National Honor Society Leadership

Government and national NHS leaders have set visions for digitizing the NHS, becoming a paperless organization. Introducing digital devices to record vital signs and for drug administration could deliver a small change for the adoption of technology bedside and a step into how the NHS uses digital technology and reduce documentation errors. This report provides an insight into the possibilities, benefits, and barriers with using digital devices. Furthermore, leadership theories and change management models are explored to motivate and engage staff.

Introduction

Nursing documentation is a fundamental aspect of nursing, having clinical and legal facet to patient care (Prideaux, 2011). The Nursing and Midwifery Council (NMC) (2018) state nurses have an obligation that all records are to be clear, concise and accurate, documenting as soon as possible after an assessment, intervention (including medication administration), condition change or evaluation.

Charalambous and Goldberg (2016) describe on how there are concerns of a disparity between the amount of time nurses spend on paperwork compared to direct patient contact of care. Sprink (2013) suggests that surveys conducted by the Royal College of Nursing show that 81% of nurses believe that paperwork keeps them away from spending time with patients and that 86% believe that non-relevant documentation has increased over the last few years.
Due to believes that paper documentation is repetitive and time-consuming, a failing in high quality documentation has occurred, alongside communication between interdisciplinary team members being a struggle (Yu et al., 2013). Aku-Zaheya, Al-Maaitah and Bany Hani (2017) further suggests that nurses felt that trying to find relevant information from paper-based documentation is arduous. Literature has reported poor quality of record keeping includes unclear, incomplete and insufficient information, illegible entry or missing signatures (Prideaux, 2011, Kent and Morrow, 2014). This has been noted to happen with recording vital signs, where data has been omitted or inaccurately transcribed which has led to missing alerts and miscalculating risk scores (Clifton et al., 2015, Fieler, Jaglowski and Richards, 2013). Medication administration recording is also a threat to patient safety if not documented timely, as this poses a risk of overmedicating or causing drug interactions if another staff member thinks that the medication as not yet been administered (World Health Organisation, 2011).

Change Proposal

The NHS Five Year Forward View (NHS England, 2014) and Wachter Report (2016) seeks to make the NHS paperless by 2023 becoming a digitised institution, therefore the change proposal for bedside nurses to use mobile devices to conduct vital signs and medication administration will contribute to this new vision of the NHS.

In the Leading Change, Adding Value Framework for Nursing, Midwifery and Care Staff (2016) one of the 10 commitments is to engage and actively support the use of technology, to improve practice and enhance outcomes, which can assist in managing workflow at a more effective level by using mobile devices. Electronic Health Record (EHR) systems are becoming used for all clinical nursing documentation including vital signs (Stevenson et al., 2014) therefore, using mobile devices to record vital signs would allow the risk score to be calculated, immediately alerting staff of a patient’s deterioration and advising on appropriate actions (National Institute of Health and Excellence (NICE), 2016).

According to Zebra Technologies’ 2022 Hospital Vision Study (2017), mobile device usage such as tablets or handheld computers, will be adopted in all hospital settings, especially by nurses, which is already improving the quality of patient care and helping to reduce medication administration errors. This study surveyed patients, nursing managers and IT decision-makers across the world, including the UK, which identified that 97% of bedside nurses will want to use mobile devices by 2022 and this will include access to electronic health records, drug and medical databases, lab diagnostic results and medicine administration online.

King’s Fund (2016) noted through a survey question that acute trusts are less digitised and structured compared to community and mental health trusts, thus implementing the use of mobile devices for vital signs and medication administration can allow acute trusts to integrate into an interoperable setting.

Resources

Financial – Watcher (2016) stated that £1.8 billion is being targeted at implementing systems to achieve a paper-free NHS, so to factor in purchasing and licensing of software/devices and staff training for the use of mobile devices could cost around £40 million with 50% of that from government allocation, making the amount needed for all trusts at around £3 billion which is over twice of much as what has been allocated. However, there needs to be consideration for trusts that are financially strapped or lacking staff meaning training and culture change to digitalise must be done effectively. Applying for funding for the change proposal could be pursued from Innovate UK and UK research and Innovation (2017) as this change proposal is an incentive to adopt and drive a cultural change in regard to a digitised NHS. Financially this may not be as much as stated as that by Watcher (2016) as this is a smaller implementation of integrating technology in a clinical area.

Training – Investment in training will be mandatory to enable a successful implementation, which should be prioritised within the financial resources (King’s Fund, 2018). Providing learning and training will allow for staff to maximise the benefits of innovation in technology and to allow the staff to keep up with the current climate and technology advancement that occurs. Training will build the confidence and knowledge to utilise technology so will feel able to use the devices to record vital signs and drug administration.
Time – By adhering to the timeline in the implementation plan from the GANTT chart (Appendix II), as close as possible but with some flexibility can assist in keeping within a budget and remain on schedule (Silow-Carroll, Edwards and Rodin, 2012).

Leadership Theory

Leadership was highlighted as a priority in healthcare in the Francis Report (2013), indicating how the lack of leadership compromised patients and the healthcare team.

Yuki (2013) draws on an extensive range of literature and studies on definitions of leadership in nursing to develop one that recognises leadership at every level of an organization, describing it as a process to influence and motivate others to adopt tasks and enable the individual and collective efforts to achieve the goals of the organization. This definition shows the importance of leadership and how it is linked to management to increase efficiency to achieve organizational goals.
The most influential factor in clinical leadership is nurturing cultures with the necessary leadership behaviors and qualities to ensure there is direction and commitment for teams and organizations (West et al., 2015). This is important for nursing leaders as they are an integral part of the profession to direct and motivate team members, which Huczynski and Buchanan (2013) and McComb (2013) supports, suggesting how effective leadership skills and behaviors helps to move and support processes of change in the best direction and adapting to leadership styles accordingly and embracing change will lead to successful changes.

The first theory that can be implemented in the change proposal is Adair’s action centred leadership (ACL), which Goodman (2014) describes as being dynamic in understanding the leader and follower behaviour. This leadership style focuses on three elements: the team, the task and the individual where Adair (2010) describes these elements as being interdependent and interlocking and explains that the leader would need to understand and manage what they have to do, which is to achieve the task, build and develop the team and to develop the individuals that make up the team. In addition, Goodman (2014) states that that the leader would need to focus on components that make up these elements by considering the team they have, the nature of the task and developing a way of working that suits the situation.

Applying this theory and the components to use mobile devices instead of paper to document vital signs and drug administration, will involve a team with mixed skill set therefore support, communication and morale will be needed to be built upon. The task could be complex for some members whilst other adopt to it quickly so checking performances, reviewing the progress and focusing on the goal will be important for the leader. Finally, each individual within the team will need training, development and recognition.

To ensure that leadership is effective using Adair’s ACL then all three elements need to be met, if there is too much concern for any one of the three than this could cause an imbalance, interfering with productivity and group efficiency (Gopee and Galloway, 2014). Clearly then, consequences could arise affecting the group morality, motivation and accomplishment, in turn affecting the quality of the outcome. For the change proposal, this could be having pressure on time and resources for training and costs of the mobile devices, putting pressure on the team to succeed and concentrate on the task, which could eventually cause detriment of the individuals involved and cause conflict. However, this type of leadership is believed to be simple and enduring, providing good clarity of what a leader should do, therefore is able to be integrated into many organisational cultures (Chartered Management Institute, 2008). This indicates that using Adair’s ACL for the change proposal, enables the leader to adapt to a situation and identify areas that could be over or under performing, keeping a balance between the three elements.
Another relevant theory of the change being proposed is the transformational leader, a concept introduced by Burns (1978). This refers to leaders who will inspire and stimulate the team with their vision, therefore everyone including the leader is expected to be engaged and motivated to exceed their abilities to achieve the vision (Kaiser, 2016). Callaghan (2007) explains how the transformational leader can be seen as a change agent, inspiring change instead of setting goals that the team is expected to achieve furthermore, Surakka (2008) highlights how the importance of rewards and how to satisfy the needs of staff both emotionally and intellectually is recognised.

Four components that make up transformational leadership was identified by Bass (1985): intellectual stimulation; individual consideration; Inspirational motivation; and idealised influence (see appendix III). Using the four components for the change proposal, the leader will need to challenge using paper documents and encourage the use of mobile devices to empower the team in new ways. Secondly, the staff should be supported through positive feedback and staff appraisals allowing for increase in self-esteem, performance and personal development. Thirdly by everyone being motivated to use the mobile devices at patient’s bedside, patient care and performances could be measured. Lastly by being a role model, the resistance to change could become less apparent and by putting a mission statement in place, staff and service user could become involved in achieving and reviewing the change proposal.

A large and growing body of literature has investigated the benefits on transformational leadership among the nursing profession, which Weberg (2010) and Cummings at al. (2018) reviewed, showing an improvement of nursing staff outcomes such as retention, productivity and increased patient satisfaction, reducing work stress and exhaustion. However, one drawback of this theory has come in the form of impression management, which can lead to followers feeling manipulated by the leader resulting in an increase resistance (Rejinth, George and G, 2015). A transformational leader must be confident and communicate their visions to their team member but also acknowledge organisational constraint.

Marquis and Hudson (2017) believe most leaders adopt and integrate a variety of leadership styles dependant on the task, therefore adopting both transformational and Adair’s Action-centred leadership alongside a change model for this proposal could allow for high quality leadership and management required for the implementation.

Change Management

Martin et al., (2013) state that those who are leading change will benefit from using change-management models to assist in the planning process. One of the earliest and classic change models operates on a unfreeze-change-refreeze framework developed by Lewin (1951), which is identifying the need for change, implementing the change and stabilising the change.

This model has a systematic way for unfreezing a set of circumstances by using a SWOT analysis (Appendix I), which identifies factors that are driving the change and those that are causing resistance (Gopee and Galloway, 2014). This is important to acknowledge because if there is an increase in driving forces than this could lead to an increase in restraining factors, however if the driving factor outweighs the restraining factors then this could lead to a positive climate change. In the SWOT analysis for the change proposal to use technology, some resistance that is shown would come from the team if there is a strong belief that the proposed change is not in the best interest as they have experienced negative experiences with health IT implementations and changes in policies, training and procedures. This could be mitigated through talking to key individuals, observing the use of technology in clinical practice in action which can eliminate reporting bias and questionnaires for feedback to explore the knowledge, beliefs, behaviour and attitudes of the team (NICE, 2007).

Lewin’s model has come under criticism for being too linear, therefore making it unsuitable for continuous change (Bakari, Hunjra and Niazi, 2017). Another criticism that has been argued against this model is that it focuses on a top-down approach in organisations (Martin et al., 2013), which indicates that any acts or omissions from those lower down in an organisational structure could be missed therefore affecting any modification or initiations of change.

To try and overcome the limitations of previous frameworks, the NHS change model was developed for large or small projects with eight core principles around ‘our shared purpose’ (NHS England Sustainable Improvement Team, 2018). Due to this being a relatively new model there is limited literature on what the practicalities of implementing this into practice however, Martin et al., (2013) acknowledged the practical elements and potential nevertheless further knowledge on the model is needed as deviations have been noted by clinicians and managers when change project have been implemented.

Clinical governance, guidelines and initiatives could be established through the SWOT analysis, in relation to using technical devices for vital signs and drug administration. There are project management tools which include an effective project management guidance for clinical staff (NHS Improvement, 2018) and a detailed guidance on managing a digital change (The King’s Fund, 2018) which can help for implementing digital devices in clinical practice.
Implementing change faces numerous barriers however, using frameworks can help eliminate some of the issues and help to act upon them. Furthermore, success isn’t guaranteed as all changes are susceptible to failure, therefore using quality frameworks and clinical governance can simplify the process for change agents and aid those affected by change to be more receptive towards it.
Conclusion

With funding going into making a digitised NHS, using government incentives, empowering and building the team and having a timeline for the implementation of using digital devices for vital signs and medication administration based on organisational readiness, will help create the culture needed to change. With nurses taking on the role of the change agent, selecting the appropriate leadership style with a change model to suit the needs of the team are essential components to effectively implement and sustain this change.

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