Managing identification and planning in change practice settings

¶ … Manage identification planning

This chapter discusses the management and planning of change process within the clinical setting. Change management plan is very critical to the success of any healthcare unit. Change may be threatening to organizations, however, successful implementation of changes is very crucial for the success of an health organization. Failing to make a change move could lead to the consistence of medical errors among the medical staff and this may damage the reputation of the organization. Typically, medical errors are among the serious issues that many medical institutions are facing, and these are among the setbacks to the implementation of quality healthcare delivery. (Mills, 2008). Identification of the critical issues that may hamper the quality healthcare delivery is very important to address the number of preventable medical errors. With analysis of the current system, several areas need to be changed before the hospital could become a vibrant organization.

Area that Needs Changing

Based on the analysis of the current system, there are areas that need changing within the hospital. First, there is need to make changes to induce learning within the system. Typically, the current system in the Hospital does facilitate effective learning among the member of the staff. There is lack of learning culture across the whole hospital. To meet the challenges posed by the rapid changes in the environment, an organization must implement effective learning culture to induce growth. Learning organization is an organization that must create and assimilate new knowledge to improve organizational development. (Singh, 2010).

Moreover, analysis of the current system within the hospital reveals that there is no standard approach to investigate serious incident. To cultivate an environment that promotes health and minimize risks, a hospital needs to promote the safety of well-being. To facilitate changes within the hospital setting, the Hospital needs to inculcate incident management. Typically, incident management is a part robust risk management that promotes quality and safety of patients. (NHS Foundation Trust.2011). Moreover, changes is also essential induce collaboration of other units to handle medical errors. Analysis of the current situation reveals that there is non-collaboration of the other units to handle medical errors. Increase in the occurrence of medical errors could jeopardize the integrity of the hospital, and this may reduce patients' patronage. To minimize the medical errors within the hospital, a health organization needs to formulate policy and procedures to prevent medical errors. Development of policy and procedure to involve multiple units within the hospital is essential to prevent medical errors. Thus, the hospital should collaborate with other units to prevent the medical errors. (American Society of Health-System Pharmacists 2011).

Further change that the hospital needs to implement is its method of record keeping. Currently, the hospital is still using the manual method recording. The use of free handwritten is still in use. The problem of using this method is that the handwritten and free text report was difficult to read and interpret. Moreover, there is lack of key data elements to aid the decision-making. In a modern healthcare environment, Electronic Heath Record systems are the foundation of high quality healthcare delivery. (National Health Service, 2011). To enhance quality healthcare delivery, the hospital should be ready to implement Electronic record systems to achieve effective data storage and retrieval. The hospital also needs to implement changes to develop staff knowledge. Analysis of the current system, there is no concrete program to develop staff knowledge. Kingston, Evans, Smith et al., (2004) argues that lack of knowledge constitutes incidents that lead to many medical errors. Ongoing education about what constitutes incidents is essential to enhance the knowledge of medical staff on the incident report.

The culture of blame is also rampant in the hospital. Culture of blame, if not prevented, it can create a setback to the growth of a clinical setting. Harber and Ball (2003) points out that a new era has come where a medical institution needs to move beyond the era of "blame game" to the culture of best practice to deliver high quality healthcare. The dissertation also identifies that there is no structured system to monitor quality. Prevention of future errors is also lacking, and this issue has led the healthcare staff to keep repeating the same errors. (University of South Wales, 2006). To improve the well-being of the patients, a medical institution should adopt a policy to prevent medical errors. Between 44,000 and 98,000 American dies yearly due to preventable medical errors. The occurrence of medical errors is also linked with lack of structured monitoring of quality within the hospital. (Vantage Professional Education, 2009) . The cumulative problems identified in the clinical environment are leading to the poor quality healthcare delivery. To accelerate the quality of healthcare delivery within the hospital, there is need to implement modern strategy of changes.

Strategy of Change

To improve the quality of medical services, the hospital must implement changes to fulfill the expectations of the stakeholders. The strategies to use in implementing changes should be both discontinuous and incremental in nature. Discontinuous changes are evolutionary or radical changes to enhance the quality of service. The incremental changes focus on the strategy to induce changes bit-by-bit to meet the changing environment. (Abrahamson, 2004). To enhance changes within the clinical settings, the hospital management should draw a vision that would become its guiding principle. The vision should focus on the improvement of health and well-being of adults and children. Moreover, the hospital should draw the mission to guide its operation. The mission is to deliver the quality health services to adult and children especially those requiring the specialist treatment. The vision and mission will be the guiding principles of the hospital. Meeting these objectives will require the integration of learning culture within the clinical environment. The strategy to meet this objective requires radical changes to inculcate learning culture within the organization. Typically, the success of any health institutions is its ability to create new knowledge. Since employees are considered critical assets of any organization, ability to create new knowledge for the workforce is very critical to enhance high performance within the hospital. (Gorman, and Panadit, 2007). The strategy to implement these changes is to introduce an education orientation to develop knowledge of the staff. (Kemp, Moerman, and Prieto, 2001). An education orientation is a powerful tool to educate medical staff about the hospital policies and procedures. Education orientation process is also used to evaluate the individual ability to perform a specific job.

To implement this change, the hospital should draw the policies and procedure that would guide the conduct of all staff with the organization. The education at orientation should also include topics such as:

Vision, mission and values guiding the hospital

Performance improvement program to enhance staff efficiencies.

Issues about environment of care

Patients safety and procedures

Description of key functions in the hospital

Job safety issues.

Education of use of specific health equipments.

Staff benefits.(Joint Commission on Accreditation of Healthcare Organizations, 2002).

"This strategy provides innovative learning and development approaches which enhances the accessibility and value of learning experiences. It is a rich mix of 'visionary' and 'stretch' objectives as well as many practical operational elements." (Darbey, Gregory, Dempsey, et al. 2009 P. 3).

As part of the program to initiate changes in the hospital, there is need to implement workforce learning and Development to strengthening the hospital's position as an excellent healthcare delivery. As part of learning and development program for the workforce, the hospital should support ongoing education with the use of case studies to highlight events related to medical issues.

Moule & Goodman (2008) argues that knowledge in the clinical setting could be drawn from multifaceted base. Learning could be derived from the experience gained in practice, and personal learning. Carper (1978) discusses four fundamental patterns of knowing: empirical, ethical, personal, and aesthetic. This can be used to acknowledge the importance of knowledge developed through personal, experience, understanding, and moral and ethical reasoning.

Carper's Fundamental Pattern of Knowing -- Empirical, Ethical Personal and Aesthetic

As being revealed in Fig 1, Carper's fundamental pattern of knowing is a useful tool to describe the importance of knowledge in the clinical practices. Ethics knowing in the clinical practice guides the conduct of nurses. Ethical knowing obliged the nursing practitioners to have the knowledge of ethical reasoning and social values. Ethical knowing is also to enhance greater understanding of health personnel on their obligation and responsibility. To inculcate the Carper's theory to enhance knowledge in the clinical setting, the hospital should impact the knowledge of the ethical codes and professional standard in the clinical settings.The strategic to induce changes will also be to inculcate the philosophy of Carper's personal knowing that involves the development of self-awareness through interpersonal relationship of medical staff. The openness, listening and reflection should be encouraged. Typically, personal knowing needs to be integrated with professional responsibilities to develop therapeutic use of staff and patients relationship.

The hospital should also impact the knowledge of aesthetic knowing to all medical staff. All staff should have greater understanding on the behavior of individual patient. This includes the ability to develop intuition and be able to respond to patients' needs with greater skills. Empirical knowing is to encourage the staff in the use of the empirical research to enhance the descriptions, explanations, and predictions in the clinical practice. The strategic for changes is to turn all Carper's fundamental pattern of knowing as a tool to impact knowledge. The hospital should make use of problem-based learning and instructional method to impact knowledge. There should be exchange of ideas between practicing professionals to encourage the development of professional skills and knowledge. To provide greater understanding on the strategy the hospital could employ to induce changes in the clinical settings, the paper examines the theories of Tacit, explicit, positivism and interpretivism in the application of knowledge management.

Fig 1: Carper's Fundamental Pattern of Knowing

Source: Behm, Comrie, Crane et al. (2007).

Tacit, Explicit, Positivism and Interpretivism

The theory of positivism and interpretivism has contributed to the development of the clinical practice. To gain knowledge, medical practitioners should apply the guideline and principles of the theory of positivism which emphasis the use of deductive approach. This approach involves testing the system to develop knowledge. Positivists employ the quantitative approach to answer research questions. (Burns and Grove, 2005). To gain knowledge through this approach, the health practitioner can make use of element of randomization. This is by randomly selecting number of patients for research. The use of interpretivism is also important to gain knowledge in the clinical setting. Unlike positivist scientific paradigms, the interpretivists make use qualitative approach to gain knowledge. In the medical practice, not all research questions could be answered through quantitative design; there are some research questions that can only be answered by qualitative approach. Thus, medical practitioner could answer some of research questions through interpretivist paradigm. Qualitative approach makes us to understand that knowledge could be gained by collecting data in the natural settings. Data collection will include interviews, focus group, and observations. Typically, qualitative method of data collection is also very suitable to analyze the views of the medical staff when a medical institution decides to introduce changes.

Tacit approach also explains method to develop knowledge in clinical practice. This involves using intuition in the application of healthcare delivery. Tacit knowledge is developed through experience gained during practice. Tacit approach helps the medical practitioners to understand the patient's needs. (Gunilla, Drew, Dahlberg, et al. 2002). "It should be acknowledged that intuition and tacit knowledge can inform the development of personal knowledge. Such knowledge may ultimately, therefore, form part of the knowledge that informs professional practice." (Moule & Goodman, 2008, P 19). However, in the environment where there is lack relevant information that could guide the medical practitioners during practice, the use of tacit approach to develop knowledge could be cumbersome. (Hek and Moule, 2006). Explicit knowledge is also advantageous in the clinical practice. Explicit knowledge is precise and formally articulated. This is developed through combinations of socialization, internalization and externalization. The use of explicit knowledge is advantageous for the communication of information in the clinical setting. (Dawes, Summerskill, Glasziou.et al. 2005).

Accumulation these knowledge will influence philosophy of care within nursing practice, and it will enhance a nurse ability to respect human dignity. (Lau, 2011).

Philosophy Care: To have a Respect for the Human Dignity

As being discussed in the previous section, the hospital needs to draw out a policy that will guide the nursing practitioners in their duties. Drawing out the Code of Conduct in the nursing practice is very important to respect human dignity. (Salerno, 2009). Respect of human dignity has become a centerpiece of modern medical practice. Ethically, it is mandatory for the nursing practitioners to have high regards for human dignity. Nurses should learn to have respect for patients. For example, the privacy of all patients should be respected at all times. When a nurse is administering injection for a patient, there is need to apply ethical approach. For example, a nurse should close the curtain to provide reasonable privacy for the patients when administering injection for a patient. Application of code ethics is very important for the promotion of healthcare delivery.

"The code of ethics is absolutely clear on the point that no nurse can act in way which comes with the sole intention of ending a patient's life, even if the motive is sympathy, kindness, or concern for the patient and his family"(Salerno, 2009, Chapter 2, American Nurses Association, 2001). Promoting ethical principles is very important to influence changes. Several theories of changes have argued that ethical changes within an organization could influence long-term success.

Theories of Changes

Change theories are very important in nursing practice to bring about planned changes. To bring about the planned changes, it is essential to recognize the problem and identify a solution to address the problem. There are various theories that can be used to address the problem in nursing practice. Choosing a right change theory to address the problem is very critical. Some of the change theories in nursing practice are Lewins, Lippit's and Gibb' theories. Lewin's Three-Step Change Theory is widely applied in nursing practice, and this involves three stages. Lewin model reveals that there are three forces that facilitates changes and which push employees to the desired position. (Kritsonis, 2005). The first step in Lewin's change process is unfreezing stage. Unfreezing is to motivate the participants in preparing for changes. In this process, the change is recognized and there is awareness on the need for changes. The second step of Lewin's theory in the process of change is movement. This is the stage where the changes are accepted and implemented. The last stage is refreezing. During this stage, the new change is made permanent. The application of Lewin's theory depends on the presence of the driving and resistance forces. Typically, the driving forces are driving employees in the direction of changes while the resistance forces are opposing the changes. While "Driving forces facilitate change because they push employees in the desired direction, restraining forces hinder change because they push employees in the opposite direction." (Kritsonis, 2005, P1).

To successfully implement Lewin's theory in the clinical settings, driving forces needs to dominate the resistance forces. ( Ngozi, 2011). The criticism of Lewin's theory is that there may be occasion when the whole employee may resist the new changes. When this occurs, the implementation of the changes may come to an halt.

Lippit's theory of change is the extension of Lewin's theory. The Lippit's model is based on bringing in the external changes and makes a plan to make the changes take effect. There are seven stages in the Lippit's theory. They are as follows:

Diagnose the problem

Assess the motivation for change

Assess the resources for change

Select the progressive change object

Choose the change agent's role

Maintain change

Terminate the helping relationships.

Lippit's theory is similar to Lewin's theory. The fist three stages of Lippit's theory correspond to Lewin's unfreezing stage, while the next two correspond to the moving stage. The last three is similar to the Lewin's refreezing stage. Since all the change theories take their root from Lewin's change theory, the dissertation uses the Lewin's theory to apply changes in the nursing practice. (Lippitt, R., Watson, J. And Westley, 1958).

Application of Lewin's Theory of Change

To apply the Lewin's theory in the nursing practice, it is essential to analyze the driving and resistance forces before introducing change in clinical organization. To introduce changes within the clinical setting, the health organization needs to create awareness of the proposed changes in the minds of workers. Typically, the health organization should plan the Lewin's freezing stage carefully for the changes to be accepted by the workforce. The first move is to create awareness of changes. This strategy is to communicate the proposed changes to the workers and educate workers how the changes will affect the whole nursing practice, and patients. To use of emphasize of reason and knowledge is very important at this stage. Many people will comply once it is realized that the proposed changes will serve their rational self-interest.

The importance of the proposed changes needs to be accepted by the practicing nurses before being implemented. Several strategies could be employed to apply Lewin's unfreezing stage. Organization could make use of personal contact, and distribute the information through the handbills. The use of case studies to demonstrate the importance of the changes could also be used to educate nurses on the importance of the proposed changes. These strategies are to reinforce the mind of the staff on the importance of the proposed changes. The use of leaders with excellence communication skills is also very critical in the change process. A leader could be chosen to educate the co-workers on the importance of the proposed changes. To introduce the awareness of the proposed changes, the organization needs to hold several meetings with staff to prepare their mind for the support of the proposed changes.

The next stage in the changes process is moving. The health organization needs to draw the implementation plan for the changes process. It is essential to understand that this stage resistance tends to manifest in the change process. Some nurses might be slightly negative and radical to the changes. (Lee, Mill, and Bausell, 2008). Thus, it is not advisable to apply radical changes in the implementation process. An organization makes choose between three and six months for the implementation to take effect. A health organization needs to evaluate the acceptance of the changes during the implementation process. The technique is to conduct interview or survey to sample the opinion of the nurses. The importance of interview and survey will enhance the greater understanding on the extent proposed changes are accepted within the clinical settings. Opinion sampling will also make the organization to understand the percentage of the medical staff resisting or supporting the changes. (Bowman and Asch, 1995. Clair, Trussel 1992).

The last stage is the refreezing. This is the stage that changes have become norm within the organization. At this stage, all health staff has recognized the changes. However, there could be still occasional resistance to changes. Regular staff meeting needs to be conducted to sample the opinion of staff towards the changes. The staff meeting will assist in the readjustment of the situation if there is need for it. ( Kaminskik, 2011).However, there are occasions where there could be difficulties in the changing process; the next section discusses method to the difficulties in the change process.

Method to handle difficulties in the Change Process.

Managing changes is the process involves acquiring skills to manage conflicting issues that could arise during the change process. One of method to manage resistance during the change process is to apply the force field analysis theory to make the resistance force to comply with changes. Typically, the use power is very essential to make all staff to comply with the changes. There is need to select leaders from nursing staff who will serve as a change agent. The chosen leader or change agent should be empowered with force to empower other to comply with the changes.

"Change Agent is someone who deliberately tries to bring about a change or innovation, often associated with facilitating change in an organization or institution. To some degree, change always involves the exercise of power, politics, and interpersonal influence. It is critical to understand the existing power structure when change is being contemplated. A change agent must understand the social, organizational, and political identities and interests of those involved; must focus on what really matters; assess the agenda of all involved parties; and plan for action." (Kaminski, 2011, P 8).

The use of change agent must have authority to order the subordinates to comply with changes. The use of regulations and law is also very essential to back the proposed changes so that all staff could accept it.

Conclusion

The dissertation examines the strategy that could be employed to manage change within a hospital set up. The paper reveals that managing changes to bring about the desired results is a daunting task. To manage change that could be beneficial to the whole organization, the paper makes use of Lewin's theory of change to analyze the strategy the hospital could use to manage change. The paper identifies several problems that the hospital is having. The theory Tacit, Positivism and Interpretivism are used to explain the method a hospital could use to develop knowledge within the clinical environment.