Leadership for Effective Positive Change in Nursing

Opening Position

Organizations indeed are “living social organisms” and that change, without intentional planning and reinforcement, will not last. In addition, if the change is not managed intentionally over the intermediate and long terms, the old ways begin to creep back in. Change has both situational and psychological aspects and ignoring either will result in a non-sustainable situation, wherein the organization is in a constant cycle of change implementation without achieving desired results. Change is constant and a complex process that requires careful planning and implementation of the proposed way of conducting activities. As such, without such deliberate planning, any form of change would not last because people are likely to fall back to their old behaviors.

Effective change management requires the unfreezing of old behaviors before introducing new ones and ultimately refreezing them. This process allows those involved in the change process to implement it, adapt, and evolve by working towards shared goals and vision. Consequently, it is important to state clearly why change is needed in the first place and communicate effectively about the set objectives and how the involved stakeholders would be affected. Change management has to focus on both the psychological and situational aspects to ensure sustainability and the achievement of the desired outcomes. This paper is a critical analysis of a change process that I witnessed at one point during my nursing practice.

Practice Example

During my nursing career, I have experienced several change processes, but one, in particular, has remained with me for a long time. I was one of many employees in a large hospital where I was involved in a change process. As part of improving patient outcomes, specifically safety, the charge nurse was tasked with coming up with a proposal on how to prevent medication errors among bedside nurses. At the time, I was a bedside nurse and thus I was part of the team that was to implement the proposed change. We were supposed to adopt standardized checklists as part of the handover process at the end of our shifts.

The objective of this change process was to prevent medication errors by ensuring that nurses had the right information concerning different patients. Initially, nurses completing their shifts would simply write down any information that they deemed necessary and place it in a file under the patient’s bed. However, this system was vulnerable to mistakes, as some nurses would omit important information due to various reasons including fatigue caused by excess workloads. The standardized checklists would allow nurses to capture all the relevant information thus ensuring consistency and avoiding gaps that could lead to medication errors.

To implement the change process, the involved nurse leader communicated to all bedside nurses through a circular indicating the need for the change process. We were all invited to a face-to-face meeting in which more information concerning the proposed change was delivered. Every person in attendance was allowed to ask questions concerning the change process including why it was important and how it would affect the implementers. The major stakeholders who attended this meeting were the chief nursing officer, the nurse leader, and all beside nurses in the hospital.

The nurse leader took time to explain the importance of the proposed change process and how it would benefit patients by ensuring their safety through the prevention of medication errors. In the end, we were given 7 days to process the information, raise further questions, and add important points that we felt should be included because we were the change agents in this process. Communication channels were opened for constant and effective communication among the team members. Additionally, we were grouped into small teams and each was supposed to attend training on how to use standardized checklists during handovers twice a week.

After the training and with surety all change agents were convinced about the need for change, we started the implementation process whereby we would use standardized checklists during handover at the end of every shift. It took over a month to fully implement the process after which it became the hospital’s standard of operation when changing shifts for bedside nurses. The process had its share of challenges but they were addressed successfully as they occurred.

I think the change process was successful in many ways and within six months, an evaluation was conducted and it showed that medication errors had reduced drastically. These positive results explain why this change process has stayed in my mind for a long time because I witnessed firsthand how patient safety could improve by making small adjustments in the way nurses operate.

Critical Analysis

The change indicated in the case above was necessary because it would prevent medication errors and improve care outcomes including patient outcomes. A study by Gholipour et al. [1] found that wrong patient information is one of the leading causes of medication errors in nursing. In the hospital where I worked, cases of medication errors among bedside nurses were many and they were mainly associated with the lack of proper documentation of patient information. Therefore, when an incoming nurse received the wrong information or data that lacked some elements, the chances of giving the wrong medication or wrong dosage would increase significantly.

As such, a change was necessary to adopt standardized checklists that would allow bedside nurses to document the appropriate patient information during their shifts. With such accurate information, nurses would make the right decisions when administering drugs to their patients [2]. Ultimately, the change process was a success as an evaluation report conducted six months later showed that cases of medication errors had dropped significantly. As such, care outcomes improved with patient safety topping the list.

The Kurt Lewin Change Theory was used to guide the said change process. This is one of the widely used change models in nursing and other professional fields. The Lewin model has three phases including unfreezing, change, and refreezing [3]. These three stages underline the three major attributes associated with this model, which are driving forces, equilibrium, and restraining forces. The first stage, the unfreezing phase, involves preparing the involved stakeholders to accept the proposed change, specifically by abandoning old mindsets.

During this phase, we were called for a meeting whereby the nurse leader extensively discussed the importance of adopting standardized checklists during shift handover among bedside nurses in the hospital. He emphasized the need for patient-centered care whereby the primary focus of any healthcare delivery system should be on the patients by meeting their needs through quality care provision. We were also trained on how to use standardized checklists, which is part of the unfreezing phase. In other words, this phase requires the involved stakeholders to unfreeze their old mindsets and habits to create space for the adoption of new ones in tandem with the proposed changes.

In the second phase where the change itself occurs, the proposed change is implemented, which explains why this stage is also referred to as the “movement” stage [4]. This stage involves the meticulous implementation of the various aspects of the proposed change. As such, effective communication and teamwork are central aspects of this stage. In our case, we were required to start using standardized checklists during handovers at the end of every shift.

All change agents were supposed to write a brief report the following day indicating what went well or wrong during the handover. We were divided into small teams with each having a team leader and we would meet after every two days to assess whether the implementation process was going according to the plan. Any changes would be communicated to the team leader who would then pass the same information to the nurse leader in charge of the change process. This process took over a month after which a meeting was convened to assess the progress so far before moving to the final stage of the change process.

In the third and last stage of the Kurt Lewin change process (refreezing), the involved stakeholders move to a more stable state by shifting from the transition phase. At this stage, a state of equilibrium is said to have been achieved because the new way of conducting activities is normalized and adopted as part of the protocols of conducting activities [5]. In our case, this phase was marked by the widespread adoption of standardized checklists during shift handover, which became the standard operating procedure in the hospital. Any new nurse would be trained on how to use the same checklists and it ultimately became part of the hospital’s organizational culture.

The Lewin change model was appropriate for the planned change. This change theory operates from the premise that people are likely to resist change and resort to their old mindsets due to the uncertainty that surrounds the change process. Therefore, Lewin simplified the change process to achieve optimum results and success by breaking down this model into three phases as discussed earlier. I think this model was the best suited for the proposed change process in our case because it is easy to implement, all stakeholders were allowed to contribute their ideas, and its gradual approach allowed change agents to gain momentum, thus ultimately creating lasting change.

The majority of the bedside nurses in the hospital were excited to implement the proposed changes because they understood the importance of patient safety. Various other change models could have been used in this case, but each has inherent flaws that could have affected the long-term success of the process. Therefore, I believe that the Lewin change model was the most appropriate for the implementation of this change process.

The potential barriers to this change process were mainly resistance from change agents and other stakeholders, which is a major challenge in any change process [6]. Some bedside nurses claimed that filling the standardized checklists at the end of their shift would consume a lot of their time. Additionally, some change agents argued that they had never made a medication error and thus they could not understand the value created by the proposed change. However, the nurse leader addressed these concerns comprehensively by noting that the fact that a mistake has not happened in the past does not mean that it would not happen in the future.

Specifically, the nurse leader spent enough time explaining the importance of patient safety as part of the hospital’s organizational culture. Specifically, he noted that a single incidence of medication error could be costly to all the stakeholders including the patient, the involved nurse, and the hospital at large. In the end, we all agreed that a change was needed and thus we decided to support the process. One of the enablers of the change process is effective leadership [7, 8] and our nurse leader demonstrated this capability by educating us on the importance and need to have the proposed change. Additionally, effective communication as an enabler played a central role in the success of this process.

The nurse leader and the hospital’s management created room to address any conflict that would arise. For instance, from the beginning, the leader stated categorically that anyone was allowed to raise questions and add input to the proposals presented during the first meeting. It was made clear that no one would be victimized for having a contrary opinion to what was being proposed. Effective and open communication is a widely applied strategy to conflict management [8] and the nurse leader in charge of the change process used this approach appropriately.

If the change did not happen, medication errors would have continued to be a major problem affecting care quality and patient outcomes. A study by Alomari et al. [9] showed that implementing interventions in a pediatric ward reduced medication errors by 56.9 percent. This information shows that intervention measures play a central role in preventing or reducing such errors. As such, if the proposed change were not implemented, the situation would not have changed. Bedside nurses would have continued to have poor shift handover practices contributing significantly to medication errors and poor care outcomes.

Reference List

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