Introducing a change of nursing model in a general Intensive Therapy Unit

Pamela Wilkinson

This paper focuses on the management of change in the context of health care and looks specifically at methods of introducing a new model of nursing into a general Intensive Therapy Unit (ITU). Rationale for change is discussed, change theory is appraised and a strategy for implementation, management and evaluation of change is provided.

INTRODUCTION

Change would seem to be an irrevocable fact of life in Western society (Stephenson 1987) and the National Health Service (NHS) provides an explicit example of an organisation confronted by continuing change (Cope 1984, Bowman 1986, Wright 1989). The pace of change in addition to change per se is an auxiliary feature which Weisbord (1988) refers to as a state of ‘perpetual meltdown’, where ‘organisations move more like bullet trains than melting icebergs’, he goes on to claim that we are in a ‘permanent, on-going transition’.

Change may be defined as ‘an attempt to alter or replace existing knowledge, skills, attitudes, norms and styles of individuals and groups’ (Wright 1989). A less rigid and perhaps more reflective definition is provided by Handy (1991) who defines change as ‘another word for growth, another synonym for learning’. For the purposes

Pamela Wilkinson BSc(Hons), RGN, ENB 100, CertEd, Senior Lecturer in Nursing, Anglia Polytechnic University, Faculty of Health and Social Work, Broomfield Hospital, Chelmsford CM1 5LG, UK (Requests for offprints to PW) Manuscript accepted 24 November 1993

26

of this paper a combination of these definitions will be used.

Change can of course be planned or unplan- ned, in addition it can occur at two levels: macroscopic and microscopic, and has direction (Mauksch & Miller 1981). The focus of this paper is planned change when ‘attempts to bring about change are conscious, deliberate and intended’ (Benne & Chin 1974). For this to occur a carefully thought, rational strategy is required (Wright 1989, ENB 1987). Part of this strategy is to be able to understand the nature and dyna- mics of change in order to use it effectively. Failure may result in apathy, anxiety, conflict, resistance and ultimately fail to bring about change (Lancaster & Lancaster 1982).

CHANGE IN THE CONTEXT OF ITUs

Staff in ITUs are frequently subjected to the influences of change. Growing expectations of technology and new management structures are applying pressures to staff working in a potentially stressful area (Stephenson 1987, Wilkinson 1992). It is therefore extremely important that nurses are not merely reactive to

IKI-EiTSIVE AND CRI1‘lCAI. CARE NURSING 27

change but take a proactive role, this role may be that of a change agent.

Essential qualities of a change agent are com- munication skills, in particular those of effective listening and understanding of motivation and group dynamics (Lancaster & Lancaster 1982). In addition Stephenson (1987) claims that the credibility of a change agent is of crucial import- ance, citing ‘technical’ and ‘truth’ credibility as essential. The change agent facilitates problem diagnosis, identifying and clarifying goals for change and developing change strategies.

THE CASE FOR CHANGE AND APPLICATION OF CHANGE THEORY

The nursing process utilising a modified version of the Roper, Logan, Tierney model of nursing (1980) was adopted by Broomfield ITU in 1987, some 2 years after the unit opened. The stimulus for this adoption was primarily to fulfil English National Board (ENB) requirements to enable the unit to be used as a learning environment for pre-registration students and later (1990) for post-registration students undertaking the ENB Course 100.

Whilst such a stimulus comes from a position of power and to some extent was imposed, this was countered by a very genuine desire for the unit to be utilised as a learning environment. A small working party was set up, discussions took place, literature was reviewed and documen- tation produced for comment. Documentation was revised three times following staff evalu- ations and has remained virtually unchanged since 1987.

Over the last 2 years there has been an increasing dissatisfaction with both the nursing model and the documentation in use. Use of a nursing model should direct nurses’ thoughts and actions along logical and systematic lines, promoting the delivery of comprehensive nurs- ing care tailored to the needs of individual patients (Pearson & Vaughan 1989). This dis- satisfaction was expressed informally initially, then more formally at staff meetings.

The criticisms may be attributed in part, to the introduction of the ENB Course 100, which for assessment purposes requires a critique of a nursing model and a detailed care study. The process of the assessment aims to facilitate an increase in critical ability in assessing the process of nursing. In addition the ITU has established a knowledge base through development and documentation of local nursing procedures and the setting of standards facilitating the appli- cation of research to practice. This latter development has additional implications for the documentation of care.

With regard to change theory Lewin (195 1) is still perceived as a pioneer in the study of change and provides a three stage model for the process of change. These stages are ‘unfreezing’, ‘cogni- tive redefinition’ and ‘refreezing’. Utilisation of this model provides a framework for analysis as well as guidance of the change process being described and examined here.

It would appear that some ‘unfreezing’ had occurred in response to changes in educational provision. Parts of a system interact and influ- ence one another, according to systems theory (Lancaster & Lancaster 1982). Unfreezing is a thawing-out phase where the group or organis- ation recognises the need for change. This is a vital phase in the change process and the group should be encouraged, supported and motivated in the direction of the desired change.

Connor (1987) warns that unfreezing can be exceedingly painful if the process is ineffective, with people remaining in a ‘psychological frozen state of resistance’. Weisbord (1988) however claims that in our climate of ‘perpetual meltdown’ unfreezing is no longer a necessary step, indeed one may ask the question does refreezing ever take place?

A consensual view obtained through debate, (not necessarily a systematic approach), indi- cated that nursing staff of all grades favoured the adoption of the Mead model - developed specifically for an ITU care setting. The salient contrasting features of the two models are summarised thus:

1, Individual at centre of model instead of Activities of Daily Living (ADL)

28 INTENSIVEANDCRITICALCARENURSING

Driving Forces Minimal finance required

Partial knowledge base of Mead model established

Inherent motivation (no imposition from ‘above’) with ITU

Existing model of care inadequate, dissatisfied within Roper et al

Less paperwork-more time with patient and family

Desire to change from staff within ITU

Successful pilot & evalution

Fig. 1 Force-field analysis.

Restraining Forces

Financial cost of printing documents

Deficiency of knowledge (for some staff and potential of conflict)

Lack of time, to prepare/ educate staff

Scepticism about nursing models

Perception of increasing work load

Emotional cost of change to nursing staff (in current climate)

Explicit dependence/independence conti- nuum used as an assessing and goal setting tool Influencing factors rather than ADL provide framework for care Based on ‘needs’ rather than ‘problems’.

The model published in 1987 (McClune 8c Franklin) has received limited review in the literature (Edwards 1992), it appears however to have been adopted by some ITUs in England, and may be utilised in Europe and Australia (Franklin 1993). The Mead care plan is oriented to be functional and efficient in the specific care setting of ITUs. This was the start of the ‘cognitive redefinition’ (Lewin 1951) phase or ‘reframing’ (Handy 1991) characterised by the group moving towards a new behaviour, based on the group or individual having ‘adequate information and understanding about the need and the way to alter their own attitudes and behaviour’.

Refreezing includes the ‘integration of the personality of the newly acquired behaviour’ into the participants’ own frame of reference. This adoption necessitates various forms of reinforcement, particularly through feedback, support and encouragement of individuals and

groups. Guidance for such strategies is provided by Locke & Henne (1986) in their critique of motivation theories and strategies are addressed later in this paper.

Within his three stage model Lewin (1951) devised a diagrammatic representation of the features impinging on the change that is sought. The purpose of this ‘Force-field analysis’ is to identify all supporting (driving forces) that are pushing for change, and all hindering (restrain- ing forces). Appropriate strategies may then be devised to increase the former and decrease the latter. The latter approach is often more fruitful because to increase driving forces without atten- tion to restraining forces may increase pressure and tension in the system to the point where creative problem-solving becomes a problem. Breu & Dracup (1976) claim that a complete evaluation of both driving and restraining forces is essential to the success of the proposed change. These are identified in Figure 1.

The success of this venture depended in part on the extent to which the philosophy of nursing models was understood and accepted. This has implications for education particularly for quali- fied practising nurses (Nolan 8c Burgoyne 1990). Kenny (1993) states that ‘many nurses are not educated or prepared for the changes inherent in the adoption of nursing models’.

It was also important to ask ‘What can go wrong?’ as there may be intended and uninten- ded consequences or ‘side-effects’ of the pro- posed change (Mauksch & Miller 1981). This is affirmed by Lancaster and Lancaster (1982) ‘the human (organisational) system is open and con- tinuously altered by inputs and the consequen- ces of the system’s own outputs’.

STRATEGY FOR CHANGE

Selection of the most appropriate strategy for change is stated by Bennis et al (1976) to be a vital factor in the ultimate success of the change process providing the necessary underpinning to the action plan. Wright (1989) claims that skills in oroblem-solvina. decision making and

The power-coercive approach

Essentially ‘top-down’ approach, those in authori*/ instruct others to change behaviour.

The rational-empirical approach It is assumed that, when given choice, people will behave in a way that will bring maximum benefit to all, and that a rational decision will be made on the basis of sound knowledge.

The normative-reeducation approach This contrasts with the others in that it is essentially ‘bottom-up’. It is based on the belief that people need to be involved in all aspects of the changes which affect them because their normative culture will determine the acceptance and implementation of change.

Fig. 2 Change strategies (after Bennis et al 1976).

communication are pre-requisite to this selection.

The literature identifies three predominant change strategies shown in Figure 2 and illustrat- ing how power and control may affect the change process. Wright (1989), citing Haffer (1986), argues that the pertinence of each strategy depends upon the ‘situation and the individuals whose knowledge, beliefs, attitudes, values or behaviour we seek to change’.

For this particular change, the normative-re- educative strategy was selected on the basis that people need to be involved at all stages if it is to be effective. The strategy whilst attributed to Bennis et al (1976) relates also to Lewin’s (195 1) belief in action research as a means of changing and participating in groups as a method of re-education. A major theme in Lewin’s work was the need to bridge the gap between the concrete and the abstract.

Tactics to ensure a successful strategy are suggested by Plant (1987) and are discussed here in the light of the change.

Helping individuals or groups face up to change Many of the nursing staff, in particular members of the pilot group, were enthusiastic about the use of the Mead model and indeed have facil- itated a successful pilot change project. The

‘facing up to change’ has therefore been intrinsi- cally stimulated. However other members of staff were unfamiliar with the model and in particular new staff were anxious about using an unknown model. A climate of education and psychological safety helped erase this fear (Rogers 1983). Availability of literature, semi- nars by staff from the pilot group and atten- dance at study days helped share knowledge and expertise, thereby dispelling fear and anxiety.

Communicate like you have never communicated before Throughout the literature on change manage- ment the emphasis on communication is para- mount, in particular listening and ensuring that the communication is a two-way process. This was facilitated by regular staff meetings with an agenda to which all members of staff contri- buted, in addition to ‘normal’ good communica- tion throughout the nursing team.

Gaining energetic commitment to the change In the current climate of continuous change gaining active innovation can be challenging. Constructive and positive feedback helped sustain motivation (Bandura 1982). In addition, giving ownership of the change to the staff through the pilot phase and the opportunity to make revisions and adaptions decreased resist- ance (Breu & Dracup 1976).

Early involvement Early involvement of participants is, of course, central to the normative-re-educative approach and helped limit resistance during implemen- tation (Plant 1987). This contrasts with the energies required to enforce compliance when power-coercion strategies are utilised.

Opportunity or threat? A perception of change Change is often perceived as a threat and ritua- listic practices may be adhered to in an effort to

30 INTENSIVE AND CRITICAL CARE NURSING

circumvent anxiety (Haynes 1992). Discussing nursing models themselves is a continued fears and worries about the planned change requirement to assure validity in the delivery of helped reduce resistance which can produce comprehensive, individualised patient care. disharmony, and was therefore a priority. Clearly evaluation is essential to assess the

effectiveness of change and may provide valua-

Avoid over-organising ble information for modification. Mauksch & Miller (1981) and Wright (1989) advocate dis-

Flexibility and adaptability rather than sticking semination of the results of the change process, rigidly to a detailed action plan in the change in an effort to enhance professional practice. In process will ultimately ensure success. Whilst the addition this may facilitate a change in nurses’ objective remained the same, the route taken was sufficiently adaptive to suit the nursing staff according to their needs and the demands upon them. In addition, whilst a time-frame was important there were regular evaluations of progress to ensure that the time-scale was in fact realistic.

EVALUATION OF THE CHANGE PROCESS

Evaluation is essential to assessing the process and true outcome of a change programme. However, it has been identified as a major problem in health care changes (Mauksch & Miller 1981, Wright 1989). This has been attri-

perception of themselves from victims to initia- tors of change (Hunt 1987).

CONCLUSION

It is perhaps important to remember that not all change is successful, however Handy (199 1) cites the value of Keats’ (18 17) ‘negative capability’ which he interprets as the ability to learn from mistakes or failures. ‘Getting it wrong is part of getting it right’ (Handy 1991), this can then be used as the basis for future development.

In addition, it would appear that in the context of rapid change nurses must learn to take a proactive role in its management. If we do not, Haynes (1992) claims, ‘those outside the profes-

buted to the complex diversity of the nurses’ sion are only too willing to do it for us’. This role. verifies the need for change theory to be a

Evaluation protocols should be developed curriculum component in both pre- and post- prior to the implementation of change as this may registration education which may be consoli- help focus on the process and goals of the change dated by exposure to role models who effectively programme. Methods of evaluation should translate theory into practice. surely reflect on the nature of the change pro- cess. It was therefore appropriate to select a triangulated method of evaluation, encompass-

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