Using Force Field Analysis in Nursing

Change Implementation in Healthcare Bringing quality improvement processes to nursing practices invariably means that nursing leaders must give considerable attention to the management of change. Resistance to change is an integral aspect of any quality improvement effort. Sometimes the resistance stems from fear or the inability to see how things can improve. When patients present challenging behavior problems, staff may naturally be concerned for their own safety and be worried that the challenging behaviors are getting in the way of providing the best possible nursing care.

This paper examines the implementation of a change process for addressing challenging behavior in patients within the framework of Kurt Lewin's change management theory (Sare and Ogilvie, 2009). Veterans with cognitive problems from memory loss and dementia were regularly exhibiting the hitting, kicking, biting, yelling, spitting, repetitious questioning of staff, and other impulsive aggressive behaviors. Staff began a series of Challenging Behavior Meetings twice a month to discuss ways of dealing with Veterans who exhibited this type of behavior.

The purpose of the behavior-focused meetings was to establish a menu of responses that staff could use when dealing with challenging behaviors ("Behavior Chain," 2005; "eCaring," 2012). While there was general understanding among the staff that any behavior response system needed to be flexible, there was also general appreciation for the need for a consistent system that would not be perceived as random and unanticipated by the Veterans ("Behavior Chain," 2005; "eCaring," 2012).

Certainly the cognitive processing difficulties of the patients did not enable them to make a great deal of sense out of staff responses to their problem behaviors, but there was an overarching desire by staff not to add chaos to the Veterans' already disrupted lives by responding in ways that seemed capricious ("Behavior Chain," 2005; "eCaring," 2012). Lewin argued that, "group life is never without change, merely differences in the amount and type of change exist" (1947, p. 13).

Levin's theory about change in social groups and his theory of change management provide a framework for considering the processes in which the staff participated in their efforts to provide good nursing care when faced with the challenging behaviors of the Veterans. As staff considered various ways to approach this situation, a paramount concern surfaced: establishment and maintenance of a care environment that would be safe for the Veterans and safe for staff ("Keeping Patients Safe," 2004).

Lewin's Force Field Analysis model encompasses three phases that groups go through when faced with change: Unfreezing, moving, and freezing or refreezing. The unfreezing stage lays the groundwork for the change participants to understand the difficulties associated with the problem of interest (Jones, 2012). The primary tasks of the unfreezing stage are to develop strategies to strengthen the forces driving the proposed changes and to weaken or reduce the forces that restrain the proposed change (Jones, 2012).

Through the unfreezing phase, the key actors in the situation gather to talk over ideas and establish lists of the driving and static forces that have the potential to impact their proposed change project (Jones, 2012). The nursing staff addressing the Veterans' challenging behaviors developed the idea for the Challenging Behaviors Meeting in their early discussions of the problem. And even though they were not using Lewin's framework in a deliberate and transparent manner, they did collectively identify many of the facilitating and constraining variables in their proposed plan.

In this way, the nursing staff progressed through an unfreezing phase (Jones, 2012). The moving phase of Levin's Force Field Analysis is the period when change actually takes place, and when implementation of the plan occurs (Jones, 2012).

Following the round table discussions by staff in the unfreezing stage, the proposed regular meetings were given an actual name (Challenging Behaviors Meetings), and the purpose of the meetings was clearly established: to bring about change in the manner and type of responses that nursing staff would utilize in the face of challenging behaviors by the Veterans (Jones, 2012). During this moving stage, staff also recognized that they could use additional information or access to expertise with regard to addressing the challenging behaviors of their patients.

They elected to search for pertinent resources and research about providing nursing care to patients with dementia and challenging behavior ("Behavior Chain," 2005; "eCaring," 2012). The staff took turns providing additional information during the first 15 minutes of the Challenging Behavior Meetings. This information could entail reading an abstract and summary of pertinent research or watching a brief instructional video.

The main effect of this infusion of information was that staff learned new strategies to try out with the Veterans as they worked to create a consistent menu of effective, dignified, and positive responses to the challenging behavior faced by nursing staff ("Behavior Chain," 2005; "eCaring," 2012). The refreezing phase of Lewin's theory is the time when the change practice has become institutionalized or is stable and undergoing evaluation. For the nursing staff attending the Challenging Behaviors Meetings, the brainstorming and testing of ideas had generated a set of reliable responses to.