Implementing change management in a dedicated oncology unit

Dedicated Oncology Unit

Case Overview

Summary of Relevant Theories

Change Management

Planning for Change

Lewin\'s Change Management Model

McKinsey 7-S Model

Kotter\'s 8 Step Change Model

Cultural Competency

Recommendations for Improving Organization

Case Overview

A 30-bed medical oncology unit located in a 450-bed hospital is transitioning from a medical oncology unit to a new 30 bed \"Dedicated Oncology Unit\", which will include patients receiving chemotherapy, patients with oncologic emergencies and post-chemo patients with neutropenic sepsis. Currently, the patient nurse ratio is 6 to 1, there is only one OCN (Oncology Certified Nurse) assigned to the unit and the acuity of the patients is going to increase exponentially.

In spite of the encouragement by Education and Development, there are no willing volunteers to sit for the OCN exam, and presently, the hospital is planning on utilizing the same staff to work on the unit. Staffing and morale are beginning to decline as this transformation is taking place. Although the Nurse Manager is an OCN, she lacks the inspiration and motivation her nurses need to study for and pass the OCN exam. The hospital has volunteered to reimburse the $450.00 sitting fee for the exam, but only if the candidate passes the exam. The unit is comprised of (2) 12-hour shifts.

The day shift has a total of 5 RN\'s (only one is an OCN), two Nursing Assistants, one Unit Clerk and one Nurse Manager. The evening shift has 4 RN\'s (no OCN\'s) and sometimes, one is a float nurse from another floor, one Nursing Assistant and one Bed & Bath employee to assist with evening care. There are two residents assigned to the unit for the day shift with a Fellow and one resident covering the evening shift. The residents that are assigned to cover this unit are second year residents and are very doubtful and insecure about their decision-making processes.

It is extremely difficult, frustrating and dangerous to the patients if the residents are not willing to give the RNs orders that need to be filled. Is this a result of their lack of experience? Could it be a result of lack of confidence in dealing with neutropenic and septic patients; or perhaps the lack of support from the physicians\' services they are under. The staffing is a mixed ethnicity as well as various levels of experience and education. The patient population is comprised of many different cultures, mostly from the surrounding area and local neighborhood. The variables of the demographics require cultural competency from all staff in order to provide safe and effective care with respect to the patients\' cultures, values and belief systems.

Analysis

Summary of Relevant Theories

There are many aspects of this case in which relevant models could offer insights. This analysis has identified two such theories. One deals with change management and leadership, and the other deals with cultural competency and training. It is clear that the department is having trouble adapting to change for a variety of reasons and looking at these high-level changes from a change management perspective could offer many insights Furthermore, that are also instances in the case that attest to the fact that there are issues with cultural barriers and one more tactical model that could help alleviate some of this friction would deal with cultural competency and fostering this competence in an organizational setting.

Change Management

The first model that was identified that could be easily applied to the case would be a change management plan. Healthcare organizations in the modern dynamic environment are expected to maintain flexibility while also increasing productivity to new levels which can put a strain on any organization. In order to maintain higher levels of productivity amidst these pressures, organizations must be able to adapt quickly to internal and external environmental pressures. Furthermore, not only must an individual be able to adapt to changes quickly, but they must also be able to perform on a team environment which takes interpersonal skills as well as a willingness to embrace collaboration.

If the organization does not have a change management plan, then many of the changes take place in a reactive capacity which can lead to resistance to change and a chaotic environment and seems to be the identifiable in the case study. When organizations are forced to change, and do not plan for the change, then the change process can be quite difficult as individuals and teams try to work out their new roles within the organization. However, when organizations take a more proactive approach to the change process and use evidence-based change management practices, then this can substantially help the organization process the changes successfully and in an efficient manner.

Planning for Change

Simply taking a proactive approach to change by planning can be one of the most relevant critical success factors in the organizational change process. A well thought out plan can put some organizations in a substantially better to position to make informed decisions about the types of issues they will encounter before the actually occur. For example, without a plan organizations are in a reactive state in trying to implement a change, and basically just make decisions as they go. By contrast, if a department takes a more proactive approach in the planning process, then they can frame the intended change process with the some of the best practices that models in the literature have identified. Three different models have been identified that can be used to help the department be better equipped in implementing the desired changes in their operational model that is needed.

Kotter\'s 8 Step Change Model

This a model takes the different approach than the previous model and assumes that successful change is more of a campaign that a static arrangement of various factors. In a way, it\'s a more complex model that is built upon the Lewin model, in the sense that Kotler\'s model considers the change process from the perspective of the organizational members and adds a more detailed account the steps in a proposed change. Since the employees are ultimately responsible for going through the change, making a comprehensive effort to give them all the tools, motivation, and support they need to endure the changes is the most salient aspect of change management. Once the employees are onboard with the change management plan, the implementation of the actual change is very easy (Green, 2007).

This model acknowledges and tries to overcome any behavioral objections to change that are held by the team and address them effectively in order to meet the needs of the changing environment. John Kotter and Dan Cohen identify \"The Eight Stages of Successful Large Scale Change\" in which leadership is an important aspect of change (Green, 2007). Leadership is one of the critical success factors and there are a variety of tools that leaders can use such as setting a vision which can help motivate the employees to make the needed changes within themselves, as well as in the organization. The eight steps in this model are:

1. Create and increase the urgency for change.

2. A team is built to work for the campaign on change

3. Create the vision for change.

4. Communicate the need for change.

5. Empower staff with the ability to change.

6. Create short-term goals.

7. Stay persistent.

8. Make the change permanent

The Kotter\'s 8 Step Change Model can be used in conjunction with other planning efforts. For example, this model could be used to plan the change, and also combined with the McKinsey model to fine tune the plan to account for the factors included in that model as well, since the model focuses more on a road map for change and not the actual obstacles that are present. However, one of the concepts that seems powerful within this model is that if you can enroll the organizational members in the overall vision of the change, then much of the work need will work itself out automatically and without the same level of friction that might be encountered otherwise.

This model also highlights the important of leadership throughout the process and leadership models could also be combined with Kotter\'s model. For example, transformational leadership focuses on a leader\'s ability to foster motivation in organizations and is argued to be among the most effective models among theories of leadership (Judge & Bono, 2000). It is especially relevant to change management because it focuses much of its attention on motivation. Transformational leaders are often described by their inspirational qualities that they project to their groups relative to motivating them to improve their own personal performances, or the group\'s performance in general. A transformation leader can stimulate a sense of motivation by setting challenging goals or expectations for example, which can motivate employees and persuade them to contribute more to the group (Bass, 1999).

Cultural Competency

The second model that seems most relevant to the case is the need for cultural competency training. Even if the organization has the best intentions of achieving patient satisfaction and patient outcomes, there can be many challenges and obstacles to these objectives that are present solely due to cultural differences. For example, the case indicates that there is a large amount of diversity in the internal organization, as well as the fact that they are also treating a diverse community. Any cultural differences that are present between the nursing staff and the patients makes treatment more difficult by inhibiting communications and making more difficult for building trust between the staff and the patients they serve.

Since cultural factors have been long recognized to be an important consideration in developing healthcare organizations, there have been various models that been constructed to help address challenges that are presented through cultural differences. One such model, the Campinha-Bacote\'s model of cultural competence in health care delivery, is defined as process of building Cultural Competence in the Delivery of Healthcare Services and is commonly remember by the mnemonic ASKED (awareness, skills, knowledge, encounters and desire) (Ingram, 2012). This model asserts that cultural competence and developing the needed skills relevant to overcome cultural barriers is ongoing process that essentially never ends because culture itself is continually evolving in many ways, and therefore integrating various cultural aspects into nursing must also be a continuous process that also never stops.

In order to build cultural competencies, the healthcare team must therefore continuously strive to improve their ability understand the cultural contexts of the patient and their environment (individual, family, community). To build such an awareness, the ongoing process involves the continual accumulation of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire (Ingram, 2012). These factors need to be continually reinforced among the staff and discussed regularly. Other models of cultural competence have also added that the process can be considered a nonlinear and dynamic and must be approached from a perspective of humility (Grote, 2008).

There are many different ways to train for cultural competencies. One meta-analysis looked at a wide range of different training evaluations of a number of training programs that were designed to improve the overall cultural competence of health professionals (Beach, et al., 2005). The study collected data from 1980 through June 2003 that represented interventions that were primarily designed to improve the cultural competence of health professionals and found thirty-four such studies that were compiled into one larger dataset. Analysis of the synthesized data revealed that there is significant evidence that cultural competence training can in fact improve the cultural competencies of health professionals (17 of 19 studies demonstrated a beneficial effect), as well as the attitudes and skills of health professionals (21 of 25 studies evaluating attitudes demonstrated a beneficial effect and 14 of 14 studies evaluating skills demonstrated a beneficial effect); furthermore, although patient satisfaction was typically higher, there was no evidence that cultural competencies actually improve patient adherence to a treatment plan (Beach, et al., 2005).

The cultural competencies, and the training programs associated with them, have been introduced in a range of healthcare environments and there have also been some best practices that have emerged. For example, there are at least five separate components of a cultural competency that been introduced to many baccalaureate of nursing programs consisting of different learning strategies, methods for evaluation, and recommendations for effective implementation for each component (Calvillo, et al., 2009). There have also been more hands-on approaches designed such as the community-based participatory research program that foster interactions with diverse community involvement which can also build cultural competencies quickly (Anderson, Calvillo, & Fongwa, 2007). However, given that the environment in the case was described as diverse and culturally complex, if the department is able to approach their roles with humility and possess the basic concepts of cultural competencies then it could also be an opportunity for them to continue their professional development.

Recommendations for Improving Organization

The first recommendation for the organization is to designate a leader to work with Kotter\'s change management model to implement the needed changes. It would be beneficial to have a leader with transformational leadership characteristics, if at all possible, to help the department through all the changes that are needed. The urgency for the changes could be easily highlighted and the department will have to designate a team to implement the changes. There seems to be a disconnect in staffing requirements and interest in the positions and therefore the team could work with HR to determine if there are any benefits that could be added to build more interest.

In step 5 of Kotter\'s model, the empower the staff step, it is recommended that the entire department be given cultural competencies training, in conjunction with any other training needed, to help them overcome their own differences as well as the differences in the patients that they will be working with. The leader will need to set some short-term goals to help manage the changes and some form of awards could be put in place to reward the team for meeting these milestones. Finally, it is recommended that there be a program for ongoing cultural competency training that is implemented into operations to ensure that the group continues building their skills in this critical success factor.