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Managing change by empowering staff

Article in Nursing times August 2011

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Ben Bowers
University of Cambridge


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Keywords: Change process/
Empowerment/Sustainable change Nursing Practice
This article has been double-blind
peer reviewed
Change management
A team of community nurses was encouraged to adapt an electronic patient caseload
tool by making sure they were all involved in its development and implementation

Managing change
by empowering staff
special instructions for the next visit
In this article... would be written by hand in the teams
Why nurses need to adapt to new ways of working shared daily diary. Information on each
patients nursing needs was often in sepa-
Approaches to implementing structured changes at work rate, handwritten nursing notes. Each
Predicting how people will react to change nurse would return from visits and indi-
vidually update the daily diary and visit
How to encourage people to embrace change in daily practice folder with future visit information.
In practice, nurses often lacked the time
to do this promptly and information would
Author Ben Bowers is community charge Although commitment to new ways of become confusing. Cross-referencing all
nurse, Cambridgeshire Community working is crucial to delivering high- this information to allocate work was time
Services Trust, and a Queens Nurse. quality healthcare, nurses often say they consuming, complicated and open to
Abstract Bowers B (2011) Managing feel change is imposed on them and that errors. The system relied on the same
change by empowering staff. Nursing their views are not taken into considera- nurses being around to hand over any
Times; 107: 32/33, 19-21. tion. This perception does little to empower important information that was not con-
Nurses must constantly adapt to a variety them to own changes occurring and to tained within the visit folder.
of radical and incremental changes in the adapt behaviours to sustain practice As team leader, I audited the time it
way they work, but their emotional improvements. took to organise the daily diary and visit
responses can inhibit changes from being When managing change it is important folder as well as plan and allocate the next
sustained in practice. to identify with people and reduce the pos- days work over the course of a week. It
Implementing sustainable and sible resistances they will have in accepting took an average of 40 minutes each day
meaningful change means supporting new ways of practising (Holbeche, 2006). not an effective use of busy nurses time.
each individual to find value in new ways Baulcomb (2003) found that successfully About a month before making the
of working. This article shows how a team leading change means helping people to changes, we looked at alternative options.
of community nurses were empowered to embrace the challenges to the point where I discussed the problems associated with
improve their practice by using an they positively accept and psychologically the existing system with individual team
electronic caseload tool. This was done in own new ways of practising. members to find out their views. Each
a structured and supportive way by using This article examines how a team of said we needed a more effective caseload
Lewins change management process, an community nurses was supported as the management system that would be easy
approach that has benefits for supporting nurses adapted to using an electronic to use and enable any nurse to walk in and
and sustaining changes in practice. patient caseload tool. Rather than being understand what was needed.

expected to adjust to a management-led
hanges in the workplace natu- change, the team was encouraged to own Electronic caseload
rally create uncertainty and can this new way of working through a struc- During daily team handovers, we discussed
be emotionally challenging for tured change management process alternative methods of planning patient
employees. Change, particularly (Lewin, 1951). visits and continuity of care. Several team
when it is unexpected, can undermine con- members said the logical answer was to use
fidence and threaten sense of purpose (Hol- Reason for change an electronic caseload Excel spreadsheet
beche, 2006). The team of seven community nurses sees to manage all future visit information in
The demands of healthcare mean housebound patients, many of whom have one place.
nurses work in constantly changing envi- complex nursing needs. Before the change, We set up a spreadsheet that enables the
ronments; they must continually adapt to each patients personal details and planned nurses to highlight any day of the week and
different demands, new technologies, gov- visit dates were held in a handwritten visit instantly see and alter which visits are
ernment policies and other innovations. folder. Due to space constraints, any planned. Information on nursing needs is / Vol 107 No 32/33 / Nursing Times 16.08.11 19

Nursing Practice

5 key to change must be

addressed to be
1 Changes in
practice always
create emotional
4 Involving
everyone in
the process from
Driving forces Resisting forces

responses in the start enables

employees resistances to be

2 Planning
change in an
open, structured
examined and
Better communication Increased anxiety

way aids Change is only Faster access to data Fear about IT competencies
communication sustainable if
and staff everyone involved Participation in shaping Lack of IT skills
participation psychologically database design

3 Natural
owns the new ways
of working Increased efficiency
Initial drop in performance

Fear of losing information

Fewer risks of errors

Developing new IT skills

Weak influence
Medium influence Current state Optimum state
Nurses need to have confidence in their Strong influence (paper caseload tools) (electronic caseload tool)
IT skills for electronic systems to work

available next to the patients details. Any To bring about a sustainable change in Unfreezing change
specific future interventions, such as using an electronic caseload system, the Lewins force field analysis offers a way
changing a wound treatment, can be whole team needed to own the change in of analysing and predicting how people
added electronically as a comment their practice. Lewin (1951) offered a will react to a given change during the
attached to the next scheduled visit. This three-step approach to implementing unfreezing period (Cook et al, 2004). This
removes many of the problems and work structured changes in the workplace. involves assessing the current situation
associated with maintaining separate Adopting this enabled the whole team to and what is needed to achieve the best out-
handwritten systems. psychologically identify with and sustain come. The assessment makes it possible to
Several years ago, our team had created the change. identify the driving forces for the change
an electronic caseload system but subse- Lewin proposed that bringing about and the likely resisting forces against it
quently reverted to the handwritten ver- meaningful structured change meant sup- (Fig 1).
sion. This was mainly due to staff changes porting employees in psychologically Lewin (1951) found that ensuring staff
within the team; when staff moved on, unfreezing from a point of comfort with actively participated in analysing opportu-
fewer members of the team were comfort- the current state of affairs. Moving can nities was vital to identifying and compen-
able using the electronic system, so nurses then occur, as team members are encour- sating for resistant behaviours. This
went back to the old, familiar paper sys- aged to alter their values and ideally gain approach is a useful way to consider how
tems. This time, we needed to ensure the ownership of the change, exploring the any changes affect people emotionally and
change would be sustainable. alternatives and defining and imple- what needs addressing to help implement
menting solutions. Refreezing occurs the changes.
Change management once the change has become integral and
Most changes in practice fail because established. Unfreezing in practice
nurses are not supported and empowered In the NHS, change often never truly As team leader, before instigating the
to adjust emotionally to new ways of reaches the stage of refreezing because the change, I talked openly to everyone indi-
working (Holbeche, 2006). next change tends to interrupt or affect vidually about the problems with the cur-
Balfour and Clarke (2001) highlighted previous ones. Nurses often talk of change rent caseload management system and the
how it is tempting to revert back to fatigue, viewing their professional life as benefits of adopting the electronic tool.
familiar ways of working once those insti- being subject to unremitting changes. By listening and discussing its strengths
gating pressure to adopt changes have For change to be embraced, it needs to and weaknesses, I could gauge peoples
moved on; they described a situation be planned and implemented in a way that perspectives. Some team members were
where a change to self-medication in an responds sensitively to peoples emotional unsure about their ability to use an elec-
inpatient setting lasted only while the reactions (Curtis and White, 2002). tronic system, while others felt it would
team leader was driving it. They said that, Lewins change model lends itself to initially create more work or that all the
for change to be embraced and sustained, healthcare practice its three stages are data could be lost. However, everyone rec-
people must identify with, and value, the comparable to the processes of planning, ognised the system would help communi-
new ways of working. implementing and evaluating care. cation and reduce duplication.

20 Nursing Times 16.08.11 / Vol 107 No 32/33 /

Although the process of discussing the shape ongoing change is essential to member of the team who had been the
proposed change was time consuming, reducing resistance (Curtis and White, most reluctant to update the caseload is
it proved indispensable in involving 2002). As a team, we agreed on what infor- now the first to volunteer for the role
everyone and respecting any concerns mation we wanted on the new system, and during handover. While all of us can forget
(Cook et al, 2004). This reduced uncer- continually adapted the information, to update comments from time to time, we
tainty about what the change would based on users feedback. For example, we support each other constructively to
involve (Curtis and White, 2002). added patients telephone numbers and ensure the system is updated.
One common concern was that staff altered how we recorded comments so
would need support in learning how to use everyone could easily find them. However, Refreezing change
the spreadsheet as a caseload management adaptations were limited by the software Through open communication and team
tool. Although all the nurses were able to we were using and the range of IT user involvement, everyone has been empow-
use computers, their IT skills varied some skills (Warm et al, 2008). ered to embrace and embed the change.
were inexperienced while others were not. At first, some team members were Allocating patient visits now takes an
To provide effective support in the first reluctant to add and delete data from the average of 10 minutes a day, freeing up a
month that the new system was in place, caseload. Some lacked the IT skills to do substantial amount of nurses time.
we ensured someone experienced at using this while others felt they would hold their
Excel spreadsheets was working alongside colleagues up by taking too long or that Conclusion
less-experienced colleagues every day. they could inadvertently lose all the data. This experience has been positive and
We agreed we would all take turns to If these concerns about change had not change has been sustainable because we
update the caseload to boost everyones been addressed, we would have had an engaged the team and worked as a team
confidence in taking the lead. ineffective caseload management tool in (Baulcomb, 2003). Using an electronic
Resistance to change was already place an unsustainable system relying on caseload management tool has become an
reduced as people could see they would be a few individuals to maintain it. intrinsic part of our work culture.
supported through the process. The team The single biggest reason technology- The team has experienced being able to
members who were more IT literate felt related healthcare projects fail is because influence changes to their practice, which
their skills were valuable in helping their users lack the suitable IT skills and experi- helps them to feel they will be able to influ-
colleagues to adapt (Holbeche, 2006). ence (Warm et al, 2008). To boost team ence and make the most of the opportuni-
members confidence, we made the elec- ties from future changes.
Moving change tronic caseload the focal point of daily Staff are not always actively involved in
Having identified the obstacles to and team handovers. It is updated as patient the inception and implementation of
opportunities for altering practice, we care outcomes are discussed and future change. If behavioural resistance is not
began using the electronic caseload man- input is planned. We take turns updating identified and worked with, they can
agement tool; on the same day, we removed the caseload during handover. This has reverse even the best-intended change
the handwritten visit folder. As Holbeche helped to build everyones confidence and projects. Equally, they may resist change
(2006) suggests, change can only be sus- develop their IT skills and familiarity with because it can damage care.
tained while the driving forces propelling the system. Open discussions are needed to iden-
it outweigh the resistant forces against it. The electronic caseload quickly ceased tify if change is realistic and will benefit
The team had previously reverted to to be a metaphorical white elephant and patients and staff. Lewins process of man-
using handwritten caseload management has become an integral part of our com- aging structured change is one way in
tools because the driving forces behind the munication culture. Supporting all mem- which busy leaders and practitioners can
change had subsided, while the resisting bers of the team as they learnt to use mentally step back and identify how sus-
forces had continued. Not everyone had the system has taken time and the tainable changes can be achieved (Lewin,
been trained to use the system confidently commitment of everyone to support their 1951). By helping nurses to psychologically
and, once most of the individuals skilled in colleagues (Cook et al, 2004). own changes, leaders are more likely to
using the electronic caseload had moved Within four weeks of instigating the see changes become sustained and
on, the team no longer had a critical mass change, every nurse in the team felt confi- embedded in practice. NT
of people able to use the system. dent enough to update the electronic
Getting everyone to participate in and caseload independently. Indeed, the References
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sustainable change. Journal of Clinical Nursing; 10:
1, 44-50.
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+ Managing venous leg ulcers
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