The purpose of writing this essay is to fulfill the requirements of the module “Contemporary Nursing Practice” in the MSc program that the author is undertaking. The author chose this concept to investigate looking back into the problems he faced with the nurses being moved from one institution to another, from department to another, or from day duty to night duty. Buraimi Governorate, Oman -where the author is working- has nine healthcare institutions, seven of which are situated in remote areas. Due to the shortage of staff, nurses have had numerous tasks added to their main duties. Many nurses view change negatively and therefore face it with resistance and this is due to factors such as; not being prepared to adapt to change, having family commitments, moving to a remote area, change is not compensated, or just being happy with stability.
The ever-changing social and political landscape has forced graduates in the nursing profession to be overly competitive in order to ensure they satisfactorily address the challenges and intricacies in the healthcare delivery systems. This implies that the educators, administrators, regulators, and association leaders rise up to the occasion and come up with amicable solutions warranted by these changes. It is therefore imperative that policy issues and competency-based education are revisited and addressed (Lenburg 1991). Change generally refers to the process of turning something from its original to another state, whether in a planned or unplanned manner (Hall 1981). In nursing, change involves a sequence of events that are implemented in order to achieve set targets or goals. Major players such as the middle and executive managers in the nursing hierarchy require basic knowledge of the change theories to enhance their selection and overall implementation of the change. Moreover, performances of players in the nursing profession and other underlying comparative issues have to be assessed, with an urgent need to develop flexible alternatives (Surgeon 2000). These alternatives have to be efficient and effective. The preliminary sections of the essay will highlight a short critical literature review of change and change theories, and possibly explore if all the theories identify the concept of change in the same way. It will also shed a light on the impact of change on the nursing practice and the performance of nurses. The essay will also discuss policy issues and influences that impact the concept of change within the context of nursing.
Literature review on Change and change theories
Of great concern to stakeholders in the health sector, policymakers, and other related disciplines, have been competence-related issues amongst nurses. This will ensure competition in the nursing profession (Surgeon 2000). Several researchers have come up with change theories that have gained wide application in the nursing field. The nursing field has gained immensely, undergone massive transformation, and integrated with the latest developments in service delivery and technological advancements owing to the effective application of these theories. Kurt Lewin’s theory, the commonest theory, is dependent on three stages that include the unfreezing stage followed by the moving stage, and finally refreezing stage (Kassean & Jagoo 2005). In this theory, change is viewed on the aspect of behavior where there are ever-changing forces that are working in different directions. The theory is dependent on achieving balance on the driving and resistant forces that dictate the direction taken by the nurse employees during the process of change. Lewin denoted that driving forces must reign on the resistant forces for real change to occur (Robbins, 2003, p. 564-65). Lewin’s theory is used widely in the nursing practice, however, for the theory to be effective, the driving force must lead the resistant force. At the unfreezing stage, the problem is identified and any opposition to designing a change strategy is identified and eliminated or its intensity lessened. Next is the moving stage in which a solution to the problem is identified, and the resources required to implement this solution. At the final stage, the refreezing stage, the change is assessed to see if it has been effective and its acceptance levels among the nursing staff.
On the other hand, Lippitt theory entirely focuses on the major responsibilities carried out by the change agent rather than on the way the change evolves. In a seven-step, they denote that information is continually passed over throughout the entire process. The authors point out that the benefits accrued have a high likelihood of gaining stability, especially when equally distributed to neighboring systems in the shortest time possible (Lippitt, Watson, & Westley, 1958, p. 58-59). The theory is focused on introducing an external change instrument to institute a strategy that will produce the change. This theory consists of seven stages: diagnosis of the problem, assessment of the motivation and available resources, the selection of the change projects, defining the roles of the main players, ways of sustaining the change, and withdrawal of the change agent from the establishment. This theory can assist an organization to effect change among staff.
The first step in effecting change using Lippit’s theory is to identify the problem that requires change, e.g. staff movement. The rest of the nursing staff is then informed of this problem. At the second stage, the management checks to find out if the entity that will be affected by the change accepts or are opposed to it. The availability of resources is also assessed and solutions to fix these problems are devised. The third stage determines whether the change agent identified will be effective in causing change, and its acceptance by the nursing staff and other staff. At the fourth stage, a plan that contains detailed information on the implementation process including timetables, deadlines, and responsibilities that will make the change plan a success. At the fifth stage, all persons involved in the change plan are informed of the responsibility(ies) of the external change agent, and at the sixth stage, the progress of the change plan is assessed at all levels or stages. At the final stage, the external change agent is withdrawn, the change plan made permanent by making rules, and regulations that have to be followed (Orem 1971).
Rogers’ theory borrows heavily from Lewin’s principles whereby its application is mainly on long-term projects (Hall 1981). The author espouses that awareness, some level of interest, continuous evaluation, implementation, and immediate adoption must be followed to ensure change is achieved. The theory focuses on behavior whereby negative reactions towards the change are overturned over time especially when they are convinced by the protagonists on the importance of the change. Its implementation relies on aspects of behavioral change where the employees absorb the change and let go of the old ways.
Based on Lewin’s stages, Havelock designed a theory that allowed flexibility in dealing with the complexities experienced in life. The theory introduces change through overall planning and monitoring. The theory follows six steps that include the establishment of a working relationship, diagnosis, timely acquisition of required resources, selection of an important pathway, embracement of the established change, and sustainability and withdrawal of the agents of change (Kritsonis 2005). To apply Havelock’s theory in effecting change in the nursing practice in a hospital setting, the first step would involve acquainting the change agent, in this case, a nursing staff, with the environment he/she will work in and suggest the necessity for change. In the second stage, the change agent gathers more information on the area that requires change and devises several potential solutions in the third stage, in consultation with other stakeholders. At the fourth stage, the nurse and her team pick the best solution among several proposals and execute the chosen plan. At the fifth stage, the progress of the change plan is assessed to know whether the nursing staff and other staff have taken up the plan and at the final stage, the change plan is made permanent by the institution of appropriate policies.
In addition to the above theories, Spradley came up with an eight-stage theory based on the elements of the Lewin theory (Kassean and Jagoo, 2005). Change is reliant on continuous monitoring in the project. The stages include the identification of the symptoms, diagnosis of the problem, identification and eventual selection of the ideal solution, planning and subsequent implementation and evaluation of the change, before stabilization sets in. Reddin’s theory of change employs seven steps in its efforts to bring change. In this theory, nurses diagnose the problem, come up with the desired goals, emphasize the group strength, and deduce maximum information before indulging in implementation and integration of rituals in the face of resistance (Shanley 2007). The participatory element carried by the nurses is useful in creating a linkage between theory and practice. The theory lays much emphasis on the need for consulting and involvement of all affected stakeholders to reduce instances of resistance to the change process. With regard to this, it achieves greater acceptance to the nursing workforce (Kritsonis 2005).
The theory of nursing brought forward by Peplau (1952) regarded illness as a chance for an individual to achieve personal growth while optimizing development. Basing it on change, Trevelbee (1971) restated the theory in relation to change despite the fact that the latter work was inherently concerned with the development of the therapeutic relationship between the concerned parties. The adaptation model espoused by Roy stresses the importance to align change towards the nursing theories that take into account the adaptation in the patients. Rogers (1970) and Newman (1979) postulated that change has to involve patterns. They underscore the need for patterning in their nursing theories. Rogers denotes that change plays a major role in enhancing a person’s evolution, especially in unitary organizations. Orem’s (1971) theory reiterated that self-care is very important and changes are related to shifts in self-care capability.
Role of Change Theories in the Movement of Nursing Staff
Of all the nursing theories discussed, Kurt Lewin’s theory of change is the most widely used change strategy, and the most acceptable. Each change theory combines different interrelated components that are implemented in succession to make the change process a success. The theories are very important towards implementing movement of nursing between health institutions and can make this movement a stress-free exercise.
The most common factor in any change theory is the change agent, which may be the nursing staff that is supposed to be moved to another health institution. The second factor consists of the driving and opposing factors as explained in Lewin’s theory. Both of these factors can also be the change agents, for instance, the driving factor could be the doctor or medical staff implementing the transfer while the opposing factor is the group of staff that do not require movement or are resistive to the plan. The driving factors could also be increasing staff in some health institutions, meeting the goals of the institution, training, or avoiding fatigue and monotony at work. Opposing factors include not prepared to adapt to move, having family commitments, the transfer is not compensated, or the staff may be contented with stability.
The final part of all change theories is the assessment and adoption of the change plan. In the case of staff transfer, this amounts to strategizing ways of making the new staff adapt to their new environment without any hassles. This may include orientations and organizing several induction meetings. The management at the new health institution could also look into other challenges that the new staff face, and find solutions.
As expounded, the theories are very essential in the identification, coming up with a solution, monitoring the progress of nursing staff movement, and finally withdrawing the change agent and adopting the plan by creating policies that will guide the nursing staff and other employees.
Impact of change on nursing practice
Change has some reasonable impacts on nursing practice. Hall (1981, p.5) noted some risks associated with a nursing preoccupation in relation to change. Policy issues regarding the integration of technological advancements in the functioning of healthcare institutions have catapulted change themes across the nursing practice. National policies with regard to dealing with nursing education, curriculum, and integration of the educational system with country needs have influenced changes in nursing, particularly in the last few decades. In fact, the same period has resulted in much involvement of nurses in managerial roles (Lorraine 2005).
However, change can also be used as an indicator of goal achievement. It has been noted that a mere assertion that nursing is all about managing changes can be regarded as less true. It would be too much for a multifaceted terminology like change to be thought to only encapsulate the nursing conceptualizations and therapeutics. This prompted Barnard and Locsin’s (2007) assertion that nursing is bound to gain much from the exploration of microconcepts. More importantly, implementation of change is meant to bring cost-effectiveness in the healthcare institutions and also ensure service delivery is of optimum quality. Moreover, the dynamic nature of the nursing practice and the requirement to meet international standards in nursing have brought a wave of change in nursing education and practice.
Change has influenced the learning process in institutions and the overall integration of the new graduates into the nursing practice. Preliminary competence reforms were initiated as early as 1970. This has evolved through the 80s into the 1990s when aspects of standards of healthcare organizations and academic institutions were highlighted. Preliminary studies by Grants (1979) in collaboration with the Fund for improvement of post-secondary education raised issues pertaining to reforms in education with a view to promoting competence that is backed by evidence. Grant’s perspective of competence-based education is indispensable in both academic and nonacademic cycles. Grant alludes to the fact that competency-based education is a form of education that derives its curriculum from analysis of the role it plays in the society and how it justifies the progress of the students on grounds of performances that can be demonstrated, often independent of time spent in formal education set up (Grant, 1979). Competence-based education in nursing has served to enhance the understanding of culture and patient needs during the delivery of services particularly palliative care. The incorporation of communication skills in the curriculum has bolstered the capacity of the nurses to effectively address the psychological needs of the patients and their families.
Policy issues and changes in the nursing context
Change is sometimes implemented as a policy issue when it comes to moving nurses to remote areas to serve communities residing there. Policy formulation is a very critical aspect of nursing practice and changes that take place. Issues related to curriculum development for nursing students, accreditation of institutions where nurses are trained, ensuring that nurse teachers are adequately trained and that they constantly undergo an assessment to ensure they are well equipped to tackle challenges that ever show up can only be actualized when relevant government departments involve stakeholders in coming up with working policies (Pew Health Professions Commission, 1998). Priorities and parameters for actions to counter arising health challenges, available resources to undertake this and other underlying factors should be considered when drawing nursing policy paper. Such a policy will be enacted through legislation. The paper will define laws and regulations and other incentives which will enable the nurses to provide the best services (Lenburg 1991). This will enable patients to access these services.
In fact, nursing professionals have been greatly affected by the changes in their workplace. The introduction of managerial roles in addition to the normal routine duties meant the nurses were overwhelmed with the workload. The fact that the majority of healthcare institutions are understaffed has compounded this problem. The change of environment also lowers the motivation and morale of the nurses thereby affecting the overall delivery of competent and quality services (Surgeon 2000). Rotation of nurses based on time of day and nursing department brings emotional and psychological problems particularly to nurses who have families. Lack of flexibility in some institutions not only results in demoralized staff but also leads to poor quality in the delivery of services thereby impacting negatively on the reputation of the nurses and the healthcare organizations.
Change is a very important component of the nursing practice. Even though the process of change from one health institution to another can be quite a challenge, the adoption of an appropriate change theory in nursing can make such a process smooth and can improve staff confidence and hence productivity at the workplace.
The main points of debate that come up out of this essay are; how to prepare nurses for change in the workplace? can we include change management in the basic training of nurses? who should be involved in policymaking? how often should nurses be moved between health institutions or units? how to compensate for change and its consequences? However, Nurse educators have to ensure that they are in touch with the changing trends in the nursing profession. Policy formulation is a very critical aspect of nursing practice and changes that take place. More importantly, Changes are very essential incentives for the nurses due to the positive impacts on all stakeholders in the sector.
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