Planning, implementation, and evaluation of proposed organizational change

Nursing

Plan and implement and evaluate the proposed change to a process of patient care

IC/PROBLEM: The purpose of this study was to demonstrate ways to include more 'stakeholders' in the care of patients in-patient environments.

Grounded theory (Forchuk, Mound and Yama*****a, 2005) was the method of choice. Interviews with nurses, nurse-managers, DONs, patients and families will be conducted in several regional hospitals sharing essentially the same population base, that is, with similar ethnic and racial constituencies. The literature will also be searched for information that can help in designing a program.

Moving care from a top-down process to one that involved all stakeholders from physician to patient, is helpful in building interest in, commitment to and behavioral changes regarding patient self-care in post-surgical periods, at least regarding the interplay between maxillofacial surgery and orthodontics in order to produce the best patient result.

CONCLUSIONS: Making the transfer of care information more interactive than informative and gaining patient 'buy in' is essential to moving the patient toward the best possible outcome.

Search terms: patient commitment, compliance, behavioral change

Introduction

In former times, patients regarded doctors, and to some extent, nurses as infallible providers of care that would result in cure or at least improvement. However, this belief has been eroded because of the vagaries of managed care (in which an administrator somewhere is the unseen arbiter of whether a patient receives excellent, mediocre, execrable, or no care at all). It has been eroded because of stunning lawsuits, that have, at the same time, driven up medical costs in order to both pay for the mounting need for insurance and for the extensive testing that is believed to protect medical personnel from lawsuits.

However, it stands to reason that any patient care in which the patient the patient's family are intimately involved would both provide greater protection from eventual lawsuits, and assist the patient in achieving the best possible result from whatever treatment is prescribed or suggested from a list of alternatives and discussed.

In fact, Young and Klingle investigated this possibility in relation to increasing patient commitment to medical decisions and increasing patient satisfaction. Their work "supported the claim patient participation is higher for Mainland American patients than Asian-American patients. The justification for cultural differences, however, was not supported" (1996, p. 29). With that information to begin, it is logical to conclude that if the Asian population, with a completely different culture than the mainstream American/Canadian lifestyle paradigm, responded substantially similarly to the mainstream culture patients, then it is likely that patients form some, most or even all other cultures will also be able to be influenced to participate in their own care in similar ways, thus providing better outcomes and potentially reducing the possibility of lawsuits due to patient care issues.

Literature Review

Young and Klingle (1996) approached the patient care process from the doctor's point-of-view, as did Gross, who said, "Knowing what to do and how to do it in no way insures [sic] cooperation" (Gross, 1987, p. 10). Young and Klingle (1996) also noted that care sometimes consists of transmitting to the patient the need for complying with often-complicated long-term lifestyle changes that will bring about benefits long-term, but may not even be apparent to the patient in the short and medium terms. The Young and Klingle solution is to ensure that the physician's communication with the patient is successful. However, the research done to date into what constitutes successful -- that is, effective -- communication in health settings suggests that doctors may not be the best delivery vector this important aspect of the patient care process.

In fact, involving the nursing staff in any discussion between physician and patient regarding the patient's own responsibility for care is likely to be more effective. According to several researchers, among them "Greenwald & Albert, 1968; Janis & King, 1954, and; Slamecka & Graf, 1978, actively constructing arguments and taking stands in front of the intended target of behavioral change lead to better recall; also helpful is using a better argument. All of those researchers also noted that taking a stand is likely to enhance recall far better than simply listening to arguments delivered by an external source. In other words, they think a 'drama' concerning the medical issue/patient care protocol at hand is far more valuable than having even the most famous, respected, honored physician simply 'talk at' the patient. Indeed, one could argue that one could employ a Nobel prizewinning researcher to do that, and the patient would be more likely to recall that he or she had talked with a Nobel laureate than anything at all about their care.

In fact, while creating awe in a patient might be conducive to stressing the gravity of one condition or another, Hoffman, Burke & Maier (1970) found, in their group communications research, that participative decision-making leads to greater acceptance of solutions and greater commitment to implementing them. A corollary investigated by Ballard-Reisch in 1990, and by Hoffman as long ago as 1979, is that individuals who are committed to a course of action (as opposed to, for example, simply being interested in it or entertained by it) are more likely to carry out the required behavior.

Young and Klingle (1996) found that those "who actively participate in the process develop or strengthen attitudes related to their communication behaviors (e.g., saying that one wants a particular treatment regimen will strengthen one's attitude toward that treatment regimen)" (p. 33).

Fazio & Zanna (1981) fund that active participation will, in most cases, lead to commitment to whatever action was communicated in the interactive encounter; attitudes, they also noted, guide future behavior, so that creating attitudes that enhance that probability are desirable. Young and Klingle (1996) note that "health communication scholars have argued that patients who participate in the medical interview will be more committed to medical decisions and more likely to carry out those decisions than those who fail to actively participate" (p. 33). They noted tat commitment to a decision does provide an indication that the individual is at least willing to carry out whatever measures have been asked of her. In addition, however, there must be present "volitional control" (Kim and Hunter, 1993b); if the patient does not have the authority, means or other conditions to perform the behavior, any amount of intention and agreement will be meaningless.

Davis (1968) and Himmelhoch (1980) both noted that patient satisfaction is linked to meeting patient expectations. Thus, the patient expectations must be constructed on a logical and supportable basis. This opens another area of inquiry to determine whether shifting the burden for patient self-care compliance from the physician to a team consisting of physician/nurse/patient, is viable.

Research question:

Is it possible to transfer responsibility for patient cooperation/compliance with needed patient behaviors to nursing staff from physicians, and, if so, what must the nurse know to accomplish transfer of information and to obtain compliance from the patient?

Steps for implementing change

While it is not possible to transfer all physician information to nursing staff, it is likely that some behavioral changes will be accepted best through the sort of 'confrontational' drama described earlier. Therefore, in order to test the hypothesis, a single aspect of patient care will be chosen (for example, 24/7 wear of orthodontic maxillary headgear post- mandibular surgery).

Using this as an example, the first aim of the transfer of knowledge is to ensure that the patient is aware of the need for wearing the appliance post-surgically. The patient is likely to be uncomfortable with the surgery and with any wiring of the jaws. Adding to this the application of the maxillary headgear might be rejected.

Ordinarily, the oral-maxillofacial surgeon will explain the importance to the patient of returning to the orthodontist post-surgery for replacement of the maxillary headgear. While this may be issued as a stringent warning that the work on the upper jaw and dentition must proceed as the healing of the lower jaw progresses, patients may be disinclined to follow these instructions due to pain and discomfort and appearance. Moreover, the patient has only a short time in the medical facility post-surgery, so that the staff has little time to transfer knowledge to the patient.

In the new regime, while it is the province of the orthodontist to monitor the patient's headgear use, and of the surgeon/staff to monitor healing of the osteotomy, the headgear wear will be included as a part of the post-surgical follow-up of the surgeon/nursing staff.

A baseline of compliance will be constructed by accessing the records of orthodontists referring for surgery concerning their patients' compliance with headgear use.

Assuming that there will have been significant non-compliance, a target for increased compliance via the new method of transferring information and gaining behavioral change will be constructed.

The change in nursing staff procedures will be:

When the surgeon speaks with the patient post-surgery, the nurse will adopt one of three postures.

He or she will simply echo the physician's warnings.

He or she will illustrate the importance of compliance with a dramatic story of how non-compliance negatively affected Patient A.

He or she will literally take issue with the physician and issue and even sterner and more emotional warning concerning why compliance is essential.

Before the patient is released, the nurse will once again speak with the patient and ask, on a scale of ten, how important do they think it is to wear the appliance post-surgically. The nurse will also ask how likely the patient himself or herself thinks it is that compliance will be virtually 100%. The nurse will ascertain that the patient is competent to apply the device, removing it only for cleaning the teeth and the appliance, and that there are no other factors in the patient's home/work environment that would preclude compliance.

The nurse will then personally assess the likelihood she ascribes to the patient's 100% compliance.

When the patient is seen by the surgeon for his or her first follow-up visit, the same questions will be asked/answered. This will be true at each follow-up visit, no matter how many there are, and also at the end of the healing/follow-up period.

In addition, at the end of this period, the nurse will access information from the orthodontist regarding:

What the patient told the orthodontist regarding the patient's compliance.

What the orthodontist has concluded medically that the patient did about compliance (i.e., if there was non-compliance to a great extent, it should be revealed in the less acceptable outcome of the surgery.)

In notating the outcomes, National Quality Measures Clearinghouse Convention 3 will be used. That convention looks like this:

An additional area of study will be that of adverse effects. These will be tabulated separately, and matched against a control group that has not gotten the nursing patient care originally, nor the follow-up.

Patients in the study will be asked about negative outcomes and will also be asked to determine whether they thought the outcome was due to their own non-compliance, or other reasons. If non-compliance is ascribed to 'other reasons,' the patient's orthodontist will be queried to see if this is an accurate assessment by the patient. If it is, the patient will be eliminated from the study. If the orthodontist believes that the noncompliance caused a problem, the patient's information will be tabulated.

It is not possible to ascertain whether compliance made a difference to the outcome of the surgery/orthodontic treatment per se; it is only possible to ascertain whether shifting the burden of information regarding patient self-care and patient follow up in that self-care improved under the new process. Therefore, a control group will be needed that is not provided with the physician/nurse 'drama' to reinforce the need for compliance. This group will be asked the same questions at before discharge, and again when he or she is released from the surgeon's care.