Healthcare: Models and Theories of Change - Essay Example

?Introduction Change in today’s world is unavoidable and inevitable. Havelock (1973, p. 4) defined change as “any significant alteration in the status quo... an alteration which is intended to benefit the people involved”. Change in organizational context can be of any type; it can be structural change, HRM change, operational change or technological change. Change is good and offer organizations competitive advantage since it helps improve performance, increase efficiency and ensure long term sustainability (Tidd and Bessant 2011). Though initiation of change process also takes place at internal organizational level, most of the time it is influenced and initiated by external forces. According to Kwun and Cho (2001, p. 128) external sources are much influential than internal ones in change initiation. These external forces can be political, economic, social and technological. Talking about change specifically from the perspective of healthcare organizations, Harris (2005, p. 68-71) stated that government and other policy making authorities affect healthcare practices in a country; country’s GDP and government budget for health impacts cost of health; people’s perception and general culture of a country affects healthcare provision; and changes in ‘global technological and information innovation’ affect ‘clinical diagnosis and intervention, as well as management and communication strategies’ practiced by an healthcare organization. Hence like other organizations healthcare organizations are also influenced by external environment which in turn affects the way change and innovation is implemented in an organization. Defining change and innovation in healthcare, Lansisalmi et al (2006, p. 67) stated that it can be “new services, new ways of working and/or new technologies”. Continuing on same lines, Greenhalgh et al (2004, p. 582) stated that these improved ways, services or technologies “are directed at improving health outcomes, administrative efficiency, cost effectiveness, or users’ experience and are implemented by planned and coordinated actions”. While talking about change in the field of nursing, Langford (1981) explained that in the field of nursing a person may go through change as a participator in the change process, he/she may act as a target of change process or he/she may work as a change initiator. Loveridge and Cummings (1996, p. 380) explains that “the nurse may be going through change individually, may be trying to change a patient’s health habits, or may be experiencing reorganization in the work environment”. Langford (1981) affirms that for decades health care sector has been a field of rapid technological growth. Out of many types of change and innovation, this essay particularly focuses on technological innovations. Technological innovations can be broadly categorized as product innovation or process innovation. Product innovation is when new product or service is introduced whereas process innovation is when the change is brought about in the process through which the product is produced. This essay will focus on product innovation where the change introduced is Biphasic Positive Airway Pressure ventilation system (BIPAP), specifically the Evita Ventilator whose impact on the delivery of healthcare will be studied. Why the introduction of BIPAP was important and how it has benefited the healthcare delivery are a few focal areas of this essay. Moreover, the whole change process of introducing BIPAP from initiation to implementation and evaluation will be studied to present recommendations for strategy development for implementing, monitoring and evaluating change in healthcare. Models and Theories of Change There are several models of change introduced by different researchers. Some of these models are for planned change whereas some are for unplanned change. Since the change implemented in my area of practice, that is, the introduction of BIPAP system, is a planned change different planned change models and theories are discussed in this section. Planned change according to Marquis and Huston (2008, p. 166) “results from a well-thought-out and deliberate effort to make something happen”. The authors continue that “planned change is the deliberate application of knowledge and skills by a leader to bring about a change” (p. 166). Welch (1979) while talking about planned change in nursing holds the view that thoughtful initiation of change leads to its planned implementation which in turn assures that the change will sufficiently promote the nursing care. Planned change models presented by different researchers take more or less same line where almost all researchers present the fact that change becomes necessary to find out a solution for a problem that enhance efficiency. Reddin’s planned change model suggest seven steps where the need for change is diagnosed, mutual objectives for bringing about the change are decided, group emphasis is ensured, maximum information is gathered, discussions take place to ensure successful implementation, organizational values are analyzed to ensure the proposed change fits in the organizational context, whereas lastly interpretations for resistance are made prior to the implementation to minimize its effects (Swansburg 1996, p. 290). Another very popular planned change model was presented by Lewin (1951). This model is known as Lewin’s Force-Field model and presents three simple stages of change as unfreezing, moving and refreezing stage. Lewin (1951) suggested that in unfreezing stage a change agent strongly feels the need for change and inform others about its need and importance. Then in the moving stage information is gathered and a plan for change implementation is chalked out; in this stage the change process is expedited and assisted by a supervisor who guides the team towards successful implementation. Then in refreezing stage the change is accepted throughout the organization and hence becomes a part of the organizational value system. Lewin’s Force-Field model has provided basis for several other change models. Rogers Diffusion of Innovations model (Rogers 1995) having four stages of change spread over initiation, implementation and adoption activities, Havelock six-step change model (1973) and Lippitt’s seven phases of change (Lippitt et al 1958) all are elaborating on three basic stages of change given by Lewin. Swansburg (1996, p. 292) gave following tabular presentation of these models relating them to the basic Lewin’s force-field model of change. Figure I: Comparison of Change Models (Source: Swansburg (1996, p. 292) Besides these planned change models, there are different change theories presented by different researchers. Kelly (2009, p. 154) has talked about two emerging change theories that can be observed in health care settings; these theories are chaos theory and learning organization theory. Chaos theory of change was first presented by Coppa (1993). This theory suggests that constant change is in place where organizations has to cope with them in order to implement it effectively since there is no time for linear change implementation. Grossman and Valiga (2000, p. 228) defined chaos theory as a “belief that hidden within the seemingly total disorganization of a situation are patterns of order”. While talking about chaos in clinical settings, Kelly (2009, p. 154) stated that “the potential for chaos means that nurses and the organization must be able to organize and implement change quickly and forcefully”. While on the other hand, learning organization theory explains the features of a learning organization. There are five dimensions of learning organizations presented by Peter Senge as ‘personal mastery, mental models, shared vision, team learning and systems thinking’. Kelly (2009, p. 154) explained that this theory can be observed in clinical settings in that an organization can only truly be a learning organization when all of its members are well aware of the importance and consequences of their actions and hence do the right things to ensure things are done effectively. The author states that all organization members must have mental models of what is expected of them which develop a system thinking leading whole organization towards a single purpose of learning which will in turn bring improvement. Since all these models are just the extension of one and the same thing where change is initiated, worked out and adopted the basic model remains the same i.e. unfreezing, moving and refreezing, hence I have decided to use the Lewin’s model of change while incorporating other models simultaneously to explain the change that was introduced in my settings. Besides these change theories, there are change types and their implementation strategies presented by Dunphy and Stace (1988, p. 331) which is presented below. Figure II: Change Types and their Implementation Strategies (Source: Dunphy and Stace 1988, p. 331) Thus these models suggest that for increased performance change is to be accepted and implemented however how this will be done will depend upon the particular work environment and leadership styles of the leading position holders in that environment. Introduction of BIPAP System The change brought about in my clinical settings was the introduction of Biphasic Positive Airway Pressure (BIPAP) ventilation system, specifically the Evita Ventilator. I work as staff nurse in a busy respiratory ward. I care for patient with long term respiratory illness and disease such as cancer of the lung, exacerbation of asthma and cardio pulmonary disease among others. Patients suffering from respiratory illnesses are quite vulnerable and need more attention and care. It is due to this reason our hospital always tries to rely on the best ways to take care of patients suffering from respiratory diseases. The introduction of BIPAP system was one of the efforts to ensure the patients get best to help their recovery process. Before the introduction of BIPAP system, we were using normal oxygen therapy via face mask nasal cannula for patients with respiratory distress. This oxygen therapy is offered by the use of a narrow and flexible plastic tube that ensures the delivery of oxygen via patient’s nostrils. This face mask oxygen therapy uses the principles of nasal breathing. Though it was also effective but a better option was BIPAP system. BIPAP system performs the same process but much effectively since it is an apparatus that gets more air in the lungs of the patient. Sometimes a person cannot breathe properly and is unable to transfer oxygen into the lungs and consequently into the blood. BIPAP is quite a small device connected to the face mask worn by the patients via flexible tubing. BIPAP detects the air pressure required by a patient and supplies the required amount of air pressure on inhalation and exhalation. It has two pressure settings which allow the user to get more air in and out of the lungs without the regular muscular activity needed for it. According to (Varma 1999, p. 21) “BIPAP is a single ventilation mode which covers the entire spectrum, from mechanical ventilation to spontaneous breathing. It is a variation of pressure-controlled ventilation and differs from conventional pressure-controlled ventilation as far as the mechanical breaths are concerned in that spontaneous breathing is always possible”. Patients having difficulty in breathing due to diseases like cardiac failure, chronic obstructive pulmonary disease, adult respiratory distress syndrome and pneumonia use BIPAP to support breathing (New South Wales Government 2011). BIPAP is highly recommended for patients suffering from sleep related hypoventilation (Kollef 2007, p. 77). BIPAP can be used for several hours and in ICUs for several weeks. BIPAP has many advantages; unlike the traditional oxygen therapy it provides different modes such as spontaneous/timed, timed and pressure control (Haddad and Stucky 2011, p. 2145). It is more effective for patients suffering from acute respiratory failure than the conventional medical therapy (Murray et al 2002, p. 403). According to Varma (1999, p. 21) BIPAP is better than conventional ventilation modes because of its advantages such as “maintained spontaneous breathing, less sedation, higher inspiratory drive and reduced atelectasis”. Murray et al (2002, p. 403) while quoting different researches stated that the patients with respiratory failure are advantaged in using BIPAP over conventional medical therapy as the former has a lower intubation rate. In adopting BIPAP, the change was specifically the use of Evita Ventilator which is one of the breakthroughs in technology due to its high performance in both invasive and non-invasive ventilation. It not only offers quite effective oxygen therapy but is also quite comprehensive when it comes to offering monitoring functions. It allows sophisticated care to patients of all ages. It has advanced features such as low flow PV loop plot, balanced removal of carbondioxide, expiratory flow patterns and automated weaning which makes it better than conventional modes of ventilation. Having introduced BIPAP in our clinical set up has given a boost to the confidence and morale of nurses in term of being in tune with the latest technological advancement. It has given all staff nurses a feel of being able to better help the patients with the use of most modern and sophisticated tools. Also, being familiar with new technology in itself is something that gives encouragement and a feeling of being tech-savvy which ultimately help staff nurses perform their duties more effectively. Considering all the specific advantages of using BIPAP opting for it in my clinical settings was a best option. Besides the specific advantages which definitely will have a positive impact on the delivery of healthcare, opting for BIPAP was also important owing to the policy requirement. It is policy of our hospital to offer best modes to the patients which offers them best treatment and swift recovery. This change has brought positive change and has benefited the healthcare delivery. Before going into the details of how this change was adopted by all of us in the hospital and what benefits it brought, let’s first look at the role of nurses in the change management process. Change Management and Role of Nurses In initiating and adopting the change i.e. introduction and use of Evita Ventilator in my clinical practices I played a proactive role. As stated by Loveridge and Cummings (1996, p. 382) while talking about role of nurses in change management, that nurses should be able to take proactive part in change management process as change has become a part and parcel of today’s society and healthcare industry is one of those industries that are subject to constant change. Authors continued that each nurse, irrespective of his or her position in the organization should play a role in change process. Loveridge and Cummings (1996, p. 383) further stated that “the ability of each nurse to identify and achieve change is vitally important to meeting the needs of clients”. This shows that the participation of nurses in change management process is very important for the change to be initiated and implemented successfully. Change Models and Introduction of BIPAP Introduction of a change requires management of an organization as well as its staff to embrace it in a way that it becomes a part of organizational value system. Unless and until proper plan is in place it becomes difficult for any change to be accepted by everyone in a group. Hence organizations are required to plan the change process according to the steps suggested in any of the change models that best suits the organizational needs. As discussed earlier there are several change models and theories; in this essay I will use Lewin’s change model while incorporating other models, where required, to discuss the change introduced in my nursing practice i.e. introduction of BIPAP, Evita Ventilator. The major reason to select Lewin’s change model is its simplicity which is adequate to cover all the aspects of change (introduction of BIPAP) that took place in my nursing practice. It is used for this essay also because it is best in situations where resistance in adopting change is minimal. As highlighted by Daly, Speedy and Jackson (2003, p. 188) while talking about Lewin’s change model that “this approach works best when resistance to change is low to moderate, and when some consensus on the planned change can be reached”; and since in my settings there is minimal resistance to this change as we all are very much a part of this change process and were made adequately equipped to accept and adopt the change easily Lewin’s model is best to explain change initiation and adoption in my clinical settings. Nurse Manager at our hospital recognized the need to have a BIPAP ventilation system in place in our hospital; this identification of need has initiated the unfreeze process. This has led to the collection of information about the available apparatus options that could possibly replace the current use of face masks in our respiratory ward. Our nurse manager has involved staff nurses as a part of this procedure and we were asked to share information on how do we feel about bringing this change and which features we think should be there in the apparatus. I was a part of this process and this has helped boost my confidence about the upcoming change. I will relate this to ‘incremental change participative strategy’ presented by Dunphy and Stace (1988) where one of the interest groups (that is, staff nurses) has been involved in the process to ensure the upcoming change is welcomed. This can also be related to Lippitt’s (1958) third phase of change process where motivation and capacity for change is assessed to ensure the organization and staff has the required capacity to cope up with the proposed change. This unfreezing has led to the next stage in Lewin’s model of change i.e. the moving stage. The alternatives were then evaluated and the features of all the available options were compared to see which could offer best match to the needs of the patients. We, the staff nurses, were also a part of this process and we were asked to give any suggestions we would like to in order to assist the solution selection process. This can be related to the fourth and fifth phase of Havelock’s (1973) change model which suggests ‘choosing the solution’ and ‘gaining acceptance’. Since we represent one of the interest groups in this change process we were a part of this evaluation process. Finally, the solution was selected and accepted; we were given trainings on how to use the new apparatus as a part of refreezing process. These trainings were aimed at familiarizing the staff nurses with the usage of new apparatus in order to ensure we find ourselves comfortable in operating it hence improving our efficiency. Once the trainings were done change was completely adopted. The process of this change cannot be categorized as chaotic which means chaos theory doesn’t fit the circumstances since there was no unpredictability; as highlighted by Manion (1994) and quoted in Daly, Speedy and Jackson (2003, p. 188) that though change is characterized by unpredictability however if the change initiation and adoption process follows a logical process it becomes easy to manage and thereof reduce chaos. Now it’s time to go through Lippitt’s (1958) seventh phase of change process which suggests ‘terminating the helping relationship’. All staff nurses, including myself are now independent and we do not really need assistance in operating BIPAP Evita Ventilator. We are well trained on different aspects / features of this apparatus and we know how to use it effectively to ensure best results to the patient. Following figure presents the change process for introduction of BIPAP system in my nursing practice. Figure III: Change Model and Introduction of BIPAP Cancelling Impediments to Change with Enhanced Acceptance Loveridge and Cummings (1996, p. 395) explained in detail the reasons that impedes the process of change. The factors that hinders the process include threatened self-interest, disagreement with the reasons of introducing change, mistaken perceptions, psychological resistance, change not in accordance with current trends, laggards attitude that give rise to low tolerance and thinking change as disrupting the stable system. All these factors could have hampered the introduction of BIPAP system in my clinical practices; however, given the fact that our nurse managers has adopted a participatory approach to change management and have involved us as a part of this process it has facilitated acceptance instead of increasing resistance to change. Owing to the fact that a planned change process was used chaos was minimal. According to Loveridge and Cummings (1996, p. 395) if people believe change as their own idea resistance will be low. Moreover, the authors stated that if the change is introduced as a way to decrease burden and enhance autonomy people feel inclined towards accepting it. Other factors, according to the authors, that facilitate acceptance to change include change in accordance with people’s value system, change process encourages people participation and proper training is given to people to ease the process of acceptance. In my settings, the introduction and adoption of BIPAP system was easy because all the factors presented by the authors were there in the change management process. We were involved from the very beginning of the change process and were asked to give our opinions about the introduction of BIPAP ventilation system. Since we were involved in the process we didn’t feel the change as strange. Moreover, we were also given trainings to help us understand the working of new apparatus installed so as to ease our anxiety and enhance our expertise in using the new system. All these factors had cancelled out any feelings of resistance with enhance acceptance. Conclusions and Recommendations The essay highlighted how change is a part of modern society and how common it is in health care industry. The essay also discussed the role of nurses in change process where it has been made clear that nurses play a pivotal role as they stand in the centre of the change process when introduced in their practice area. The essay presented the complete process of introducing BIPAP system and how the organization (where I work) has reacted and adopted the change. In the light of above discussion, following strategies for implementing, monitoring and evaluating change in healthcare are recommended to ensure change in a health care organization is implemented successfully. Strategies for implementing, monitoring and evaluating change in healthcare Participative Approach – When change process is to be initiated in a healthcare organization participative approach should be the main focus of change agents. This is because change in health care majorly affects the staff members and involving them from the beginning of the process boost their confidence while encouraging them to provide input and accept change whole heartedly. It will also make them feel change as their own idea which facilitate acceptance and eliminate resistance. Boosting Capacity for Change – It is important for change leaders to boost capacity for change adoption. All the required resources should be provided to the staff to make the process of change adoption easy for them. Gaining Acceptance – If participatory approach is adopted from the beginning of the change process it will not be difficult for change agents to gain acceptance of the staff. Gaining acceptance of staff will help them adopt change swiftly which is of course beneficial for the whole organization. Trainings – To help staff accept change easily and do not be afraid of it they must be given required trainings as otherwise they may find adopting the change difficult which may de-motivate them. If staff gets demoralized before stabilization, the change will face resistance where people are reluctant to adopt it as they might feel threatened due to lack of knowledge and expertise in adopting the change. This is even more important in health care settings because change in health care settings is most of the time related to technology and helping staff be tech-savvy is what will help adoption process. Terminating helping Relationship – It is also important to withdraw assistance and allow staff practice autonomy at a particular stage to help them put in their own efforts without being dependent on the assistance provided to make them familiarize with the new settings. Once the staff feels independent they will put in their own efforts and accept and adopt the new settings vigorously. All the above given strategies will help change initiation, implementation and adoption process where the staff feel the change as their own idea hence reducing the chances of resistance. From the introduction of BIPAP in my clinical settings, I found that no doubt change is good to improve efficiency in delivery of care to the patients however proper implementation is only possible via the keen involvement of staff nurses, as myself in this case. 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