an organisation has to unfreeze the driving and restraining forces that hold it in a state of quasi-equilibrium. Second, an imbalance is introduced to the forces to enable the change to take place. This can be achieved by increasing the drivers, reducing the restraints or both . Third, once the change is complete the forces are brought back into quasi-equilibrium and re-frozen’. The above theory although explains the role of secondary forces in an organizational environment does not offer an adequate explanation regarding the criteria on which the ‘frozen, de-frozen’ procedures are going to be based. Moreover, it has been stated [2] that ‘appropriate leadership is essential for successful change. Most leadership reflects two principal styles - transactional and transforming; The normative-re-educative strategy lends itself to adopt a transforming style of leadership to allow the stakeholders to control the change and decision making process; This will allow the restraining forces and driving forces to balance and change is more likely to succeed’. This view is in accordance with that of Lewin although it is rather more managerial – oriented and less depended on a specific scientific environment. Figure 2: Burnes (1990) elements to change create the vision assess the need for and type of change develop the strategies plan and implement change create the conditions for successful change involvement create the right culture sustaining the momentum and continuous improvement A theory that has examined the issue of change from a different aspect is that of Burnes (1990) who highlighted the importance of nine elements to the formulation of a successful change management. On the other hand, Bennis et al. (1976) identified ‘three change strategies that are based on the reasons people change their behaviour - rational-empirical, power-coercive and normative-re-educative; The rational- empirical approach assumes that people are rational and will adopt change if it can be demonstrated to be justified and in their self interest; The power- coercive style is a top down dictatorial style to change and the normative-re-educative approach is a bottom up approach, taking into account social and cultural implications of change; This strategy is based on the philosophy that all stakeholders need to be involved in all aspects of the change process to participate effectively, create ownership and achieve change collectively’. The above theory can be considered as a logical consequence of the one of Lewin as it recognizes the existence and the influence of existed powers on the formulation of the organizational strategy although it tends to differentiate to the level of intervention of the participants. From a rather innovative point of view, the Diffusion of Innovations Theory (Sullivan et al., 2001, 38) describes ‘how individuals differ in their response to change’. According to the theory, ‘for any change that takes place, you can measure how soon an individual adopts the change by laying off standard deviations from the average time of adoption; The adopters fall into five categories: innovators (2.5%), early adopters (13.5%), early majority (34%), late majority (34%), and laggards (16%)’. This theory focuses on the existence of differentiations among the individuals regarding a particular change strategy and does not analyze the elements or the directions of the strategy itself (a more human – oriented perspective). III. Nurse – description and characteristics Nursing has been called the oldest of the arts and the youngest of the professions. As such, it has gone through many stages and has been an integral part of societal movements. Nursing has been involved in the existing culture—shaped by it and yet helping to develop it. Confusion exists regarding the proper role or function of the nurse, since the connotations of the word nurse have changed over the course of human history. Nurse and nursing currently have many meanings, a condition that causes varying interpretations of the appropriate work and function of the nurse. The role of the nurse gradually expanded from that of a mother whose biological function included the nourishing of infants and the nurturing of young children to one with a much broader scope. Care of the sick, the aged, the helpless, the infirm, and the handicapped and promotion of health became vital components of the whole of nursing. In addition, "care" eventually encompassed affection, concern, and solitude, as well as responsibility for individuals in need. (Donahue, 1996, 3-5) In the early nineteenth century nursing was not an identifiable and self-conscious occupation. Anybody could freely describe themselves as ‘a nurse’ and call what they did ‘nursing’ until the General Nursing Council Register became operational in 1923. Even since then it has continued to be difficult to draw a boundary between nursing and non-nursing work and to discriminate between those parts which are reserved for members of the occupation, those which are shared by members of other occupations, and those which may be done by anybody. Care at this level involves basic assistance with feeding, toileting or personal hygiene. At its margins this form of care would merge into two other types of involvement. One would be the simple techniques of pre-industrial medicine—diet, dressings, poultices, herbal infusions, etc.—and the other would be the spiritual care of the terminally sick or injured (Dingwall et al., 1988, 4-7) IV. Management of change by nurse During the development of nurse’s profession in the history (Shelley, 2002, 13) the role of the nurse was differentiated in accordance with the views of the particular researchers and the scientific community in general. Florence Nightingale (1859) was of the opinion that medicine and nursing should be clearly differentiated from each other. Regarding another model of nursing management - the medical model, knowing the disease inevitably determines the treatment strategy; The goals of therapy are seldom client-centred and the individual must assume the client role with the concomitant obligation to co-operate; This compliance is an important element in the treatment process; There is also a perception that nurses will comply and co-operate with the physician’s orders; Nurses are discouraged from providing information to the patient about their possible prognosis - this is the doctor’s job and the desire to meet goals within a nursing care plan is not a sufficient reason for a patient to remain in care once the medical treatment is complete’. It has also been found (Arneson et al., 2003, 35) that professional nurses experience ‘increasing workplace demands from inside and outside the hospital; The internal pressures of patient care and a traditional organizational hierarchy are coupled with external factors such as medical reimbursement guidelines and competition from other healthcare providers’. On the other hand, Shelley (2003, 13) stated that experienced nursing leaders and change agents ‘understand that staffs reactions to change vary widely; While change itself isnt good or bad, its relative to whomever is experiencing it. Some will feel motivated and energized by change, others will feel threatened, anxious, fearful, or a sense of loss of the familiar and status quo. Some may even experience a grief reaction’. Change is a phenomenon that can take place in all aspects of organizational environment while it can also refer to the customers of a firm. Regarding specifically the healthcare industry and according with the study of Flanagan (1990, 152) when managing change, the nurse should try to help clients identify the triggers--times, places, situations, or circumstances-that consistently spark off the behavior that they are trying to understand and change. Once these triggers have been identified, a chain of responses can usually be traced, and the problem can be put in context (Flanagan, 1990, 152). Growing evidence indicates that treatment efficacy varies among different cultural populations, and that we must integrate these variations into quality measurements if were to provide culturally competent treatment. To offer quality care for all patients, health care service and support systems should inherently recognize that: a) each culture defines the family as the primary support system and preferred intervention; b) most racial and ethnic minority populations speak more than one language and that this may create a unique set of mental health issues to which the system must be equipped to respond; c) patients and their families make different choices based on cultural forces; d) culturally preferred choices, not culturally blind or culturally free interventions, drive practice in the service delivery system; e) all cross-cultural interactions offer dynamics that require acknowledge went, adjustment, and acceptance; f) health care systems must sanction or mandate the inclusion of cultural knowledge into practice and policy making (Rumay, 2002, 33) V. Deliver effective patient care The task of delivering patient care in accordance with the existed rules of laws but mostly with the ethics applied in the medical area, is really difficult. A successful and effective communication between the nurse and the client could be really helpful to the achievement of the above target. In this context, it has stated by Riley (2000, 9) that assertiveness could be the key to ‘successful relationships for the client, the family, the nurse, and other colleagues; The assertive nurse appears confident and comfortable; Assertive behavior is contrasted with nonassertive or passive behavior, in which individuals disregard their own needs and rights, and aggressive behavior, in which individuals disregard the needs and rights of others; Assertiveness "... involves taking an active role, having a positive, caring, nonjudgmental attitude, maintaining your rights without denying the rights of others and communicating your desires in a clear and direct manner without threatening or attacking". Moreover, Hunt (1994, 183-184) found that there are ‘three elements that characterise the caring relationship, and it is in these elements that the attractiveness of the theory for nursing can be found; They are receptivity, relatedness and responsiveness. Receptivity is the acceptance or confirmation of the cared-for by the one caring. Noddings uses the term engrossment to describe the internal response of the one-caring to the cared-for; This need not be intense or pervasive but must be present in the one-caring; Caring means considering living things natures and ways of life, needs and desires; trying to apprehend the reality of the other; This other-orientation is part of the nurses stance in approaching a patient; It is a desire to know and to help the patient’. After the completion of the above procedure it has been found that the most appropriate stage to continue is the assessment phase where ‘the focus on the patient is intense, and the nurse uses cues from many sources; It may also be seen as a posture of unconditional positive regard, wherein a trusting relationship is established as the nurse demonstrates acceptance and an effort to understand the patients reality; Relatedness is basic-the relation of the agents as a fact of human existence, in the case of nursing, as a raison dêtre-without patients there would be no nurses. Responsiveness is the commitment of the one-caring to the cared-for; This involves a motivational shift in the one-caring, a displacement away from self and towards the cared-for. The one-caring becomes available to the cared-for, is present to and focused on him. This displacement varies in conditions, time-span and intensity, as well as the nature or proximity of the one-caring to the cared-for’. The above views are in accordance with those of Rumay (2002, 31) who believes that ‘language and perception barriers not only impact patient communication, but also discharge planning and the patients overall ability to maneuver through the health care system whereas gender, age, ethnicity, race, sexual orientation, and disabilities create challenges for health care providers’. Communication in order to be used as an element of a successful change management strategy has to be analyzed in its elements and described analytically. In this context, it has been found that ‘to communicate responsibly when a problem has to be solved means to communicate in a logical way based on your nursing knowledge and on the facts presented in the situation; Responsible communication demonstrates accurate problem-solving behavior for the particular situation; Nursing process is a systematic means for nurses to demonstrate accountability and responsibility to clients. Discussions of the nursing process offer several different formats, with the steps varying in number; The American Nurses Associations Standards of Clinical Nursing Practice (1991) presents six steps: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Nurses base their practice on nursing diagnoses, clinical outcomes, and critical pathways; Yet all of the variations are based on a simple model into which all the steps and strategies can fit; The four-step method, easily remembered by "A PIE," can be a useful tool for the nurse to remember when interacting with others: a) Assess—collect the essential verbal and nonverbal data about the clients (or colleagues) thoughts and feelings; b) Plan—analyze the data to determine the diagnosis and identify outcomes. Include the client and at times the family to create a plan of care that prescribes interventions to attain expected outcomes. Plan your communication strategy ... what, when, how, and where you will present the plan; c) Implement—implement the interventions identified in the plan of care; d) Evaluate—evaluate the clients progress toward attainment of outcomes. Here is where you check whether your response was assertive and responsible, and whether your objectives (expected outcomes) were achieved’ (Riley, 2000, 15) VI. Conclusion The presentation and the analysis of the above issues regarding the nurse – patient relationship has led to the assumption that while managing change, nurse tend to show to the patient the same level and quality of care as of this change had never happened. However, it has been noticed that under specific circumstances the care provided to the patient may be influenced by changes occurred in a healthcare institution especially when the level and the importance of these changes are significant. On the other hand the personality of each particular nurse may permit the intervention of change to the nurse – patient relationship. As a general assumption it should be stated that the nurse has a significant role in the operation of a healthcare institution no matter the position and the level of experience although these elements may influence the level of trust showed to the specific nurse both by the hospital’s management team and the clients. In any case, the delivery of patient care is usually remaining in very satisfactory levels no matter the influences of the organizational environment. References Arneson, P., Carroll, L. A. (2003). Communication in a Shared Governance Hospital: Managing Emergent Paradoxes. Communication Studies, 54(1): 35-54 Bennis W.G., Benne K.D., Chin R., Corey K.E. (1976) Cited in Watkins S. (1997) Introducing Bedside Handover Reports. Professional Nurse, 12; 4: 270-273. Burnes B. (1990) Managing Change - A Strategic Approach to Organisational Dynamics. Financial Times Management, London. Dingwall, R., Rafferty, A. M., Webster, C. (1988). An Introduction to the Social History of Nursing. Routledge. London Donahue, M. P. (1996). Nursing, the Finest Art: An Illustrated History. Mosby. St. Louis, MO Flanagan, C. M. (1990). People and Change: An Introduction to Counseling and Stress Management. Lawrence Erlbaum Associates. Hillsdale, NJ Hunt, G. (1994). Ethical Issues in Nursing. Routledge. New York Lewin K. (1951) Field Theory in Social Science, Harper and Row, New York Mckenna, H. (1997). Nursing Theories and Models. Routledge. London Riley, J. B. (2000). Communication in Nursing. Mosby. St. Louis, MO Rumay, A. G. (2002). A mind for multicultural management. Nursing Management, 33(10): 30-34 Shelley, C. (2003). Constant change equals constant challenge. Nursing management, 34(2): 13 Sullivan, E., Decker, P. (2001). Effective Leadership and Management in Nursing, 5th ed. Prentice Hall. New Jersey http://en.wikipedia.org/wiki/Change_management [1] http://www.jcn.co.uk/journal.asp?MonthNum=05&YearNum=2002&Type=backissue&ArticleID=462 [2] Read More