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Management of healthcare

Management in Health Care Organisations

This assignment will aim to discuss the implementation of a nursing initiative, which could change practice. It will focus upon the process of change in relation to evidence-based practice. Then go on to discuss barriers to change, the role of change agents and how different management and leadership styles influence the change process.

The implementation of research based evidence into nursing practice has long been recognised as an important issue. The aim of evidence based practice (EBP) being to help clinicians base their actions on best current evidence. Newly educated nurses are aware that nursing research is very valuable to nursing because it challenges and tests the effectiveness of the care we give. However much nursing practice still remains rooted in myth (Walsh and Ford, 1989). To overcome this problem nurses must recognise the importance of evidence based care and the improvements to nursing practice (Parahoo, 1997).

The UK National Health Service (NHS) Research and Development strategy launched in (1991) acknowledges the importance of developing a NHS where practice and policy is more evidence based. The strategy is designed to create research-based health services in which scientific information is available to influence the process of health care delivery systems (Sullivan, 1998). Evidence-based practice appears to be largely derived from the concept of Evidence-based Medicine. Furthermore, Sackett et al (1996) states that this development should come as no surprise as nursing has long had an interest in identifying a clear theoretical basis for practice and considerable work has examined the relationship between theory, practice and research.

Despite the advantages to EBP, it is not as widespread as one would expect. In addition to this Cutcliffe (1997) states that there is a regular requirement for those at the centre of NHS self-governing trusts to implement new health care policies. The Department of Health document (DoH, 1993) ‘Report of the Taskforce on the Strategy for Research in Nursing, Midwifery and Health Visiting’ stresses the need for EBP to become the norm and highlights the benefits in terms of improved quality of care and increased patient satisfaction, that should occur as a result of the implementation of EBP. However the profession still appears at times to struggle to base practice and the development of services on research findings.

In order to facilitate and support health care professionals in having the necessary knowledge and skills to deliver EBP, it is essential that their employing organisation encourage this approach (Haddock and McSherry, 1999). Over the past 15 years, health organisations have become so concerned with ensuring ‘financial governance’ (balancing the books) that other important organisational issues integral to patient care such as clinical risk, quality, standards and patient outcome have taken second place (DoH, 1997).

Therefore to achieve clinical effectiveness the government has introduced a framework of Clinical Governance and EBP is a critical component within this process (Haddock and McSherry, 1999). Within the Clinical Governance framework, advocated by the White Papers ‘The New NHS Modern Dependable’ (DoH, 1997) and ‘A First Class Service: Quality in the New NHS’ (DoH, 1998), there is an emphasis on improving quality of care, treatment and services through employing the principles of clinical governance. Clinical governance gives the NHS as a whole and trusts at local level, responsibility to ensure quality of care: consistent standards of quality and emphasises the importance of routine EBP.

As discussed the introduction of Clinical Governance emphasised the importance of ensuring quality in standards of clinical care. It is acknowledged that research can potentially provide the knowledge base required for the development of nursing care and services. Thus ensuring that not only do clients get the best possible care and treatment, but also, the knowledge acquired through practice and research contributes towards making professional practice more sound (Kay et al, 1995). The UKCC endorses the concept of education and lifelong learning stating "As a registered nurse you are personally accountable for your practice, and in the exercise of your professional accountability, must maintain and improve your professional knowledge and competence" (UKCC, 1996, 9, (3), p9). Therefore the implementation of EBP would enable professionals to enhance their professional knowledge and give them a sound basis to justify their decisions.

Nevertheless, implementation of EBP in mental health nursing and the change in practice it commands, is an idea of enormous merit, but as well known, an ideas merit, does not guarantee acceptance (EBMH Notebook, 1999). This notion therefore leads on to the discussion of change and change theory.

Change is nothing new and indeed has been our only constant, but change today is faster and more complex than it has ever been before (Manion, 1994). Change is a concept currently enjoying much debate and analysis within nursing (Pryjmachuk, 1996) hence one of the purposes for this assignment. Change is an essential part of life, however in essence it is only likely to be welcomed if it is perceived as being necessary, rather than inevitable.

Change theory originated from Kurt Lewin in 1951. His model of change is one of the most widely promoted models. Lewin introduced the concepts of driving and restraining forces that either help or restrain the change process (Lancaster and Lancaster, 1982). He describes driving forces as those that facilitate change, by electing a change agent and moving the group with this agent. Restraining forces are those who slow the change process or stop the change from taking place. Change occurs when one force outweighs the other. Lewin states that it is important to know the driving and restraining forces in order to deal with the restraints.

There are numerous theories that explain how and why change occurs, but Lewin (1951) identified three phases to change, unfreezing, moving and refreezing. Therefore for change to occur, the current state must be ‘unfrozen’ by people becoming aware of the problem and the necessity for change. Then the forces holding the change in equilibrium must be worked on by increasing the forces driving the change and minimising those resisting it. Finally everything must be ‘refrozen’ with the change integrated into the person, the organisation and the culture.

However a number of other models derived from sociological research attempt to explain events as the process of change unfolds. Stocking (1992) in her article ‘Managing the human side of change’ discusses promoting change in clinical care and the social interaction model based on the work of Rogers and Shoemaker (1971). This model describes the process involved when an innovation is communicated to members of a social system. Rogers and Shoemaker proposed that four factors influenced whether changes were accepted and incorporated into practice. Firstly, the advantage of a new practice and how it can improve on existing practices. Secondly, how compatible the change is with the present practices and staff attitudes. Thirdly, the complexity of the innovation, the feasibility for easily understanding and implementing it and finally, the possibility that the innovation can be realistically tried out. Rogers (1983) observed that the factors influencing change largely revolved around the perceptions of those who were involved in introducing the innovation. Therefore innovations that demonstrate high relative advantage and compatibility, and those that lack complexity and can be tried out, are more likely to be adopted than changes that do not demonstrate these characteristics.

While on placement at a community based in-patient unit, the ward sister highlighted the need for therapeutic activities, for the clients, to be implemented into each shift. Research shows that therapeutic activities provide an opportunity for clients to interact socially, to improve communication skills, to build confidence and gain the ability to develop effective relationships. They also provide the opportunity for nurses or other health professionals to closely observe the client’s mental state, social interaction, behaviour and progress (McCaffery, 1998). Integrating therapeutic activities is an example of evidence based practice and therefore falls within the parameters of clinical governance.

The need for change was highlighted by the ward sister, when she noted that clients were spending their time either in bed or in front of the television, so the ward sister held a community meeting, which involved clients and staff and discussed which activities would be appropriate to implement onto the unit. The meeting generated many ideas, some of which required financial resources. The ward sister noted the ideas and the process of change began.

Another model of change proposed by Post (1989) suggests that change has five phases: preparation, movement, synergy, the new reality and integration. The preparation phase involves defining the purpose of the change, and identifying resources to implement it. For example, identifying a problem in practice area i.e. lack of therapeutic activities and identifying resources on the ward and how to gain financial resources. The second phase of movement involves devising a plan. For example, identifying a plan of action, which highlights the process for implementing the change. Planning the activities to be implemented into practice and identifying those who can aid the implementation of change i.e. nursing staff and clients. McCaffery (1998) supports this idea by stating that it is important to work out a thorough going rationale for activities in order for clients and staff to see how they can become an active element in therapeutic work. The third phase, synergy involves co-ordination and co-operation, which includes using interpersonal skills, for example employing suitable leadership styles and effective communication skills. The fourth phase, new reality would refer to introducing methods to ensure that the change is maintained, and regular monitoring of the change would be implemented. Finally the integration phase highlights quality issues related to the change for example, ensuring consistent quality standards and highlighting the need for evaluation. McPhail (1997) states that if nurses follow the phases proposed by Post then the effectiveness of the nurse as a change agent is greatly enhanced.

Wright (1993) states that a change agent might be a person who has his or her own ideas about what needs to be changed, who can marshal the arguments, keep up the pressure and often carry things forward using charisma, passion and enthusiasm. The change agent is described as a ‘catalytic protagonist of the change process’ (Broskowski et al, 1975). It is the role of the change agent to generate ideas, introduce innovations, develop a climate for planned change by overcoming resistance and implement and evaluate change (Lancaster and Lancaster, 1982). A successful change agent needs to be able to formulate goals amongst colleagues. Be able to motivate others, solve problems and make decisions, communicate effectively and be assertive although remain sensitive to the needs of others (Wright, 1993).

According to Lancaster and Lancaster (1982), there are two types of change agent, external and internal. The external change agent can often see the situation more clearly, this is because they can be an outsider or stranger to the group. This could however be a disadvantage, as the group may not welcome a stranger and it would take longer for the group to learn to trust them. Whereas the internal agent has the advantage of knowing the group and the system. In order to implement successful change to practice, Mauksch and Miller (1981) identify that the status of the individual who suggests new ideas seems to have great bearing on the manner in which new ideas will be accepted. The ward sister would be recognised as an internal change agent, who knows the system well and is trusted by her colleagues. It was also her support and enthusiasm for the change to practice which generated interest from the staff and clients.

As discussed various theories attempt to describe how the change process actually develops. Some models describe change in a theoretical way, while other models refer to a framework for practical action (Egan, 1985). The change process is also described in terms of being a ‘top-down approach’ or a ‘bottom-up approach’. Because the ward sister is in a managerial position, it would be viewed that the change came from a top-down approach. The ward sister initiated the change, and planned to move the change down the hierarchy. The power/cohesive approach is a top-down method with people in authority ‘instructing’ others to do things differently. This would be viewed as a destructive approach as it is usually accompanied by some sense of threat (such as loss of job) (Bassett and Cutcliffe, 1997). The rational/empirical approach, which was adopted by the ward sister, assumes that people, will act in a way that brings benefits to all, by being guided by reason and self-interest. This also has a top-down approach, but may involve the manager asking the staff to perform a new duty in a more effective and efficient way (Bassett and Cutcliffe, 1997).

In comparison, the bottom-up approach tends to be based on rationality and logic. It is based on ideas of leadership and change agents who drive the change through from the ‘shop floor’. It has been conceptualised as being participative. It mirrors some of the characteristics of organic organisations, namely the consensus about decisions, solutions that are sought jointly, high participation, high dependence on the group and the sharing of satisfaction among the group (Plant, 1987). The normative/re-educative approach is where change also originates from the bottom-upwards. This looks at the fact that people can achieve the best results by acting collectively. It suggests that due to the way the group owns the change by following this approach, it is more likely to be accepted and the change sustained.

In order to implement change, Hoffer (1986) suggests that the chosen strategy must be matched to the people involved, while Wright (1986) supports the view that effective change is not only dependent on the selection of appropriate frameworks for practice, but also on the active involvement of participants. Stokes (1994) argues that professionals can have difficulty working out a coherent and shared purpose in practice as they have had different training which has given them different values, priorities and preoccupations. It is felt that if some nurses have come from a background, which did not incorporate research into their education, they may find it hard to except the many changes that evidence based practice commands. If this was the case then ‘action research’ may be a useful tool because it is more likely to promote innovation rather than mere change. Action research is usually a bottom-up approach, which has it roots in the work of Kurt Lewin. It involves the implementation of some pre-planned change, after which its effects are observed, evaluated and reflected upon. If the desired outcomes of the planned change are not evident, the plan is modified and the whole process begins again. The same process occurs for the modified plan, until the desired outcomes are achieved (Pryjmachuk, 1996). Even though this process sounds simple in theory, it would prove to be a lengthy process especially with large organisational changes and probably expensive as well. However, if the change is necessary, the change process will be necessary also.

Muller (1994) suggests that if we approach change in a positive light, we could see it as a way to make the lives of our patients better, which in turn should encourage active involvement from participants. However if the participants/staff disagree with the change, the process becomes difficult. Resistance and reluctance and the accompanying heightened emotions, tension and stress have been implicated as factors, which hinder the change process. Smith (1996) stresses that a more holistic approach, which confronts the fears and concerns of the staff and draws them with the change process, is what the human side of change is all about. The only concerns expressed by the staff was being able to find the time to implement the changes during a busy shift, however the ward sister reassured the staff that the activities to be arranged on the unit, would not always require full participation from staff.

Practices in general can be adversely affected by factors such as staff shortages and a heavy workload. With increasing public expectation and limited budgets, quality is an ever-present issue. Due to increased pressures of work, nurses and other healthcare professionals are not always able to do a clinical audit or implement the quality improvements they would like. A lack of awareness as to the need for change, misunderstanding of the change or a lack of trust between the change agent and staff are barriers found to slow down the progression towards reaching the desired outcomes. Salmond (1991) states that change initiatives or strategic plans often fail, not because the idea was wrong, but because the change process failed to consider the human side of change.

McPhail (1997) discusses comfort zones in relation to secure and safe situations. He describes how nurses develop a comfort zone with themselves and work. Staff become comfortable with work routines and become increasingly attached to this comfort, which then causes an unwelcome attitude towards the change that may disrupt the security and safety. If a certain aspect of the ward has been managed in the same way for many years it is often considered ritualistic. Evidence is required to either support the way the practice has always been carried out, or research needs to be undertaken to support a change, which is then considered evidence based practice.

If the negative attitude continues throughout the whole team, then it could be because of lack of shared vision, which is a major factor that impedes change. Cartor (1993), stated that it is critical to achieve staff involvement and input, and therefore ownership of change, maximising the commitment and minimising potentially ‘them and us’ feelings. Some staff on the unit may not see the need for the therapeutic activities on the ward as they have worked for many years without it. Therefore in the case of resentment, the ward sister would need to give a clear theoretical purpose for change, possibly in the form of a teaching session, which includes all staff.

Another barrier to change, cited in McPhail (1997) is the lack of forward planning. The ward sister, being the change agent, would have to consider all potential barriers to the change, and must plan everything in advance. Careful considerations will need to be taken, in relation to the staffing levels for teaching sessions and then staffing levels in relation to being able to practically implement the change and importantly the staffs attitudes. The perceived attitudes to the change should be discussed in staff meetings, and any worries alleviated to ensure the team will have a ‘shared vision’. Poggenpoel (1992) suggests that most practical situations require positive attitude and behaviour for change to be effective. He goes on to say that the nursing managers can alleviate negative feelings caused by the change process, by using interpersonal and communication skills and actively participating as a team member.

Crucial to the success of change in practice, is communication between the change agents and the other participants. Clear consistent communication that effectively describes the vision of the change can bring clarity to confusion. The vision openly shared with everyone, serves as a guiding beacon, that people can fall back on, in ambiguity. The clearer the communicated vision, the stronger the guide (Morrision, 1997). Poor communication between professional colleagues during a change process can impede an effective result. While it is possible for professionals to provide highly skilled patient centred care, without adequate and appropriate communication between teams, conflicting or inconsistent advice may be given resulting in a breakdown of the planned change strategies (Stokes, 1994). The Audit Commission (1995) and Clinical Systems Group (1998) recommend that better communication standards between health care professionals and patients be adopted. This should involve shared views, practices and information across the professions and a commitment to developing better communications. If thoroughly planned and organised change to practice could be relatively straight forward, however if communications systems are not effective, it could have serious implications for the proposed change and for practice in general.

The evidence based change highlighted in this assignment is relatively small, compared to some evidence based practices, such as the implementation of twelve-hour shifts for example, which was implemented on the premise that it would ensure consistency of care and give nurses more leisure time. However a change as large as this will probably have more barriers to it and more concerns from staff, because it effects not only working conditions, but also staffs’ personal lives. This type of change may be viewed as a form of cost cutting, with little or no relevance to improved patient care. Illingworth (1999) writes that the real purpose of evidence based practices are to rein in medical spending power and is about resources, reducing costs and rationing in services. He goes on to state that evidence based cost cutting will not bring about a more compassionate profession. Research carried out into twelve-hour shifts, by Todd et al (1998) concluded that considerable dissatisfaction was expressed about hours of work, conditions of work and the impact of the shift on domestic and social arrangements. The vast majority of nurses (83%) reported that they did not want to go on working the shifts and there was support for the view that recruitment to nursing would be adversely affected by the shift. Personal attitudes are just one factor that causes barriers to the implementation of research findings and Parahoo (1997) states that attitude is an important variable in research utilisation. With views that these it is no wonder that attitudes and beliefs effect change to a great degree (McPhail, 1997).

Those individuals who are resistant to change show various behaviours, which reveal patterns of coping that individuals have adopted in past crisis. Kane (1992) describes these behaviours in his article. The first type of behaviour described is the ‘controllers’. They need support in order to relinquish the degree of control they already have in the present situation and support in recognising the reward for the change.

‘Passive-aggressive’ styles is when the individual alternates between the stance of the victim and an aggressor. ‘Impostors’ on the other hand, always fear they are not good enough and express major anxieties, particularly in relation to change. However according to Kane (1992) these people, are still valued employees. The ‘nurturers’ take the first steps towards the change; they support the team and the individuals who are afraid to take risks. ‘Mixed tricks’ are the high achieving individuals who are failing to cope with the change. The final group discussed by Kane, are the ‘co-dependency group’ and these individuals refuse to assist change and require support and guidance in order to co-operate. The ward sister and other team members would need to ensure they had a supporting relationship with these individuals, by stating the achievable goals and informing them of the advantages of the proposed change.

The culture of the organisation is important in how the group of nurses react to change. Nursing staff are constantly experiencing change in order to keep up with the organisations (NHS) goals, which is highlighted through Clinical Governance and more specifically, the Mental Health National Service Framework. Ootim (1997) recognises that the effectiveness of an organisation depends on how well it responds to the demands of its staff. Managers have to maintain a careful equilibrium between individuals nurse’s needs and the needs of the organisation. Lobb and Reed (1987) suggest that it is high time for health care mangers to seriously address such seemingly mundane issues as heavy workload and insufficient resources. The culture of an organisation is important to it and will influence the way that change happens within that organisation (Corrigan and Kleiner, 1989). The NHS is considered by Bryman (1986) as an organisation characterised as being bureaucratic and hierarchical in nature, and as such Bryman believes its ability to change is severely handicapped. Bryman (1986) also considers that the NHS culture itself is a considerable barrier to change. Ootim (1997) believes that the more nurses learn to adapt to new situations, the more they become confident in their ability. This can, in turn, contribute to more effective healthcare organisations. Once effective systems of practice and professional development, research development, clinical risk and clinical audit have been established, the overall cultural emphasis shifts from reactive, to proactive. This, according to Glanville et al (1998), is when an organisation can claim to be clinically effective in establishing efficient and effective quality standards and patient outcomes based upon research evidence. This then leads the discussion to different leadership styles and how they influence change with in the culture of the nursing team.

The groundwork of good leadership and good team management creates a culture in which change is acceptable (Redstone and Wilson, 1993). However Broome (1998) states that research on leadership shows that there is certainly not just one style of leadership that will be successful at all times. Leadership is the process of influencing people to achieve a goal. It is also an interpersonal relationship in which the leader employs styles, approaches and strategies to influence members of the group towards goal setting (Lancaster and Lancaster, 1982). The autocratic leader, for example, controls their followers, and makes decisions for the group. They discourage group participation, and also determine how the goals they have decided are going to be met. According to Lancaster and Lancaster (1982) this leaders behaviour creates fear among followers, which often leads to hostility, resentment and generally poor morale. Therefore this leader often proposes a change they solely deem appropriate and imposes the change on the group regardless of groups feelings. For a change to occur through this type of leadership, it would need to originate from a managerial position through a top down approach, with the change agent taking a power/cohesive position. McPhail (1997) states that the use of moral power, such as shame or guilt, may accomplish some short term compliance with a change, but is likely to be counter productive in the long run. On the other hand the democratic leader makes decisions, but also allows the members to be active participants (Lancaster and Lancaster, 1982). They encourage suggestions and opinions from the group and are also a good motivator. It is felt this leader would be more likely to be approachable and act as a team member, therefore accomplishing a productive change, usually adopting a bottom-up approach.

Davidhizar (1993) believes that in a changing and chaotic health care arena the nurse leaders need to utilise the qualities of transformational leadership, which focus on people and solving problems in an ever changing environment. Transformational leadership is a style, which actively embraces and encourages innovation and change (Brown and Sofarelli, 1998). Broome (1998) also consider transformational leadership as being an empowering leadership style with highly ethical people taking this position. Transactional leadership on the other hand, is considered less effective as these leaders tend to lose vision and energy, with only short or medium term focuses.

Nurses in the present working climate have to accept necessary changes with open arms. Not only should they accept changes as they take place, but should also be constantly reviewing working practices and being proactive in implementing changes as and when necessary. If this does not happen, nurses will have to deal with the fallout of changes imposed on nursing by others (Ootim, 1997).

Overall, although management skills are important and necessary, the future requires leadership to provide the dynamics essential to challenge and lead organisations into an era where management of rapid change is the necessary key for future survival. Nursing leaders are ideally positioned to influence these changes and to play a major role in facilitating the changes (Brown and Sofarelli, 1998).

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