This assignment will look at how the change theory of Lewin can be applied to a clinical situation that has ethical, advocacy and legal ramifications
This assignment will look at how the change theory of Lewin can be applied to a clinical situation that has ethical, advocacy and legal ramifications. The elder care facility it will be applied to provides all staff with the same uniform regardless of their designation, also, within this facility all staff are referred to as nurse whether they are or not. This makes identification of staff designations very difficult. The change theory developed by Kurt Lewin in 1951 will be applied to change and improve this situation and an analysis of the situational factors that impact on change will be explored. The principals of change theory will be discussed and applied to the planned change and conclusions about determining the success of the change will be made.
Whilst on clinical placement with first year students in an elder care facility it was noticed that all the staff members, except the nurse-manager who wore contemporary clothes, wore the same uniform. Only one nurse was seen to be wearing her badge and inquiries regarding the uniform were met with the response "we all want to look the same - no hierarchy here". Furthermore, all staff were referred to as "nurse" whether they were nurses or not. Being unfamiliar with the staff, students were further disadvantaged by being unable to rely on uniforms and badges to determine the staffing designations. It was also noticed that visitors to the facility had these same problems. Having staff designations identified by different uniforms would enable patients, visitors and other staff to instantly know whether they were talking to a registered nurse, a care associate or chatting to the cleaner.
The theory of change was developed by Kurt Lewin, who identified three phases to accomplishing change (Marquis & Huston, 2003). The first of these phases is that of unfreezing, when "the change agent unfreezes forces that maintain the status quo" (Marquis & Huston, 2003, p. 82). For this phase to be successful, an accurate assessment of the problem must be made along with a decision to change. In this phase people become disenchanted and become aware of a need for change. In the initial unfreezing phase of change the individual becomes aware of the need for change through three mechanisms. Hein and Nicholson, (1994) identify the first as occurring when the individuals expectations fail to be met (lack of confirmation). The second occurs when the individual feels uneasy about a certain action or lack of action (guilt/anxiety), and the third is when an obstacle to change has been removed (psychological safety). Change must then be planned to satisfy an existing need or to reduce stress. The change agent may even use strategies to initiate this process.
Movement is the second phase of this trilogy. This involves the change agent developing a plan, setting goals and objectives, knowing who will be supportive and where to expect resistance (Marquis & Huston, 2003). This is also the phase where the planned change is implemented, evaluated and modified if necessary. With change comes resistance. The values, perceptions and attitudes of those involved in the changes must be acknowledged, barriers discussed and solutions identified. The third and final part of the change theory is termed refreezing. This is a supportive role, requiring the change agent to reinforce individuals in their efforts to adapt to the change, so that the change is maintained (Marquis & Huston, 2003).
Marquis and Huston (2003), state that there are ten emotional phases of the change process. These are similar to those of the grief cycle and state that change is often accompanied by a sense of loss and grief. These emotional phases include the sense of stability that is achieved when professional and personal goals meet. Denial occurs when the reality of change is faced followed by anger, and bargaining occurs when those affected by the changes attempt to eliminate or reduce the change. Loss of security and powerlessness result in feelings of depression and chaos (external locus of control). As new roles emerge openness occurs and there is a sense of readiness, renewed energy and emotional reunification. The individual feels empowered (internal locus of control) and begins to introduce new ideas and projects. This phase is termed re emergence. If the change is a big one involving many staff members then the change agent may have to take into consideration that the staff members may move in and out of the various emotional phases and this may happen at different times for individual staff members.
Initiating change requires good leadership skills. Leadership requires ability, skill, vision and confidence and the ability to lead is best nurtured in an environment that provides opportunities for recognition of performance, constructive feedback about performance and supported risk taking, (Crew, 1999). Hardiness is a quality Marriner-Tomey (1993) describes as being a characteristic of a good leader. Hardy leaders believe they have control or influence over the events of their lives, an internal locus of control, as opposed to others who feel powerless in various situations, an external locus of control (Marriner-Tomey, 1993).
Managers who are willing to ...
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Initiating change requires good leadership skills. Leadership requires ability, skill, vision and confidence and the ability to lead is best nurtured in an environment that provides opportunities for recognition of performance, constructive feedback about performance and supported risk taking, (Crew, 1999). Hardiness is a quality Marriner-Tomey (1993) describes as being a characteristic of a good leader. Hardy leaders believe they have control or influence over the events of their lives, an internal locus of control, as opposed to others who feel powerless in various situations, an external locus of control (Marriner-Tomey, 1993).
Managers who are willing to empower their staff and staff who are willing to accept the challenges inherited with empowerment will have an internal locus of control and are therefore less likely to feel as unsettled by the effects of change in their workplace as those with an external locus of control.
Leadership style is significant. Transformational leaders motivate and empower staff to work to their full potential and enable individual staff members to be accountable for their work practices (Wilson, 1992). This allows for risks to be taken and mistakes to be viewed as learning opportunities, providing a supportive workplace that nourishes new ideas and supports change.
For change to occur a leader must have vision and direction and the ability to induce people to follow their direction and understand their vision (Clarke, 1994). One of the most difficult tasks for the manager is to enable staff to view the changes as a challenge instead of a threat (Marriner-Tomey, 1993). To successfully accomplish this there must be a degree of trust within the organisation. Trust arises from the mutual understanding that the actions taken by the organisation will not be detrimental to the employees (Hein & Nicholson, 1994). If staff members feel they are a valued part of the organisation they will be more inclined to accept changes rather than oppose them. Trust between the manager and staff is a key factor in implementing and maintaining changes. A trusted manager will gain the respect of their staff and colleagues and in return will offer them trust and respect. For change to be effective, all people involved in the change must feel valued, supported and feel they are being listened to.
One of the critical factors to ensuring successful change is communication. The breakdown of communications is cited at the most common reason for the failure of change programs in organisations (Clarke, 1994). Clarke (1994) states that "information is power to the people, information is control over your own destiny, information is understanding why change is necessary, information is the antidote to fear" (p. 158). This is an important observation because staff do not like to feel that changes that affect them are happening and they have no say in them. Regardless of whether the change is small or large staff members like to have a voice and want management to acknowledge that.
According to Clarke (1994), research shows that when communicating change, an open, two-way type of communication is the most effective in ensuring a lasting and irreversible change. This type of communication opens the way for management and staff to engage in a dialogue rather than the manager being responsible for informing staff of the change and expecting them to obey. In an environment that encourages open two-way information, staff who will be affected by the proposed change may express any doubts or fears regarding how the change may impact on them.
It is also important that the communication begins even if all of the facts are unknown at that point because this demonstrates a consideration for staff by acknowledging feelings of insecurity, and lack of control over ones destiny (Clarke, 1994). This proves to staff that they are trusted by the management and are considered a valuable part of the organisation.
There are two aspects to this planned change. The first one is to introduce different uniforms for different staff designations and the second change is to ensure the only people who are referred to as "nurse" are those who are registered or enrolled nurses. It is anticipated that the introduction of a uniform change will be easier than changing the way people refer to each other because a uniform change can be done at a managerial and policy level, whereas ensuring people refer to each other correctly relies on the individuals themselves.
According to Simms, Anderson, and Ervin (1994), a change that involves changing specific behaviors is easier to implement than one involving underlying beliefs and values. Many of the care associates at this elder care facility may like being called nurse, with all of the implications associated with being a nurse as opposed to being a care associate. Certainly none of them seem to correct anyone who does call them nurse, so the change agent could probably expect more resistance to this change than to the uniform change.
The change agent in this facility would probably be the nurse manager, who appears to have a positive pro-active effect on this workplace. She would have to act as a role model and view the change positively. She would accept that there will be initial resistance from some members of the staff and this is a natural response (Clarke, 1994).
As part of the unfreezing phase of this change the change agent would explain to the staff that there was a problem and because of this problem there was a need for change. According to Stephen (1999), staff wearing the same clothes is particularly unsettling to the elderly, and she goes on to say that it is important for nurses to identify their designation as registered nurses. If all staff look the same people may be inadvertently mislead into thinking they were receiving care from a registered nurse when they were actually being cared for by care associates. This deception is further reinforced when all staff are referred to as nurse. It is important for nurses to participate fully in defining themselves in their nursing role and ensure that in a setting where everybody may be regarded as "family", they stand out.
According to Richardson (1999), nurses are proud to wear their uniform because it identifies them as belonging to the profession of nursing, and indicates responsibility, accountability and education. This is also reflected by the general public, who equate the nurses' uniform with competence, stability, reliability and professionalism (Richardson, 1999). So it could be concluded that the nurses in the eldercare facility are not declining to wear a uniform that identifies them as nurses, rather they are not being offered one. This could give the change agent a clue as to where she can expect resistance.
As part of the unfreezing phase of this suggested change the change agent may have to coerce the staff to begin the change process. Part of the organisational culture of this facility is the staff regarding an obvious designation of staffing positions as being a 'hierarchy', which they appear to view negatively. Staff appeared to be quite satisfied with the status quo and would probably be resistant to the suggestion that a uniform change is necessary. Another factor the change agent may have to consider when proposing a uniform change is the cost of a new uniform and who is going to carry that cost. So the change agent could expect resistance from two avenues - the staff who do not appear to desire a new uniform and the management of the facility who may be reluctant to pay for new different uniforms.
The other issue the change agent will bring to the attention of her staff is that under the Nurses Act, 1977, it is illegal for people to call themselves "nurse" when they are not on the Nursing Council of New Zealand's register of nurses (Burgess, 1996). Burgess, (1996) goes on to state that the right to call oneself a nurse is a privilege and carries certain obligations. These obligations are not necessarily legislated rather they are considered a social contract between nurses and society. Society has high expectations of nurses and it is important that these expectations are upheld. The care-givers are probably unaware they are violating a law when they refer to themselves and each other as nurse, so informing them of this would be the beginning of the unfreezing process. Part of the unfreezing process may involve creating dissention and making people uncomfortable about working outside the law is one way of beginning the unfreezing process.
In this environment the change agent could begin communicating her desire to make the changes in the weekly newsletter that is circulated to all the staff. She could then follow up by discussing the changes in more formal staff meetings, which would give her the opportunity to clarify the proposal and provide more information to staff. This would have given the staff members enough time to have thought about the changes and how they will be affected by them and they would be given an opportunity ask questions and to voice their opinions at the staff meeting. This would then provide the change agent with a gauge of how the changes may be received and where she may expect resistance. This is the 'movement' phase of Lewin's change theory, and it is at this phase where individuals may experience the emotional phases associated with change. This is also the phase where the manager and the staff will acknowledge their attitudes and values associated with the proposed change. These can often be seen as barriers to change which the change agent and the individuals will work to overcome.
In the movement phase the change agent will give staff time to voice their opinions regarding the change. Change often upsets individual's sense of equilibrium, which is maintained by the concurrent occurrence of driving and restraining forces. Driving forces motivate a person to move forward and may include recognition, the achievement of personal goals and financial remuneration. Restraining forces are forces that hold back change and may include the fear of change, little opportunity for input from those affected by the change, potential problems not being identified and an inadequate trial period (Hein & Nicholson, 1994). For change to occur and be successful the driving forces must be stronger or able to overcome the restraining forces. The movement phase also allows for any problems to be sorted out, for goals and objectives to be set and for any alternative solutions to be explored.
Culture change that involves changing underlying values and beliefs is difficult to change (Simms, et. al. 1994), so the change agent may have to use a reward system to motivate individuals to accept the challenge of change as part of the 'refreezing' phase. This can be important because staff often feel there is a loss of rewards when they make changes. In this instance some staff members may feel belittled or sense a loss of prestige when they are no longer called "nurse" and when they wear uniforms that clearly identify their designation.
To ensure the success of this change the change agent will depend on her ability to effectively communicate and motivate the staff to accept the change. According to Simms et. al. (1994), behaviors that are continually reinforced will eventually change values. The change agent can determine the success of the change by comparing the new behaviours with the standards of earlier times. The change agent could also use the 'refreezing' phase as an opportunity to motivate staff and encourage them to further their education, either by holding more 'in-house' educational opportunities or encouraging their formal training. According to Schweiger (1980), it is the responsibility of the nurse manager (change agent) to encourage and enable staff "to develop and grow educationally and as people" (p. 99). By keeping the lines of communication open and being aware of the mood of the staff, the change agent will soon know when the changes have become a daily habit, and thus successfully refrozen into the organizational culture.
The scope of the change is not big but it will impact on the staff. Nurses will be identified as such and other caregivers will not be identified as nurses. This change will empower patient's as they will know who is providing their care. Making this change will also encourage all the staff to accept more responsibility for providing a high standard of care within their scope of practice. By including staff in the change process, the change agent invite's them to become more attached to the organisation, which in turn leads to greater commitment, motivation and willingness to accept change (Hein & Nicholson, 1994). It will also allay any potential confusion from patients and their families about exactly who is performing cares for them or their loved ones. From a managerial perspective this gives the organisation a very professional public face. Anyone entering their premises will be able to easily identify the designations of staff by looking at their uniforms.
Change is an essential factor in growth and development and while many people are initially resistant to change, others often feel empowered by it. Change involves three phases beginning with an idea and a change agent with vision and the ability to motivate and empower individuals will accomplish the change and ensure it is permanent. Excellent communication skills enable barriers and resistance to be overcome and allows those affected by change to have their say. All healthcare professionals work in an environment of constant change and must adapt to it. The right to be called "nurse" is one that is earned and carries legal, ethical and social obligations. While the practicalities of this change are not large, they will have a big impact on those affected by them. Nurses will be identified as nurses, and other staff who are not nurses, will not refer or be referred to as a nurse. Change is vital for development and empowerment, and whilst change is not always welcomed, without it there would be stagnation.
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