only the nursing assistants present, even though the staff nurses taking over had not arrived on the ward. This arguably resulted in double handling as a second handover had to be carried out for the late arrivals (Currie, 2000). In order for consistency to be achieved these alternative changes need to be incorporated in the Trust Policy of Procedures once the proposals have been addressed at ward level with members of staff using reflection to work with the identified innovation (Kopp, 2001). Kopp suggests that such reflection can bring about other aspects of the event.
Set times for handover need to be accepted in order that identical information is passed on to all team members at the same time. The venue has to be private and conducive as stated by the NMC Code of Conduct (2004), the existing ward round room, could be allocated as this contains no telephones and other members of staff could be directed from entering by the use of a bold sign outside the door, such as, “NO ENTRY – HANDOVER IN PROGRESS”, thereby removing any distractions. Participants will be encouraged to use information drawn from the patient’s care plan and pertinent to their current presentation (appearance, behaviour, speech, mood, thoughts, insight, perception, belief or cognition) might arguably enhance handover information and communication (Currie, 2000), adhering to the view of Lamond (2000) that, “the main function of the handover is one of communicating vital information about patients from one shift of nursing staff to another”. Any other discussion by nurses might best be addressed in other forums, for example clinical supervision.
CHANGE THEORY
A 'change agent' is one that promotes and effects change as proposed by Sullivan and Decker, 2001. Sullivan 2001 pg. 249 defines change as "the process of making something different from what it was". The climate of change produces new opportunities for nurses; it is an unavoidable as it is necessary for growth but it often produces anxiety and fear. Change can be planned or unplanned but in both ways it can be threatening and brings a sense of loss of the familiar vis-à-vis the "Status Quo" Hunt and Pearman (2001) proposed that nursing now and in future is becoming increasingly dependent upon the ability of the nurse to ensure not only that patients receive the highest quality of nursing care but also they are skilled and competent managers of people. The writer will look at change as a challenge and try to manage it proactively and creatively by understanding it as phenomenon and by identifying emotional reactions to
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change and key aspects of managing it. The philosophy of today's nursing is on the rights of patients, the patient being the priority; focus of care and nursing approach to patient care, being holistic and individualised, Whetton & Cameron (2005). The chances of survival of change seem very slim due to resistance by nurses and because of the way it is implemented.
MODEL OF CHANGE
The writer has chosen to use Lewin's Force Field Model of Change (1951) cited in Marquis and Huston (2006). As there are several 'theories' and 'models' of change and in order to make it clear, I will offer both definitions of Tiffany and Lutjens (1998), 'Theories are idea structures whilst models are more abstract than theories”. The choice of Lewin's theory is based on clearly defined stages for change which appear to represent the nursing process, when applied together with other most frequently used theories cited by Huber (2006) which are Rogers Theory (1962) and Lippitt's Theory (1973).
Lewin's identified three phases through which the change agent must proceed before a planned change became part of the system: - unfreezing that is to thaw out the ancient or old way of doing things and bring about the most ideal conditions for change; moving, that is shifting to a new position or level, gathering information and begin to action the change, and; re-freezing which is the new position or level, when newly acquired behaviour is accepted and integrated into the new way of doing things. With this theory Lewin had condensed his force field analysis (Huber 2006).
Lewins identified that change is the result of completion between two forces, which he identified as the driving and restraining forces. This is when one set of influences or pressures is pushing for change and a different set is pushing for things to remain as they are or "status quo". Lewin's force field analysis approach suggested that change will occur when the interplay of various forces and influences at play in that situation alter. The change agent needs to identify and analyse these forces and if possible manage them by allowing the driving forces to take effect (Carney 2000). When these two forces driving and restraining, are at the same or the restraining forces are stronger, the change agent needs to use their participative or, quality skills to reduce the restraining forces and increase the driving forces in order to
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implement change (Tappen 2001). This in turn will result in 'unfreezing', (Sullivan & Decker 2001) the ideal climate for change. As part of my strategy I overcame the restraining forces by having an informal talk with my ward manger about my identified change and how, I intend going about implementing it. By having a conversation with my manager I was thawing out that is unfreezing the system and creating the motivation and preparation for change. Talking to my manager was my way of seeking his authority and reducing resistance I expected from other staff members. After seeking permission from the managers in implementing my change, I called for a meeting to tell all staff about my intended change and seek for their opinion. During the meeting I informed staff about my intended change asked them if they had any concerns or suggestion on how it could be achieved. The meeting generated so many ideas.
The next stage was Lewin (1951) Moving stage. This is when clients and the staff must have proceeded to a new level of behaviour and the actual visible change occurs. This is a stage where clients and the staff must have collected enough information to clarify and identify the problem. During this stage the actual identified change occurs. The first day of implementing change l was encouraging those on duty to carry out handover in the ward round room. Staff was supportive and seemed committed to the change. The change was slowly introduced as part of my driving forces l encouraged staff to participate in it.
Refreezing this is the final stage of the Lewin’s change theory is when proposed change would have been integrated, implemented and stabilized. The author will use positive feedback, encouragement and constructive criticism to reinforce the new whole process to ensure that change has actually achieved the purpose for which it was planed for and give credit to all those who may have contributed and made the change a success.
Roger (1983) cited in Rumbold (1995) draws on the earlier work of Lewin and Lippitt although he assumes a more flexible view. He recognises that change is reversible. Participates will sometimes, initially accept the need for change and whatever proposals are put forward but then subsequently reject them or vice versa, initially reject the change and then adopt it (Sullivan & Decker, 2001). Even though change could be rejected at the first attempt, Roger points out that it may be resurrected at a later period using a different approach and may go on to be successfully implemented. However acceptance does not guarantee permanence as proposed by Sullivan & Decker (1992) cited by Rumbold (1995). Roger (1983) has come up with the following five stages to the implementation of change: The first is knowledge,
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where the group is introduced to the new idea or innovation and begins to understand. The second is persuasion to establish their persuasion towards the idea rather than acceptance of the need for change.
This is a very important stage as it is here that attitudes towards the idea or innovation begin to form. Attitudes may be positive or negative. The third stage being decisions, where the group declares whether they accept or reject the change proposed. This stage cannot be rushed but should be developed through discussion and debate. Implementation comes in at fourth where the idea or change is put into change with any necessary revision and or adaptation. The final and fifth stage is confirmation where the group seeks reinforcement that the correct decision has been made. Once established that the reinforcement is positive the change becomes established practice. Should there be disagreement then the decision reached may be reversed (Rumbold, 1995).
One could argue that change is effected by democratic leaders and for the purpose of this essay, transformational leaders who encourage participation of members of staff to get involved fully in the identification of what needs to be changed, to develop a plan, implement and evaluate the change process. Transformational leaders thrive on change and believe it is essential while using their charismatic approach to inspire followers (Soffarelli &Brown, 1998). However there are individuals who may not be easily persuaded. Therefore any change is likely to produce resistance, as previously shown by Lewin. Curtis and White (2002) in their findings on resistance to change have proposed, lack of understanding, lack of motivation, increased stress to staff. They further suggest that in order to alleviate these feelings, change should be introduced gradually whilst management remain constantly aware of the feelings and concerns of all the staff to the proposed change. In Curtis and White (2002), they propose that motivation of staff is a basic need for change and that participants should not feel that the change is imposed on them as they may feel threatened. Expression of empathy on the part of the change agent is crucial to success of any change (Hunt and Pearson, 2001). This involves the change agent being sympathetic and understanding the feelings of their team and their perspectives of the change, being non-judgemental and avoiding criticism. “Skilled reflective listening is crucial,” (Hunt and Pearson, 2001), this will create positive reinforcement and can create ownership of the change within the staff resulting in those staff believing that the innovation for change emanated from them.
Using Lewin’s theory, which the change agent has already discussed above I am going to discuss the action plan (APPENDIX I) to effect a change to the handover procedure. Firstly - the status quo procedure
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is examined and any conflict of ideas or attitudes to change will be explored. Miller & Rollnick (1991) believe that it is conflict of ideas (ambivalence) that prevents change. This can be explored by open communication between those staff that are affected by the change; but also of the advantages and disadvantages of not changing. Miller & Rollnick (1991) believe that by balancing the advantages and disadvantages (ambivalence) of the change, staff will develop discrepancy - where they examine their own behaviour and how change may affect that behaviour. This removes ambivalence and increases motivation and staff will be able to form realistic view of the proposed change (Hunt & Pearson, 2001). Lewin argues that if people feel too comfortable with the status quo they will not want change (Tappen, 2001); while Sullivan & Decker (2001) note that any change may provide a source of conflict, as it is a loss of the familiar. One might argue that it is this very imbalance that creates the climate for change and has the effect of unfreezing the ancient way of doing things.
Secondly - The innovation is slowly introduced and those affected by it are persuaded to participate in it by gathering any new information, inviting speakers and or arranging visits in those areas where it is already implemented and working well and by the reassurance of their team leader that this change will be monitored after a specific time to evaluate its effectiveness. The team is also encouraged by the change agent to ventilate their concerns and identified barriers through debate to the proposed change and to identify strategies to overcome them. For instance, Lancaster (1999) identifies communication as “the backbone of effective change - everyone must be kept informed to keep to a minimum the potential for rumour and misinformation”. In the writer’s opinion, in order to reduce resistance due to lack of communication, managers could register staff on courses to improve their communication skills? Hoban (2003). As discussed above, Curtis & White (2002) advocate staff involvement to engender the feeling of ‘ownership’ of change, whilst Hunt & Pearson (2001) focus on the change agent’s use of empathy and understanding during reflective listening to acknowledge any anxieties experienced by staff in relation to the change. Lewin believed that adoption of theses strategies would result in moving to (achieving) a new level (Tappen, 2001).
Thirdly - Lippitt’s Theory aptly describes the new way of doing things as “maintenance of the change once it has been started” (Lancaster, 1999), although Lewin believed that by stabilising the change, it is gradually integrated into behaviour and so becomes part of regular functioning (Tappen, 2001). This establishment of routine can be likened to the ‘institutionalisation phase’ of Rogers’ theory (cited in
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Tappen, 2001). However, one might argue that institutionalisation of an approach could lead to reluctance to try an alternative way of doing things. This has been identified by Curtis & White (2002) as producing negative attitude that could result in a barrier change. On balance, Solfarelli & Brown (1998) say that the change agent would need to adopt a positive attitude in order to educate and empower staff so that they readily embrace change and achieve Lewin’s refreezing stage.
EVALUATION
The change has now been implemented, but it appears noteworthy to mention that this change will need to be evaluated after an agreed period of time, say six weeks, in order to assess its effectiveness. This is in keeping with Rogers’ Theory that changes are not irreversible depending on their efficacy (Sullivan & Decker, 2001). The change in handover procedure could be evaluated during my practice placement’s normal staff meetings held on the ward once every fortnight.
It is important to note at this stage that the professional change or innovation discussed and analysed above is based on the experiences gained throughout the three-year mental health pathway. The writer in achieving professional and personal growth has gained invaluable knowledge in interpersonal skills and communication, an in-depth knowledge of health promotion, the management of self and others, the knowledge and skills of nursing care delivery and knowledge of ethical and professional issues within mental health practice. Through reflection Author has been able to identify the pathway of nurse training enabling me to appreciate my continuing personal development through witnessing changes over time thereby leading to increased confidence (Kopp, 2001).
CONCLUSION
In conclusion, l have identified an area, which might benefit from change within my clinical placement. I feel that being given the opportunity to be a change agent has facilitated personal professional growth. I am now confident to say that this has led to a belief in my increased competence, in turn leading to the acceptance of the responsibility and accountability required of a registered nurse practitioner (NMC Code of Conduct, 2004). Therefore, l also used Lewin’s theory to implement change in an area of personal
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development (Lewin, 1951) cited in Tappen (2001). Reflection has facilitated me to change the practice and behaviour in a specific way in order to provide better patient centred care (Kopp, 2001).
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APPENDIX 1
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