Art & science mental health
Planning a change project in mental
health nursing
Thorpe R (2015) Planning a change project in mental health nursing. Nursing Standard. 30, 1, 38-44.
Date of submission: July 7 2014; date of acceptance: February 2 2015.
Abstract
This article outlines a plan for a change project to improve the
quality of physical health care on mental health wards. The plan was
designed to improve the monitoring and recording of respiratory rates
on mental health wards, through the implementation of a training
programme for staff. A root cause analysis was used to explore the
reasons for the low incidence of respiratory rate measurement on
mental health wards, and the results of this establish the basis of
the proposed change project and its aims and objectives. The article
describes how the project could be implemented using a change
management model, as well as how its effects could be measured
and evaluated. Potential barriers to the planned change project are
discussed, including the human dimensions of change. The article
suggests methods to overcome such barriers, discusses the value
of leadership as an important factor, and examines the principles of
clinical governance in the context of the planned change project.
Author
Rebecca Thorpe Registered nurse (Mental Health), Central and North
West London NHS Foundation Trust, London, England.
Correspondence to: rebeccawayman@hotmail.com
Keywords
Change management, change project, clinical governance,
early warning scores, innovative practice, mental health,
quality improvement, respiratory rates, service improvement
Review
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EARLY WARNING SCORE (EWS) systems
are used throughout the NHS to promote early
recognition and treatment of deteriorating patients
(Royal College of Physicians 2012). When used
effectively, such systems have been associated with
improved hospital mortality rates (Smith 2011).
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Monitoring patients’ vital signs is considered a
standard aspect of physiological observations,
and is an essential task for nurses and healthcare
assistants on hospital wards (Smith et al 2008).
However, studies have revealed that, of the four
vital signs (temperature, blood pressure,
heart rate/pulse rate and respiratory rate),
the respiratory rate is the one least often recorded
and most often completely omitted from hospital
documentation (Butler-Williams et al 2005,
Hogan 2006, Cretikos et al 2008, Parkes 2011).
These findings are cause for concern because
the respiratory rate is an important and sensitive
indicator of acute illness and distress and of early
signs of physiological deterioration (Royal College
of Physicians 2012). Assessment of respiratory
rates can allow practitioners to detect subtle
changes in patients’ health status and reduce
the risk of serious adverse events such as organ
damage, cardiac arrest or even death (Parkes
2011). Furthermore, a full set of the patient’s
physiological parameters is essential for early
warning scoring to be carried out (Hogan 2006).
Monitoring of respiratory rates may be
overlooked in mental health settings, despite the
importance of this aspect of nursing practice.
This was the author’s perception as a mental
health nursing student. During the author’s
inpatient placements, it was observed that
respiratory rates were rarely measured and
recorded, while blood pressure, pulse rate and
pulse oximetry were routinely measured using
electronic devices and documented. Therefore,
this article outlines a proposal for a change
project to introduce service improvement,
including a mandatory staff training programme,
with the aim of improving understanding of the
significance of respiratory rates and, ultimately,
improving the monitoring and recording of this
vital sign on mental health wards.
Promoting physical health care
on mental health wards
Continuous quality improvement is one of the
principles of the healthcare agenda (Department of
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Health (DH) 2015), and this has been particularly
emphasised following the findings of the Report
of the Mid Staffordshire NHS Foundation Trust
Public Inquiry (Francis 2013). Improving the
monitoring and recording of respiratory rates is in
keeping with this principle and also reflects central
values associated with healthcare services, such as
the commitment to innovation and excellence in
standards of care for all. Published studies into the
measurement of respiratory rates are not specific
to mental health wards. The focus of the planned
change project on mental health wards arises from
the author’s experience as a mental health nursing
student in clinical practice. It is also supported
by national strategies to improve physical health
care among those with mental health disorders
(DH 2011, 2014). Research has shown that those
with mental health problems are more likely to
have poor physical health and die prematurely
compared with the rest of the population (Royal
College of Psychiatrists 2009). The government’s
mental health strategy for England aims to
improve physical health outcomes and to ensure
that mental and physical illness are treated
equally in healthcare services (DH 2011, 2014).
Furthermore, The NHS Outcomes Framework
2013/14 (DH 2012a) includes an indicator to
reduce premature mortality for those with serious
mental illness.
An abnormal respiratory rate is a significant
predictor of acute deterioration and serious clinical
events such as cardiac arrest and/or admission to
intensive care units (Butler-Williams et al 2005).
There is evidence that those with a serious mental
illness are at risk of dying 10-20 years earlier
(Chesney et al 2014). For example, compared with
the general population, those with a serious mental
illness have three times the risk of dying from
chronic heart disease, and there are reports of a
tenfold-increase in deaths from respiratory disease
for people with schizophrenia (Rethink Mental
Illness 2013). Rethink Mental Illness (2013),
a charity in England, asserts that people who
have a serious mental illness are one of the most
high-risk groups in the UK in terms of avoidable
deaths. Therefore, comprehensive physiological
observations, including recognising and recording
alterations in respiratory rate, are crucial.
The aim of the planned change project would be
to ensure that nurses and healthcare assistants who
are tasked with performing vital signs monitoring
are adequately trained and supported to carry
out the task effectively, in accordance with the
guiding principles of The NHS Constitution (DH
2015). Healthcare staff should also understand
the potential meaning of results, to promote high
quality patient care. The project plan also aligns
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with the 6Cs of nursing (DH 2012b), specifically
those of care, competence and commitment,
by striving to improve health outcomes, ensuring
that staff have the relevant level of training and
expertise appropriate for the tasks they are
undertaking, and promoting positive patient and
staff experiences.
Change management process
The change management process involves:
identifying possible causes, identifying an
appropriate solution, defining project aims and
objectives, change management, evaluating
change, overcoming barriers to change and
ensuring quality.
Identifying possible causes
The cause of a problem in nursing practice should
be explored to understand what needs to change
and to enable the issue to be tackled effectively
(Hewitt-Taylor 2012). A root cause analysis was
conducted to investigate why respiratory rates
might be neglected and what the underlying
causes could be.
This was undertaken using the ‘5 Whys’ tool,
which can help to clarify and describe a problem
in detail (Kerridge 2012a). This involved
identifying the reasons why respiratory rates
are not monitored and recorded in the literature
and then repeatedly asking ‘Why?’ to dissect the
problem and determine a root cause. In this case,
four main underlying causes were identified from
the literature, some of which were supported by the
author’s clinical experience. These were examined
further in accordance with the 5 Whys tool to
reveal root causes of the issue (Figure 1).
The 5 Whys approach was useful to the
planning of this change project; however, it may
not be suitable for all types of problem because
it does not always clearly show connections
between causes (Hewitt-Taylor 2012). A further
limitation is that it may not be possible to identify
the causes of a problem and/or link such causes to
a solution (Hewitt-Taylor 2012). Another method
of obtaining the required information could
involve the use of workshops. Such an approach
could be beneficial because it could involve staff
from the early stages: they may then feel more
invested in assisting with the delivery of the change
plan (Gage 2013).
The 5 Whys analysis identified a lack of
knowledge, confidence and understanding of
respiratory rate measurement and an over-reliance
on equipment (as opposed to manual monitoring),
as reasons why respiratory rates are not
monitored and recorded.
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Art & science mental health

Identifying an appropriate solution would include information on the significance of

The common theme was a need for information
and guidance, and so the author identified training
as an appropriate solution to the problem, based on
the literature the author examined and on clinical
experience. The content of the proposed training
respiratory rates, by providing examples of clinical
scenarios related to alterations in these rates.
It would emphasise the importance of measuring
the respiratory rate in identifying acutely
unwell patients and early signs of physiological

FIGURE 1
‘5 Whys’ analysis

Why are respiratory rates not monitored and recorded?

Because some staff
are unsure how to
monitor respiratory
rates correctly.
Evidence: Hogan
(2006) and clinical
experience.
Why?
Because some staff Because nurses and Because some staff
feel unconfident healthcare assistants are unaware of
or uncomfortable rely on equipment the importance of
with measuring when observing respiratory rates in
respiratory rates. patients’ vital signs. the assessment of a
patient’s condition.
Evidence: Hogan Evidence: Hogan
(2006) and clinical (2006), Parkes Evidence: Butler-
experience. (2011) and clinical Williams et al (2005),
experience. Hogan (2006).
Why?
Why? Why?

Some staff have not

been shown how to They are unsure
monitor respiratory how to measure They are used to They have been
rates correctly. respiratory rates using equipment taught the skill but
without the patient’s when measuring not taught why they
Why?
knowledge. other vital signs and need to perform the
Why? therefore prefer to skill.
use this method Why?
It is assumed Why?
that nurses and
healthcare assistants They have not been
know how to do this. shown relevant It is assumed
techniques. For They are unaware that staff will
Why?
example, telling of the limitations of carry out the
the patient you are equipment and have observations without
checking the pulse become unpractised understanding the
It is assumed that when you are actually in manual monitoring reasoning behind
all healthcare staff checking respiratory skills. them.
receive training when rates. Why? Why?
they are inducted Why?
into their role and
that existing staff
already know how to They have not It is one of the vital
do this. It is assumed that received training signs and is included
staff are familiar updates on on early warning
with checking monitoring of vital scores charts.
respiratory rates signs.
and do not need Why?
to be shown how
to perform the
technique.
It is assumed that
staff know how to
check all vital signs.

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deterioration. Attendees would also be educated on
the relevance of respiratory rates within the EWS
system and the need for a complete set of vital sign
measurements. Trainers could then demonstrate
the correct techniques for measuring respiratory
rates, and attendees would have the opportunity
to practise these techniques in pairs. There would
also be time allowed at the end of the session for
questions and comments.
The use of a training programme to improve
monitoring and recording of respiratory rates
is reported by Butler-Williams et al (2005).
The authors performed a hospital audit and
results showed a low rate of documentation
of patients’ respiratory rates (24/341, 7%).
A training programme was implemented in the
hospital to increase staff awareness of the value of
respiratory rates.
When the audit was repeated, a considerable
improvement (199/325, 61%) in the recording of
this vital sign was observed. Following the success
of the project, the intention was to disseminate the
training across the trust with the expectation that
EWS rates would continue to improve. However,
long-term results of the project could not be
verified (Butler-Williams et al 2005).
Defining project aims and objectives
Once a solution, such as a training programme,
has been established, a clearly defined aim and
set of SMART (specific, measurable, achievable,
realistic and time-bound) objectives should
be developed, to enable the change project
to be planned effectively and to inform those
involved of the main events and their rationale
(Kerridge 2012b).
The following aims and objectives were
proposed for the planned change project:
The aim should be that 100% of patients who
have their vital signs checked will have their
respiratory rate monitored and recorded on
the EWS chart.
The first SMART objective should be that
nurses and healthcare assistants receive half a
day of ward-based training on how to assess the
respiratory rate correctly and its significance in
the EWS system.
The second objective should be that the
ward-based training will be provided to all new
nurses and healthcare assistants as part of their
induction programme, and will be included
in the mandatory continuing professional
development programme for existing staff.
Specific dates should be given in which to achieve
objectives and aims. A baseline audit should
be conducted to assess the current recording
of respiratory rates on EWS charts (NHS
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Improvement 2011). A follow-up audit of the EWS
charts after the training would show if there had
been any improvements.
Change management
At the planning stage, support should be
gained from those senior members of staff who
have an appropriate area of responsibility, and
who would benefit from this service improvement
idea; these staff could assist to raise the
profile of the change project and support the
implementation of the project plan (Gage 2013).
Potential candidates to approach might include
the ward’s modern matron, ward managers and
clinical team leaders.
A change management model is recommended
when planning to implement a service
improvement. A systematic, tried and tested
approach can enhance a project’s chances of
success (NHS Improvement 2011). Lewin’s (1951)
three-step process to change management offers
a structured approach to understanding and
changing behaviour in the workplace. It relates
well to healthcare practice, as its three stages of
‘unfreezing’, ‘moving’ and ‘refreezing’ are similar
to the healthcare processes of ‘planning’,
‘implementing’ and ‘evaluating’ care (Bowers
2011). Lewin (1951) recommends that the
‘driving’ and ‘resisting’ forces to the planned
change should be examined using a force field
analysis (Figure 2). The three-step model can then
be used to facilitate a shift in the direction of the
proposed change.
Lewin’s (1951) first step, unfreezing, involves
changing the magnitude of the forces that
maintain the status quo. The best way to do this
is by reducing the ‘resisting’ forces rather than
increasing the ‘driving’ forces (Kerridge 2012b).
For example, the resisting force relating to lack of
knowledge of how to correctly measure respiratory
rates could be reduced by training, during which
staff would have the opportunity to watch and
practise the correct techniques. The moving
step involves implementing the change. Nurses
and healthcare assistants should have received
the relevant training and could move forward,
routinely measuring respiratory rates as part of
their observations of vital signs.
The final, refreezing step occurs after the
change has been made; it involves stabilising and
evaluating change. For example, staff could be
provided with ongoing education and support.
However, it might be argued that the refreezing
step cannot be wholly achieved within the
continually changing environment of the NHS,
since subsequent changes usually affect any
changes made previously (Bowers 2011).
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Art & science mental health
Evaluating change
It would be beneficial to pilot the change project
to test its effects on a small scale, identify any
unanticipated problems and make necessary
adjustments (Kerridge 2012c). Research suggests
that people are more likely to engage with small
changes and then, if these go well, to feel more
confident in accepting any major change (NHS
Improvement 2011). Such a pilot trial could be
undertaken using the Plan, Do, Study, Act (PDSA)
cycle (Edwards Deming 1986):
The ‘Plan’ stage relates to aims and objectives.
In the case of the planned change project, these
would be that the monitoring and recording of
respiratory rates would improve following the
introduction of a new staff training programme.
The ‘Do’ stage refers to the implementation
of the plan and collection of data; that is,
that the training programme would be rolled
out to staff. Data would be collected on
attendance at training and data collected on
documentation of respiratory rates on EWS
charts following training.
FIGURE 2
Force field analysis for improving monitoring and recording of respiratory rates
Driving forces
Consistent with government policy
Improved patient care
Improving
monitoring
Promotes continuing professional and
development recording of
respiratory
rates
Improved adherence to early
warning score system
More effective detection of physical
health issues and/or deterioration
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The ‘Study’ stage would involve data analysis
and identification of problems or areas
for improvement.
The ‘Act’ stage involves making any changes and
then repeating the cycle.
The PDSA model allows the effects of a project to be
evaluated and improved continually (Gage 2013).
The model is primarily an auditing and evaluation
tool and does not specifically focus on the human
dimensions of change. Therefore, it may be best
used in conjunction with Lewin’s (1951) change
model, as the latter considers the cultural effects of
service improvement and how they can be managed.
Overcoming barriers to change
Successful implementation of service improvement
requires understanding and anticipation of barriers
to proposed change. Developing an appropriate
strategy for overcoming such barriers is also
required (National Institute for Health and Care
Excellence (NICE) 2007).
People’s responses to change can relate to:
awareness and information on what needs to change
Resisting forces
More resources required, for
example staff time
Reluctant to change established
practices
Negative past experience of
change
Feelings of increased workload
Staff not knowledgeable about correct
measurement of respiratory rates
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and why; practicalities, for example time and
resources; skills, for example people’s confidence
in new ways of working; individual attitudes and
beliefs; the external environment, including political
and financial influences; and external and internal
motivation, for example financial reward and
self-improvement (NICE 2007, Hewitt-Taylor 2013).
Many of these elements were identified as resisting
forces in the force field analysis (Figure 2) and relate
predominantly to how staff perceive and respond to
proposed changes.
This is consistent with research conducted
into team service improvement (NHS Institute
for Innovation and Improvement 2005). Studies
have shown that the human aspects of change
management can have a significant effect on a
project’s success or failure and that dealing with
such aspects is fundamental to embedding and
sustaining change in practice in the long term
(Gage 2013). Therefore, although some aspects
of staff members’ reactions to change may be
beyond the control of the planned change project,
many aspects may be anticipated and addressed.
The training session would aim to equip staff with
up-to-date, evidence-based knowledge to carry out
respiratory monitoring and record observations
with confidence and expertise. Further, the session
would seek to empower staff to play an active
role in their continuing professional development,
rather than criticising or undermining previous
ways of working.
The role of leadership is another fundamental
component of service improvement. Research
shows that effective leadership requires engaging
and motivating staff, creating a shared purpose
and vision in line with people’s values and
experiences so that staff feel invested in the
change (Finney 2013, Storey and Holti 2013).
Without a sense of shared purpose, staff may
perceive the planned change project simply as
an exercise in compliance, with tasks imposed
from the top (Finney 2013). The Report of
the Mid Staffordshire NHS Foundation Trust
Public Inquiry (Francis 2013) emphasised the
value of leadership in health care and found that
when effective leaders are not in place and work
is perceived as purely target-driven, there is a
deterioration in staff engagement and, hence,
patient care. The Chartered Institute of Personnel
and Development (CIPD) (2008) suggests a
model of leadership that focuses on engaging
and motivating staff. This model comprises
four elements: engaging individuals, engaging
the organisation, moving forward together,
and personal qualities and values.
The CIPD model promotes teamworking,
transparency and consistency, questioning and
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feedback, and working together to create a shared
vision. Further, it emphasises that leadership does
not involve ‘distant leaders’ who are inaccessible,
high-level, individuals, but ‘nearby leaders’
whom people interact with on a daily basis.
This idea is consistent with the notion of ‘opinion
leaders’, a term that refers to individuals who
can be found at any level of an organisation but
who have a significant influence because they
are respected (Hewitt-Taylor 2013). Support
from these nearby leaders is an important part
of change management.
Ensuring quality
Clinical governance is central to contemporary
healthcare services and provides a systematic
approach to improving the quality of services
(Braine 2006). Clinical governance should
therefore be a central consideration in the
conception, planning and implementation of the
planned change project. The Royal College of
Nursing (2015) identifies five key themes of clinical
governance: patient focus, information focus,
quality improvement, staff focus and leadership.
A service improvement strategy should work in
accordance with these themes by measuring the
effects of the project through continuous auditing,
staff development and training, promoting
effective leadership and teamwork, and improving
awareness of the EWS system.
All these elements should contribute to
improving the quality of patient care. However,
one particular aspect of clinical governance
would require development and careful planning:
the issue of patient involvement and experience.
The difficulty with this aspect of clinical
governance relates to the fact that, for effective
measurement of respiratory rates, patients should
not be aware that it is being measured, because this
might influence their breathing pattern (Mooney
2007). It is therefore unlikely that patients would
be able to provide direct feedback or make
suggestions for improvement on respiratory rate
monitoring. One alternative approach could be
to ensure that the patient-focused component of
the change project involved exploring patients’
experiences of and feelings about vital sign
monitoring. Respiratory rates would be measured
unobtrusively as part of this process.
Conclusion
This article provides a systematic, comprehensive
and measurable plan for a change project
to improve the recording and monitoring of
respiratory rates on mental health wards,
with the overall aim of promoting high quality
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Art & science mental health

physical health care in mental health practice.
The root cause analysis described indicates that
limitations on the awareness, competence and
confidence of nurses and other staff are potential
reasons for poor recording of respiratory
rates. The proposed solution included a staff
training programme to empower staff and equip
them with the knowledge to perform the task
effectively. A training programme to overcome
potential barriers to the change project, by taking
into account the human aspects, is proposed.
Leadership is identified as an important element
of effectively managing change, and engaging and
motivating staff NS

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