With the rapid development of modern society, especially in the field of medicine. New technology and management models have been changing every day. Nursing also needs to evolve to adopt this change.
Change in the workplace is never simple. People are usually afraid of and resistant to change. A successful change is a planned change. It requires the right environment, good timing, and cooperation between people in various positions. Thoughtful and executive leadership is an important factor in successful change. A successful leader must have the ability to continuously and reasonably lead the team to achieve a successful change. A mature theory of change is a helpful tool for leaders. This article will discuss how to use Kurt Lewin’s change theory to achieve changes in nursing work, using effective prevention of pressure injuries as an example.
Lewin ’s Change Theory
Summary of theory
Lewin’s change theory is one of the most important workplace change theories. The essence of this theory is simple and powerful, the contents are clear when implemented.
Lewin extends the concept of field, and his theory of change focuses on the analysis of human behavior and thoughts. Lewin believes that there are reasons for the change.
When behaviors of a person or group are not consistent with the current status of development in one field, change is inevitable (Bozak, 2003, p. 80). Successful leaders should be sensitive to changing needs, recognize the problem before unexpected changes occur, and plan to implement the changes, which will significantly increase the success of the change (Rockwell, 2015). Lewin’s change theory including three steps. First, unfreezing phase. In this step, leaders need to identify the problems, explain the reason why it needs to be changed, and assess the current status and staff’s needs of education. Second, movement phase. Leaders in this step then need to identify the driving forces and restraining forces, set up goals, plan and implement strategies to make sure driving forces exceed restraining forces.
And finally, the refreezing phase. In this phase, leaders use some skills and strategies to support staff to continue this change.
Per a report from the hospital, the incidence of PIs increases on our floor for the past month. PI is one of the most common and serious medical problems that happens in patients when they are in hospital. Hospitals have the responsibility to treat PIs that happened in inpatients while they stay in hospitals. Studies showed that “treatment costs fort a single PI can range from $10,000 to $ 86,000 (US dollars) (with a median cost of $27, 000) and that treating PIs can increase nursing time by up to 50%” (Suva et al., 2018, p. 581). PIs can happen during the first 4-6 hours in a hospital stay. High-risk factors include reduced mobility, moisture skin due to incontinence, decreased blood supplies, and nutritional insufficiency. Prevention of pressure injury in an interdisciplinary collaboration job, successful prevention interventions need strong teamwork to achieve.
To better plan a change, current status and problems need to be assessed. I reviewed chartings of some recent PI cases and found out blurry responsibilities of different positions are the main cause, and lack of communication is another problem. I will also talk to some personnel to better understand the reason each individual failed doing their job and assess further education needed for our team.
I will then announce this problem we have now and my decision of making a change in an all-staff meeting. I will also do some private talking to individuals who need more education or support during this change, and make sure they can feel confident and comfortable in the process of change.
Besides announcement within our team on the floor, I will also talk to leaders of other professionals involved in this change, such as physicians, physical therapists, speech therapists, and dietitians. In the meantime, I will also accept suggestions and ideas, and utilize them in my plan of change.
I will set of goal of no new incidence of preventable PIs on our floor in 6 months. The most useful intervention to prevent PIs is repositioning. As discussed above, this job is always blurry between nurses and CNAs which causes patients did not get turned and kept in one position for a long time and PIs happened. In my plan, I will set clear responsibilities for each team. First, RNs have responsibilities to assess patients in 2 hours after patients are admitted on the floor (from outside facilities or inpatient transfer from different floors), which including current skin status, risk of developing PI using Braden Scale (Aboud & Manna, 2019), and interventions needed to prevent PI.
RNs then need to put on necessaries orders and consults within RNs’ scope of practice and hospital policies, such as order special mattress, put in consults to dietary, physical therapy, or skin treatment team (called SWAT in our hospital). RNs also have responsibilities to delegate the job to CNAs. Although CNAs can see patients’ needs of manual turns in the computer system, we do notice that misunderstanding happens, so RNs will be required to delegate specific needs of each patient to assigned CNAs in person. CNAs have responsibilities to turn, ambulate, and toileting patients as RNs’ order. CNAs need to inform RNs when patients are not available or they cannot perform their job due to a high workload. RNs have responsibilities to help CNAs on this job or delegate another qualified person to do it.
As mentioned earlier, the prevention of PIs is an interdisciplinary collaboration job. Studies showed that team-based approve is more effective in the prevention of PIs (Suva et al., 2018, p. 585). Besides RNs and CNAs on the floor, physical therapy needs to assess patients’ mobility and plan implements to improve patients’ mobility levels to prevent long term pressure on one area and increase blood flow. SWAT consult is needed to assess existing PIs and provide a guide of skincare and prevention for further PIs’ incurrence.
Also, nutrition is important in the prevention of PIs, especially for patients needs a special diet, such as patients with diabetes or difficulty in chewing or swallowing.
To improve proper nutrition intakes, interprofessional care from physicians, dentists, dieticians, nurses, speech therapists, occupational therapists, and CNAs is probably needed (Posthauer et al., p. 179). In this case, communication is key to make sure this huge teamwork is successful. I realized that the computer system sometimes is not helping in this situation. I will develop a form by the bedside of patients with a high risk of developing PIs, includes the status of skin and any updates, interventions needed to implement from any necessary teams based on patients’ situation and background. RNs have responsibilities to assess patients and fill out this form and notice all of the professionals who will be involved. Any professional need to document what did they do and any suggestions and sign in flowsheet part in this form to clearly show other professionals what else needs to be done. Again, RNs have responsibilities to monitor and follow up with this form to make sure all of the work is done.
Change is never easy, staff usually try to against the change instead of accepting. Change can bring stress and frustration to staff. Leaders must ensure enough knowledge, skills, and emotional support during the process of change.
Watson’s caring theory can be helpful in this process. I will first respect staff’s background, treat them as a whole person (Caritas one), so I can build a trust relationship with my staff (Caritas four), let them express both negative and positive feelings about the change and their suggestions about this change (Caritas five).
I will also use a scientific problem-solving method to collect data, analyze the current situation, and create a plan (Caritas six). Also, I will assess straining force existing in staff and provide interpersonal teaching-learning (Caritas seven) and enough physical, emotional, sociocultural, and spiritual support when necessary to help my staff to achieve the team goal of the change (Caritas eight). Watson’s caring theory is not only for patients’ care but also very helpful with caring between team members in health care (Watson Caring Science Institute, 2010, p. 3-6).
People need some time to turn the change into their habits so they can keep the success of change, and this period usually takes up to 3-6 months (Marquis & Huston, 2017, p. 191). In this period, I will keep monitoring how implements have been performed and the effectiveness of this change. I will still talk to nurses and professionals outside nursing but involved in this planned change and find out more problems that need to be addressed and questions need to be answered. I will keep providing any supports my staff need and make sure they will all gradually feel comfortable in this change.
Most of PIs happening in the hospitals are preventable. PIs can be a financial burden on hospitals and harm to both patients’ physical and mental health. This interdisciplinary collaboration change is believed to help improve the current situation in PIs in our hospital. As a leader on the floor, to make sure this change can be successful, I will use Lewin’s change theory to help my staff to realize the necessity of change (unfreezing), ensure my staff can be confident and comfortable with implanting interventions of this change (movement), and provide support to make sure the change continues (refreezing).
Aboud, M. A. & Manna, B. (2019). Wound pressure injury management.
Bozak, M. G. (2003). Using lewin’s force field analysis in implementing a nursing information system. CIN: Computers, Informatics, Nursing, 21(2), 80–85. doi:10.1097/00024665-200303000-00008
Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing: Theory and application (9th ed.). Wolters Kluwer.
Posthauer, M. E., Banks, M., Dorner, B., & Schols, J. M. G. A. (2015). The role of nutrition for pressure ulcer management. Advances in Skin & Wound Care, 28(4), 175–188. doi:10.1097/01.asw.0000461911.31139.62
Rockwell, D. (2015, October 7). 10 principles of the thorn. Leadership Freak. https://leadershipfreak.wordpress.com/2015/10/07/10-principle-of-the-thorn/
Suva, G., Sharma, T., Campbell, K. E., Sibbald, R. G., An, D., & Woo, K. (2018). Strategies to support pressure injury best practices by the inter-professional team: A systematic review. International Wound Journal, 15(4), 580–589. doi:10.1111/iwj.12901
Watson Caring Science Institute. (2010). Core concepts of Jean Watson’s theory of human caring/caring science [PDF file]. https://www.watsoncaringscience.org/files/PDF/watsons-theory-of-human-caring-core-concepts-and-evolution-to-caritas-processes-handout.pdf.
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