Introduction
It is said that in this world, change is the only permanent thing. Indeed, changes in the nursing profession and health care industry are inevitable as a result of external and internal catalysts. Policy reforms occur because of social, economic and political pressures. Knowledge is created every day, technology evolves at a fast pace, and consumer demands change. Organisations must respond effectively by modifying their strategic goals, structures, systems, processes, and culture (Anderson & Ackerman-Anderson, 2001). As a result, the professional roles of nurses expand, clinical practices improve, the work environment benefits from redesign, and patients receive better care. For this reason, change for the better must be welcomed.
The success and sustainability of change relies on the quality of its management. Instituting change entails the effective use of leadership, management, motivation, communication, goal-setting, planning, implementing, monitoring, and evaluating skills (Borkowski, 2005). It also requires the change manager to address issues of resistance, power, conflict, and teamwork. Amongst the nursing staff, an outcome must be the adoption of new behaviors compatible with structural changes. Change management, like any other competency, improves with practice (Stevens, 2013). Hence, it is imperative that nurse managers reflect on their practice to generate learning insights useful in future change projects.
Reflection is done to “work out what is already known and add new information with the result of drawing out knowledge, new meaning, and a higher level of understanding” (Patterson & Chapman, 2013, p. 133). It means challenging one’s own understanding, attitudes, and behaviours to discover personal biases. In so doing, the nurse attains greater awareness of who he or she is and is able to engage in self-criticism that engenders openness to new ways of thinking and doing. Reflection also assists in bridging theory and practice as the nurse refers to literature in evaluating his or her change management experience. This critical thinking exercise is a reflection on change that was implemented in the workplace. It provides a description of the reflection model selected and the change project. It also outlines key learning insights from the different aspects of the change management process.
Reflection Model
A model is a framework that guides an activity. To structure the reflective process, this student chose Gibb’s reflective cycle. It is based on Kolb’s experiential learning that starts with breaking down a concrete experience into its different parts (Patterson & Chapman, 2013). This is followed by reflection to analyse feelings and establish links with previous knowledge and experiences. Abstract conceptualisation occurs next wherein the professional consults the literature and colleagues to reappraise the experience and change ways of thinking (Patterson & Chapman, 2013). The last stage is active experimentation that entails an application of new solutions, approaches, or theories learned. Experimentation then triggers another cycle of learning and implies that this is a continuous process.
Gibb’s reflective cycle expands Kolb’s learning cycle to provide a more detailed framework for investigation and analysis (Patterson & Chapman, 2013). Reflection begins by describing what happened and exploring thoughts and feelings related to the experience. An evaluation is aimed at discovering the positive aspects of what happened and the challenges encountered. During analysis, the nurse attempts to make sense of the experience and appreciate its impact on professional practice. The conclusion involves exploring the literature and consulting peers to achieve a better understanding of what transpired including alternative ways of doing things (Patterson & Chapman, 2013). The last phase is developing an action plan delineating the nurse’s options when faced with a similar situation. The reflection below follows the six steps of this reflective cycle.
Description of the Change Project
The setting of change was a perioperative unit. In light of a nursing shortage, one approach to help resolve the problem was to develop a more efficient use of human resources. The status quo of staffing was that nurses were assigned to only one specialty during their employment. As a consequence, a nurse will gain competence, proficiency, and eventually expertise in orthopaedics, urology, or general surgery whichever specialty he or she is assigned to. It was determined that during a shortage in one specialty, nurses from other specialties were called on or floated to augment the staff. However, the skill level of the float nurse was typically wanting considering the lack of experience in a different specialty. Thus, whilst this practice resolved a staffing shortage, it posed a threat to patient safety and the quality of perioperative care.
A training needs assessment of all nursing staff was done to validate the above observation. The results highlighted the necessity to broaden the individual nurses’ skills. The best strategy to achieve this was to create new specialty teams through staffing that involved the rotation of nurses through different specialties. Therefore, nurses who worked in orthopaedics would also experience working in urology or general surgery. Initially, and as was expected, some of the staff were not keen on and lacked the motivation for practicing in another specialty. Resistance was noted most among scrub and instrument nurses in general surgery. A strategy used to address the issue was to conduct a survey of the nurses’ preferences of specialty.
Subsequently, meetings were held with senior nurses to assess the competencies of junior nurses who needed training and support the most, and brainstorm the optimum staffing strategy to be used. The meetings also established the objectives for the change and the process and outcome measures used to determine the success of the project. Further, consultations were opportunities to anticipate problems and possible solutions. In addition, meetings were held with junior nurses to discuss the need for a change in staffing and elicit their input on the project. During the meetings, majority of the perioperative nursing staff had positive views about the change. The change project was implemented and a feedback survey from the nursing staff is scheduled after three months for outcomes assessment.
Thoughts and Feelings Regarding the Experience
This student was convinced of the need for the change and the effectiveness of the strategy chosen to improve the unit situation. Although it meant going beyond our comfort zone, and this was the major source of apprehension, the rationale combined with support from leadership elicited buy-in. Whilst there were unexpected glitches, the experience had been largely positive. It engendered openness to change, learning, and professional growth. It was also empowering for the staff to have been consulted during the development of the project. It created the feeling of being part of one experience together and everyone had an important role to play in reaching a common goal. Personally, the experience was fulfilling and increased this student’s satisfaction as an employee.
Evaluation and Analysis
There were more positive than negative aspects of the change. The change was based on a sound analysis of needs and various data were presented to support it. First, the actual staffing in the unit was below the ideal nurse-to-patient ratio, but the organisation did not have the resources to hire additional nurses. Second, our current performance indicators showed that still more work needed to be done to reduce adverse events. Third, nurses who experienced being floated did acknowledge that they encountered difficulties. Fourth, the training needs assessment showed that nurses had minimal knowledge of work in specialties outside their own and expanding skills through training constitutes professional development. The change was also linked to the organisation’s mission of providing excellent care and its strategic goal of improving human resource capabilities. For these reasons, the project is backed by evidence.
Another positive aspect was the use of democratic leadership. The change was not planned or implemented through coercion. The project lead treated the staff with respect, actively solicited their views and preferences, listened to them, and kept communication lines open. There was transparency during the process and buy-in was elicited from majority of the nurses before implementation, partly through the championing efforts of senior nurses. In order to convince the nurses who remained reluctant and solidify buy-in, a pilot was conducted before full implementation. Moreover, the process was participative. Getting input from the nurses was not a token gesture. Rather, suggestions were integrated in the plan and for this reason the staff members were able to influence the project objectives.
As primary stakeholders, they also had the opportunity to influence major decisions such as when implementation should commence, how the staffing change and training can be best accomplished, and what policies need to be put in place. For instance, the staff voiced their concern about the outcome of surgical procedures if majority of nurses new to the specialty will be working in the operating theatres. Various schemes were suggested and it was agreed upon that the change will be gradual and should take into consideration the capacity of senior staff and the safety of patients. With regard to the training, they suggested that it should incorporate lectures on technologies, instruments, and best practices unique to each specialty. The staff also requested coaching from senior nurses. In addition, they requested that the policy should consider nurse preference of specialty as one criterion in staffing, but that no one must be exempted from rotation between different specialties.
The participative nature of the project further permitted direct-care nurses to learn about how problems and needs can be resolved through change, as well as how change is conceptualised, planned, implemented, and evaluated. The experience then becomes part of the organisation’s history that the staff can refer to in order to make sense of future change projects. It is also very positive that management was supportive of the change. The chief nursing officer attended several of the meetings and situated the unit’s initiative in the context of what other departments were also doing to cope with staffing shortages and other issues. She gave encouragement for us to pursue the project objectives and indicated interest in knowing the outcomes.
There were some challenges faced during planning and initial implementation. Some surgeons were used to working with familiar nurses and were uncomfortable working with new ones. The observation underscored the need to coordinate the change with other disciplines involved in providing perioperative treatment and care. Another issue was the unit-based educator’s assigning second priority to the training component of the change project in favour of finishing improvements on new nurses’ orientation modules. As such, the training plan and materials for the project were delayed and slowed down the momentum. There was miscommunication with regard to the nurse educator’s workload and capacity. The incident would have been prevented if she was invited to the meeting wherein the training was discussed with the staff to prevent duplication in efforts of relaying the minutes to her. It also became apparent during initial implementation that a few senior nurses tasked with coaching were better at it than others. The need to standardise the coaching process was not anticipated early on. The issue led to the formation of daily coach huddles intended for the sharing of knowledge and effective practices.
In making sense of the situation, there were factors that contributed to the success and challenges of planning and initial implementation. An organisational culture that values human resource or talent development stimulated change projects wherein at least one objective must involve personal and professional growth for the staff. The new management regarded employees as people who generate value and they must be given the tools, resources and support to solve problems at the unit level. Direct care nurses have intimate knowledge of what is happening in the unit and thus they are in the best position to resolve it. The positive regard for the nursing staff, for improvement, and for professional autonomy contributed to buy-in.
The project lead’s personality and capabilities also contributed to the initial success of the change. She has an exceptional ability to listen and empathise with the staff and this allows her to accept as valid the concerns being raised rather than dismissing or ignoring them. She has advocated for increased staffing prior to the current change but was unsuccessful because of the organisation’s financial difficulties. Her actions communicate a genuine concern for the staff that has earned her their trust where mistrust is often a barrier to communication, information sharing, and change (White, 2014). She facilitates planning workshops well leading to highly productive meetings, and employs data efficiently so that the staff can make informed decisions. She strives to overcome resistance by taking the time to engage nurses in order to explore what hinders buy-in.
She also employs motivational techniques effectively such as inviting the chief nursing officer to meetings, asking senior nurses to champion the change, and organising a pilot of the project. She also recognises the effort of both individuals, teams, and the entire staff, as well as gives fair and accurate feedback of performance. She makes her rounds to observe how the training is going along and to provide supervision and other forms of support on a daily basis. She has mediated a misunderstanding between a coach and a nurse new to the specialty before it escalated into full-blown conflict. She did so by hearing both sides and helping each party understand the other’s perspective. She elicited their suggestions of resolving the issue and then gave her own suggestion before allowing the parties to talk and arrive at a consensus.
Conclusion and Action Plan
The literature provides strong support for participative change. Engagement and empowerment of the staff establish collective ownership of the project that generates commitment (White, 2014; Ramanujam, Keyser & Sirio, 2005; Gershenghom, Kocher & Factor, 2014; Kerridge, 2012; Stonehouse, 2013). It minimises resistance because alternative perspectives are expressed and there is transparency and trust. It is a form of motivation because it upholds professional autonomy and the worth of each individual, which promote a positive work environment and a sense of achievement for participants. It facilitates learning that leads to advancement and growth. Engagement also creates a positive relationship between the change manager and the staff. In Herzberg’s two-factor theory, the impact of empowerment and engagement are hygiene and motivator factors that contribute to satisfaction and commitment (Borkowski, 2005). Informal feedback from colleagues was largely appreciation for the way the change was managed.
Training needs analysis, especially at a small-scale level, was also shown to generate findings which most likely had a positive influence on service delivery and patient care quality (Gould et al., 2004). There is also evidence for the use of coaching by senior nurses in the perioperative setting (White, 2014). It has been found to be an effective teaching-learning strategy. A study also attests to the usefulness of having a colleague champion proposed change (Kirchner et al., 2010). It is an effective way of disseminating information and convincing stakeholders. In addition, piloting is often used as a mini-trial to generate evidence on the likelihood of success and improve projects further before full implementation (Cummings et al., 2011). Literature further supports daily observations or walk-arounds as a strategy for sustaining positive behaviours (Ramanujam, Keyser & Sirio, 2005).
The process of change is consistent with Lewin’s theory stating that change goes through the stages of unfreezing, moving, and refreezing (Spector, 2010). By presenting data on staffing, patient safety, and the staff’s competencies, she was able to establish the urgent need for change which is a precondition to unfreezing. Generating discontent with the status quo facilitated the planning and implementation of activities with the aim of resolving the issues in the moving stage. This stage also includes motivation, the management of resistance and utilisation of change champions. All relate to Lewin’s force field analysis that entails optimising supportive forces while minimising the impact of opposing factors (Mitchell, 2013). In the refreezing stage, giving feedback, observing practices, evaluating performance, and enforcing policies serve to cement the change until it becomes the new status quo. This theory has been proven to be effective in the perioperative setting (White, 2014).
Her leadership style matches the theory of servant leadership by Greenleaf which posits that a great leader must first be a servant (O’Brien, 2010). It is a model that puts premium on helping others in achieving greatness, which ultimately benefits the organisation from the excellent performance of its employees. It builds a sense of community in the workplace, encourages power-sharing, and promotes a holistic view of work that seeks to value staff members for who they are (O’Brien, 2010). The change manager exhibits some of the leadership traits of servant-leader, namely listening, empathy, persuasion, and a commitment to the personal and professional development of others. Feedback from colleagues reflects her being a good role model of this type of leadership. Servant leadership aligns with the organisational mission and the strategic goal of talent development. A good match between leadership style and organisational aims is shown to positively affect change implementation (Salmela, Eriksson & Fagerstrom, 2011).
When planning and implementing change in the future, it is important to employ participative change management, as well as an appropriate theory and leadership style. Evidence-based practices must also be explored and utilised in the context of the setting of the change (Schaffer, Sandau & Diedrick, 2012). An analysis of needs also constitutes evidence. To prevent the problem of not sufficiently involving the nurse educator and other disciplines in the planning process, however, Kerridge (2012) recommends conducting a stakeholder analysis. It is a matrix that requires listing down major and minor stakeholders, their impact on the project, and who should be appropriately informed, monitored, managed, or satisfied. The nurse educator also suggested that in future initiatives, learning or training needs assessment must be conducted for every skill set that will be used in project implementation, i.e. perioperative nursing skills and coaching for the present change. This will ensure that nurses have all the tools they need to carry out the change.
Conclusion on the Change Management Process
Based on this student’s experience, change does not happen out of the blue. There are drivers to change which in this case were professional development, staffing, and patient safety issues. Change initiatives are well-planned responses to address such issues for the purpose of advancement and growth at the individual and organisational levels. There must be alignment of the chosen theoretical model, leadership style, and implementation strategy with organisational goals in order for change to be appropriate and acceptable to stakeholders, and likely to obtain the support of management. Further, a change manager’s success is based on a combination of personality, knowledge, skills, and experience. There are several essential elements for successful change implementation, the primary being an active engagement and empowerment of stakeholders. In every change experience, it is important to reflect to continually improve practice that is an assurance of the attainment of objectives.
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