NR 451 Implementing Change Despite Resistance Discussion

Change in any setting is difficult, we go through changes every day, new laws, new way of doing things, new technology and so forth. Some embrace change as inevitable and others just refuse to change. My mother is an avid reader and has literally hundreds of books, trust me I know I have moved her twice in the past 10 years and know all the books she has. I bought my mother a nook several years ago and taught her how to use it. Instead of embracing this new-found way of reading thousands of books that are stored in one place, she chose to hide the nook and claim it was lost. Recently she started having trouble with her eye site and could not read regular print books so I searched her apartment and found the nook, I charged it and set the font to large type and re-oriented her to its use. Again, she stashed it away saying it would not charge. Now I know that was not true, she just will not change to use of new technology, she will not learn to use a computer or tablet, she has no interest in doing that. Change scares her and that is the bottom line. As nurses, we are a lot like my mother, afraid of change, and this fear holds us back in our practice and in safe quality care and positive outcomes for our patients.

There are several major barriers to the advancement of EBP which would bring about change in nursing. These include:

Lack of knowledge and skill
- Low comfort level with search techniques
- Perceived lack of time-REAL LACK OF TIME
- Challenges with critically appraising research
- Lack of organizational/administrative support
- Educational programs that continue to teach research the “traditional way” with focus on producing instead of using evidence
- Negative attitudes-skeptics and fear

I had one negative encounter with implementation of change early after I earned my masters’ degree. My barrier with leadership and their lack of knowledge and insecurity with staff effecting change. I was basically told after my presentation of my idea for change that I was hired as a staff nurse and nothing more. Their insecurity with staff effecting change that could improve patient outcomes along with their lack of knowledge in nursing research became the barriers to positive patient outcomes. In the past year, the culture at that facility has changed and nursing research that includes the staff has been implemented.

Tell the class about the barriers you may encounter in your practice if you were to attempt to implement a change? It could be from staff or leadership or both.

Feeg, D. V., Suny Downstate Medical Center Department of Nursing , Nursing Research and Evidence-Based Practice
     Conference, May 26, 2010; Strategies for Overcoming Barriers in Implementing Evidence-Based Practice; retrieved from
     http://www.downstate.edu/icl/Feeg-Downstate2010Presentation-BarrierstoEBP.pdf

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It’s been said that “ changes are inevitable,” but clearly they have not work with some of my coworkers.I was assigned a project to create flowcharts for a department at my job. The goals were to create a new process that would be easy to use and decrease the time and help eliminate some of the problems that exist with the current process. This assignment was given to me three months ago with a timeline for completion in six weeks.
I have created and revised the flowcharts four times following the specific narratives the department presented to me. During my research, I offered several prime solutions. One of the solutions was to revise the process from manual to an electronic. The newer staff were excited and ready to proceed, however, the staff who used the manual process did not feel the need to change to electronic.
In my presentations, I was able to demonstrate how the new process would be faster and easy to use. The department director and the older staff push back when the electronic solution was presented. I have no doubt that the fear of something new lies within the staff who are familiar with the manual process, and no matter what I said or did their response were the same.   According to our reading assignment for this week states that I need the endorsement of the participants and those impacted by the change in order to ensure that the innovation is implemented successfully.  The current process has several problems that prevent easy flow and delay the transition from one step to another in a timely manner. Because of the support of the program director, I haven’t been able to transition the process to electronic, but it is still on the table for further discussion.

Reference

Agency for Healthcare Research and Quality (AHRQ). (2008). Patient safety and quality: An evidence-based handbook for nurses. Retrieved from http://www.ahrq.gov/qual/nurseshdbk/

That’s awesome that you were asked to create the flowcharts. But how very frustrating that some of your coworkers were not as excited. I know from personal experiences that some coworkers don’t really care what the evidence says, or what’s best for the patients but are more interested in how the change effects them. And I really agree with your response that, “its all about bottom line”. There was NEVER a truer statement than that. My department is in the process of attempting to hire more people. First my bosd has to submit for need, then it goes to committee, then fiance, and I think a couple other places, then she gets told if she can have the position or not. Then she can start the hiring process. The whole process can take 6 months or more! In the meantime the rest of the staff has to work extra and overtime, which can cause fatigue and burnout. I wish there was a quicker solution.

Nursing is one of the most versatile occupations within the health care workforce.1 In the 150 years since Florence Nightingale developed and promoted the concept of an educated workforce of caregivers for the sick, modern nursing has reinvented itself a number of times as health care has advanced and changed (Lynaugh, 2008). As a result of the nursing profession’s versatility and adaptive capacity, new career pathways for nurses have evolved, attracting a larger and more broadly talented applicant pool and leading to expanded scopes of practice and responsibilities for nurses. Nurses have been an enabling force for change in health care along many dimensions (Aiken et al., 2009). Among the many innovations that a versatile, adaptive, and well-educated nursing profession have helped make possible are:

the evolution of the high-technology hospital;
- the possibility for physicians to combine office and hospital practice;
- lengths of hospital stay that are among the shortest in the world;
- reductions in the work hours of resident physicians to improve patient safety;
- expansion of national primary care capacity;
- improved access to care for the poor and for rural residents;
- respite and palliative care, including hospice;
- care coordination for chronically ill and elderly people; and
- greater access to specialty care and focused consultation (e.g., incontinence consultation, home parenteral nutrition services, and sleep apnea evaluations) that complement the care of physicians and other providers.

With every passing decade, nursing has become an increasingly integral part of health care services, so that a future without large numbers of nurses is impossible to envision.

Reference

Aiken, L. H., R. B. Cheung, and D. M. Olds. 2009. Education policy initiatives to address the nurse shortage in the United States. Health Affairs 28(4):w646-w656. [PMC free article] [PubMed]

Lynaugh, J. E. 2008. Kate Hurd-Mead lecture. Nursing the great society: The impact of the Nurse Training Act of 1964. Nursing History Review 16:13-28. [PubMed]

That question is a multi focal event. Nursing now is a hot job and students coming in have this glorified notion of nursing. First, there are plenty of jobs, they go in for the income. Most of my students want to go straight to specialties, not Med/Surg and when they have to go to Med/Surg they are disillusioned with the work load. Nursing is nothing like nursing school. I have taught fundamentals in the past and now teach critical care. In fundamentals, I focus on the basic patient care like bathing, changing, turning, etc. Some students say they don’t want to do that as a nurse and should not have to do it in school. I reply with “are you kidding, this is nursing” They have no idea when they come to clinical. I have critical care students who resist turning and getting involved with the patient care. I immediately have a conversation with them.

In the medical field, I have always heard “the only constant around here is change”. This is very true. The medical field is constantly changing as more and more research is developed to find better, more effective care for patients. Some nurses like to say, “that is not the way we have always done it” or “why change something that isn’t broken?” The reason for change is simple. There is a cause for change. With the new technology, we have a better ability to track results in an effort to find out what works, what works well, and what really does not work.

If I were to implement my project, complete skin assessments on all patients admitted from the Emergency Department and the development of an Interdisciplinary Wound Care Team, I would expect to meet resistance. Emergency nurses would insist that they did not have time to do a thorough skin assessment on admitted patients. They would make statements like, “I was too busy keeping the patient from dying to worry about the status of his skin” or “just more time treating the computer and not the patient”. They are right, of course. “Long and variable hours, heavy patient loads, and complex care needs that require multi-tasking are just some of the challenges that nurses face every day” (American Nurses Association, 2015, p. 22). It is difficult to explain to staff members why they need to do even more work.

Gesme and Wiseman explain that “resistance to change usually comes from fear, on one of three levels—what will happen to me in my world, how will my relations to my colleagues change, or how will our practice and our patients be affected” (Gesme and Wiseman, 2010). To lessen the resistance, I will focus on these three levels of fear. I will educate each staff member involved of what his / her direct role will be and what is expected of him / her. I will explain to staff that this change should cause no changes to relationships with colleagues. I will educate the staff on how the change will affect nursing practice and how the patient will benefit from the few extra minutes that the skin assessment and charting will take. I will also thoroughly educate staff on the causes and preventive measure for pressure wounds. After staff receive education, I feel that they will be more receptive to the change.

References:

American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.

Gesme, D., & Wiseman, M. (2010). How to Implement Change in Practice. Journal of Oncology Practice, 6(5), 257–259. http://doi.org/10.1200/JOP.000089Links to an external site.

It is very unfortunate that we have to think of money. If the hospital operates at a loss, our salary would not be substantial and we would not receive any raises. Nurses do not see the big picture, it is not until we are exposed to healthcare management that we really realize that we have to think about money as well as the quality care we provide along with taking into consideration patients experiences. Healthcare is a business just like any other business. One reason for thinking money is Medicare reimbursement. Medicaid pays hospital supplemental payment for fee-for-service to their Medicaid beneficiaries, this payment varies from state to state and could be billions of dollars annually. Hospitals have to meet certain criteria of Medicaids the rule and regulation and failing to meet these criteria can cause the hospital to lose millions of dollars. Nurses are forced to make changes to meet the standards and criteria for Medicaid reimbursements. For example hospitals across the United States have made changes on how to the delivery care and documentation on conditions and procedures of Core Measure patients, which is one of the program of Medicaid to reduce patients readmission and provide the quality care for these patients. According to the information on the Medicare website, “Hospital Readmission Reduction Program- The Affordable Care Act authorizes Medicare to reduce payments to acute care hospitals with excess readmissions Links to an external site.that are paid under CMS’s Inpatient Prospective Payment System (IPPS), beginning October 1, 2012. The program focuses on patients who are readmitted for selected high-cost or high-volume conditions and procedures, namely, heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), hip/knee replacement, and coronary artery bypass graft surgery.”

Reference:

Medicare.gov, Hospital Compare.(2013). Linking quality to payment, Retrieved fromhttps://www.medicare.gov/hospitalcompare/linking-quality-to-payment.htmlLinks to an external site.

NR 451 Implementing Change Despite Resistance Discussion