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This assignment will present a proposed change in the way cardio-pulmonary resuscitation (CPR) is taught in hospital. This assignment is written from a nurses objective and how he/she will go about being the change agent to a ward. Models of change will be analysed and reasons for choosing Lewins 1951 model will be given. When looking at CPR techniques of nurses, studies showed that the knowledge and retention of CPR psychomotor skills deteriorated after time (Madden 2006, Ornato & Peberdy 2006). Therefor CPR training was the chosen proposed change as it is a key aspect of clinical practice and delaying CPR after cardiac arrest results in poor outcome (Ibrahim 2007). For every minute without CPR from witnessed arrests, survival decreases by 7-10% (Ornato & Peberdy 2006). With heart disease causing a third of all deaths in the UK last year (Scarborough et al 2010) this skill will be one of utmost importance and the need to perform this skill to the highest standard cannot be overstretched. The Resuscitation Council (2008) agree that every health care worker should have update depending on clinical area at least once per year, therefor this is a skill that each nurse must maintain throughout their career despite whether they are using this skill regularly or not.
The change proposed here is to have a manageable sized resus manikin on a portable cart to be kept on the ward at all times. The manikin will give an instant print out of results on how staff performed in chest compressions and ventilations. Staff can practice whenever they feel necessary so the psychomotor skill of CPR does not deteriorate. The recommendation for practice would be at least twelve times per year. Accordingly this change must be followed by an audit to see if not only staff are complying but the patients who are the forefront of this are seeing the benefits (Cork 2005). This change was trialled in another health care establishment and was welcomed by the staff and further enhanced the nurses skills and improved practice (Niles et al 2009).
The concept of change can simply be defined as ???becoming different??? (Soanes 2006). Planned change represents an intentional effort to improve operational effectiveness, planned change gives the person leading the change the ability to accustom the group or individual with the tools they need to gain themselves with sense of control and the time to accustom to the change (Newson 2007). Although the focus on this paper is planned change it is important to note that change often unfolds in a spontaneous and unplanned manner, when this sudden break in continuity happens people feel robbed of self control and disorganisation and confusion emerge and the focus of the change is lost (Higgins 2003, Martin 2009). Change therefore is fundamentally a process of making different with planned change being the favoured option for this occasion. Managing change requires skills such as creativity, transferring knowledge, flexibility and the ability to modify new behaviours to reflect current knowledge and insights (Hewison 2007). No single method or strategy will fit all situations for the implementation of change, therefore change agents need to be skilled at choosing the right tools for each circumstance (Hewison 2007).
The literature about change can be difficult to assess as it comes from psychological, sociological, business and social policies with the most valuable contributions being made over sixty years ago with no current theories making its way into the current literature (Mc Brien 2008). However if change is approached in an enthusiastic way with a certain level of excitement it will create opportunities that will make the lives of patients better (Cork 2005).
ADKAR which stands for awareness, desire, knowledge, ability and reinforcement, is a goal-oriented change management model that allows change management teams to focus their activities on specific business results. The model was initially used as a tool for determining if change management activities like communication and training were having the desired results during organizational change. The model has its origins in aligning traditional change management activities to a given result or goal (Hiat 2006). As this model looks at businesses out with the health care sector and has the underlying feeling that change will produces profits, using this model for this change seems inappropriate. The Positive model of change focuses on what the organisation is doing correctly and looks at how by creating positive change it can build on excellence (Cummings & Worley 2008). This model does not give solutions to people resisting change therefor using this model would unhelpful to the change agent. The force field analysis model by Lewin 1951 appears to be the most favoured in nursing literature (Mc Brien 2008). According to Medley & Akan (2008) this process separates change into three phases ??“ unfreezing, changing and freezing (Appendix 1). In step one, the status quo must be unfrozen. This means that everyone involved must believe there is a need to change (Marquis & Houston 2009). Cummings & McLennan (2005) state that each stakeholder must feel the change has individual meaning to them for it to be successful. Phase two is changing, this is the movement period where the change happens (Marquis & Houston 2009). Phase three is freezing to ensure the change is managed and and new behaviours are the norm and old ones diminished (Cummings & Worley 2008). Its theory argues that the nature and pace of change relies on balance and it uses the force field analysis tool kit to identity situations that may or may not occur. Driving and restraining forces within the team are focused on and aims to maintain equilibrium within (Marquis & Houston 2009). The three step process by Lewins seems straight forward and possibly too simplistic and Kilmann (1991) cited in Tomeli (2004) agrees and claim that the process of change outlined by Lewin is not only too simplistic but also outdated. This is the positive take on Lewins model that it has proven that change can happen in a simplistic and smooth transition. This is was makes it impressive from the change agents perspective. If the three steps outlined are followed in a realistic manner and the driving and restraining forces are balanced it means that the change proposed will happen in a manner that stakeholders will also appreciate and hopefully be enthused by. Given this, and and its wide spread use-age in nursing literature it seems reasonable to use this model for this proposed change.
STEP 1 UNFREEZING
The first thing to note is that the Nursing & Midwifery Council code of conduct (2009) states that the nurse must always make the care of patients their first concern and if this means complying with a change that would enhance the lives of patients then this must be adhered to as failure to comply may bring fitness to practice into question. The nurse must work co-operatively and respect the expertise and contributions of their colleagues (Cummings & Worley 2008). Currently each nurse must attend at least one session of CPR per year, however depending on their area of practice this could be more frequent (Resuscitation Council 2008). Each nurse is responsible for maintaining these skills , however if not used for some time the skills can deteriorate (Losert 2006). Therefor its recommended that the skill of CPR must be practiced at least twelve times a year, or more, where the individual feels necessary on the manikin. This would be done whenever the nurse gets a free time and twelve competent print outs for evidence of success must be evidenced each year and presented to the change agent. This manikin is a perfect way for the nurse to maintain skills without having to take time off the ward to attend study days. The change agent must have skills which include excellent communication, coaching abilities and being able to reward and praise members of their team (Higgins 2003, Gilley et al 2005, Pollard et al 2005). This change will affect all nurses and support staff on the ward, these stakeholders must have been given clear guidance on why the change is being implemented and why it is important as change that people feel unnecessary causes chaos and confusion (Marquis & Houston 2009).
Bennett (2003) states innovation from the agent in preparation must be used to prepare for the status to be unfrozen and recommends that this could be done with a brief informal meeting and a teaching pack before the change day where questions can be asked and any worries surfaced, this would also give the staff time to read over the changes proposed at their leisure to gain a better understanding into the reasons surrounding the change and how to operate the manikin. Norris et al (2009) agrees with this and adds that the role in change must be fuelled by creating desires, supporting, participating, acknowledge any risks involved and providing information on the purpose of this change.
It will be of the change agents best interest on the day of the informal meeting if he/she can source the stakeholders who appear to be resisting the change to be paired in a training group with those who are excited about the change keeping in line with the force field analysis tool kit of Lewin 1951 (Bennett 2003). A sense of loss can be felt when leaving old behaviors behind. Nevid (2007) states that Kubler Ross??™s five stages of grief model (denial, anger, bargaining, depression, and acceptance) can be seen here. Her ideas are often looked to for personal grief in death but are also transferable to personal change and emotional upset resulting from factors other than death and dying. Schooflield & Orduna (2001) recommend that if the change agent recognizes anyone in any of these stages to employ active listening skills, be non judgmental, explore ways of resolution by use of conflict management and win-win negotiation. The employee should be allowed time for reflection and to search for identity and meaning with the manager giving the employee the patience to let go one step at a time. This is particularly hard time for some stakeholders who have seen how well an old regime worked and cannot see how the new routine will benefit (Newson 2007).
A short training session will be presented on the weeks leading up to the change, at this stage the group will be encouraged to work together to provide unified commitment, complementary skills, a collaborative climate and mutual accountability to provide standards of excellence (Martin 2009). Elements such as technology, financial constraints and personal values must be finalised and a balance met for the change to progress to the next stage (Burnes 2004, Medley & Akan 2008).
CHANGING STEP 2
This stage requires diligent planning and if it is managed correctly and executed well the change is hoped to be welcomed and embraced by those involved (Guy & Gibbons 2003). On the day of the proposed change there will be plenty time set aside to practice on how to use the manikin. The change agent must also appreciate each individuals own personal learning needs (Martin 2009). The phase ???life long learning??? is adopted often in health care and is a part of personal development plans in the National Health Service, its aim is to help employees reach their full potential in their role by developing existing skills and gain new ones (NHS KSF 2004). Barriers to learning include lack of support from co-workers or peers, inability to concentrate, inadequate facilities and lack of energy (Martin 2009), so for this change to operate it is proposed for staff who are struggling with the skill of CPR extra time be set aside for each individuals own personal learning needs. It is proposed that the resuscitation manikin will be on a small portable trolley therefore it can be pushed into a small conference room to practice without the distractions of the ward and for fear or embarrassment from other colleagues.
FREEZING STAGE 3
The final step in the process of change is freezing or sometimes referred to as re-freezing. This looks to stabilise the group at a new equilibrium in order to ensure the new behaviours are becoming a constant and the old ones diminished (Cummings & Worley 2008). The most important point to be made here is that the new behaviour must run in conjunction with current policies and practices therefore a final date for the new change must have been set in place by the appropriate governing bodies (Burnes 2004). Lewin described successful change as a group activity as he believed if group norms and routines were not being met then individual changes would not be sustained (Martin 2009). After a year the stakeholders will present the change agent with twelve successful print outs from the manikin. This data will not only contribute to personal development plans but will also help compile an internal audit of all cardiac arrests. Statistics, opinions and overall improvement to the service will be taken into account. Clinical audit is a quality improvement process that determines improvement and monitors outcomes through a systematic review when changes have to be implemented (Johnstone et al 2000). The audit follows a cyclic movement process to ensure that the changes that are being made have achieved the goal of making things better (Johnstone et al 2000). When done well, clinical audit has provided a way in which the quality of care can be reviewed objectively and is seen as part of professional accountability (NICE 2002).
Evaluating the change is an important factor as it gives not only the patients but the staff a chance to see how well this new change is progressing and to encourage further progression and innovation (Hodges 2008). The change agent can now provide a valuable opportunity to give staff feedback on their performance over the period thus giving them a sense of empowerment in the hope of gaining motivation and mutual respect (Higgins 2003). The change agent can now report back to managers on how the change has been perceived. They will discuss issues such as is the change being well integrated , is it becoming part of everyday norms, are people comfortable with the change and is it being well accepted, if not they should look to develop solutions to these problems (Whitehead 2007).
Management of change is part of everyday life whether its planned or unplanned, work or personal, the key to dealing with it lies with the individual. (Whitehead 2007). Some changes are welcomed and some can be seen as a threat but the reality is that many have to be accepted as it the policies and drivers of the companies that the individual is employed in that make many of the changes (Hodges 2008). There may not be a simple solution or a set formula to changes and some changes come with an amount of controversy. The responsibility lies with the managers and the change agents to give direction, influence them and sustain momentum within. Educational preparation to prevent de-skilling was the key element in this change , the author feels that if this is managed correctly and tailored to each individuals needs this would produce safe and consistent practice. The outcomes here of the change cannot be predicted but the manikin was well received in another study by Niles et al (2009) therefore one can only predict better results that the nurse and patient will see. Communication, monitoring and feedback between the group and working together to ensure open, honest and approachable working relationships will be another challenge in itself. Lewins work provided a solid framework to guide the author on how to plan the change, other disciplines had to be drawn on however to tailor it to the individual needs. Problems that arise from this change other than non-compliance with staff are difficult to pre-empt but that is what makes this model impressive is that when faced with a problem or situation the change agent will know they have to find a balance to maintain equilibrium within the group for change to commence. Lewin undoubtedly had an enormous influence within the field of change therefore this model is recommended for use within any health care change process as it has been tried and tested through real change situations with good effect (Guy & Gibbons 2003, Hodges 2008, McBrien 2008). The policy drivers of the country must not only work to ensure that first aid training in and out hospitals are being successful, in that health promotion and prevention of these coronary diseases are also being taken seriously and looked at in the bigger picture. A change of lifestyle would be welcomed by the healthcare system so the need for critical incidents like these, happen less. Taking charge of your own personal change can be a painful time, moving beyond it however can provide one with the knowledge and skills to give better care to patients.
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