- Email: [email protected]
Driving Change—Not Just a Walk in the Park: The Role of the Nurse Champion in Sustained Change
Driving Change—Not Just a Walk in the Park: The Role of the Nurse Champion in Sustained Change April Mount, MSN, RN, RNC, and Ida Anderson, MSN, RN, ONC
I
f the one constant in professional nursing is
they are able to assist staff in navigating clinical
change, then change management becomes sig-
practice changes and professional development.1
nificant to nurse leaders. Nurse leaders must focus
Change models are widely recognized to provide a
on managing change to achieve desirable patient out-
useful
framework
in
the
change
management
2
comes and promote the success of their staff. A
process. This article describes one hospital’s experi-
leader’s personal response to change can be a defin-
ence in navigating a major practice change by using
ing leadership trait, either positive or negative. As
Kotter’s 8-step change model as implemented by
nurse leaders develop change management skills,
designated nurse champions.
36
Nurse Leader
August 2015
W
ith the advent of the Affordable Care Act (ACA), health systems are focusing on value through quality, cost, and patient outcomes.3 Value-based purchasing is an ACA program designed to improve patient safety and patient care quality.4 Value-based purchasing establishes benchmark scores for patient satisfaction and quality outcomes, and ties hospital scores directly to Medicare and Medicaid reimbursement.3 Lean processes are now a mandatory element of any healthcare organizational change. Utilization of existing resources can be the biggest challenge to implementation of change. Nurse champions represent an untapped resource vital to change management in today’s metric-driven culture. When bedside nurses are identified as champions, it can be a powerful and rewarding experience for professional growth.5
BACKGROUND For a large level II trauma center, improving length of stay and quality outcomes can be a daunting task. If nursing can improve processes and positively affect quality outcomes by decreasing overall length of stay, both patients and organizations will benefit. Mobility was identified as a clinical practice change with the potential for global impact on hospital quality performance, including length of stay. Mobility has historically been an established preventative nursing intervention for hospitalized patients.6 However, in recent years, nurse-led mobility has come to be seen as a low nursing priority and is the one nursing intervention most frequently missed.7 Establishing mobility as a fundamental nursing clinical practice now requires a cultural change within the organization to return nursing focus back to basic patient care needs. A nurse-led mobility program was formulated to assist the hospital in achieving the overall goal of decreasing length of stay. Kotter’s 8-step process for organizational change has been proven to be effective in achieving sustained change, and nurse leaders chose this as a framework to facilitate the nurse-led mobility initiative. Interestingly, the steps were introduced in multiple layers of the project throughout the change implementation.
CREATING A SENSE OF URGENCY Nurse leaders set the tone for establishing the urgency surrounding the need for change. Urgency was created by identifying the key stakeholders and educating staff on the benefits of nurse-led patient mobilization. It is important to note that a sense of urgency does not equate to reactionary behaviors. A systematic plan that involves frontline nurses as champions is essential in this stage of the process to obtain staff buy-in and engage frontline staff early. Nurse champions assisted nurse leaders in reinforcing the need for their peers to accept patient mobilization as an important intervention in a patient’s plan of care. Maximizing mobility for the hospitalized patient is critical to decreasing risk of complications such as falls, venous thromboembolism, pressure ulcers, and pulmonary function.8 These factors contribute to both increased length of www.nurseleader.com
stay and healthcare costs.6 Organizational performance and financial benefits are a direct reflection of patient quality indicators. To remain competitive, organizations must adopt methods to improve their efficiency while achieving positive patient outcomes.
CREATING A GUIDING COALITION To create a unified approach, a guiding coalition promotes collaboration among disciplines as staff partner in their efforts to meet patient needs. Many organizations have established guiding coalitions in the form of shared governance councils at both unit and system levels. For the nurse-led mobility project, unit-based nurse champions were recruited to participate in action planning, lead peers, monitor unit progress, and collect data. These champions were nominated by their nurse leader based on their informal leadership skills and their ability to positively influence their peers. Nurse champions are singularly effective in effecting change because of their ability to promote peer-to-peer accountability without a punitive dynamic.
VISION FOR CHANGE A strong vision helps leaders inspire their team to commit to a shared goal.9 Additionally, a clear vision provides meaningful purpose and can help nurses to remain focused on the transformation of the practice.10 The vision for the nurse-led mobility initiative was to increase daily patient mobilization and achieve 100% unit compliance. As nurses developed consistency in their practice and saw positive trends, performance stabilized, which maintained the new expectation as a standard of care. Nurse champions played a vital role in engaging team members in a shared vision by reinforcing goals and recognizing positive performance. Peer-to-peer accountability empowered the team to achieve the desired goal.
COMMUNICATION Communicating the vision for the initiative is often where the change process breaks down.11 Consistency and frequency of communication are important components for the process. Ensuring that the delivery of the message is clear and concise promotes understanding of expectations.12 The communication plan for the nurse-led mobility program began with a meeting for nurse champions and then included mandatory educational in-services for all staff, visual cues, and leader rounding. Nurse champions were responsible for posting weekly results in the form of a graph to track individual unit progress and to promote transparency of metric data.
EMPOWERMENT Staff becomes empowered when organizations use internal resources.9 Additionally, staff relates well to their own team members. Because nurse champions belong to their individual nursing units, there is a history of trust between nurse champions and their peers before the project even begins. Empowerment is created when successful outcomes and meaningful patient experiences are accomplished.
Nurse Leader
37
CELEBRATING SHORT-TERM WINS Transparency of compliance allows units to easily see results. Quality metrics must be posted in a common area where all staff can see performance outcomes. This will help motivate staff and maintain focus on the initiative. When consistent positive trends occur, both nursing units and individual staff can be recognized for their contributions to the success of the program. The nurse champion played a pivotal role in celebrating short-term gains by developing quality competitions to enhance comradery and reward success.
CONSOLIDATING IMPROVEMENTS All organizational change implementations require adjustments over time.13 Transparency of metric data through discussion and posted results helps promote shared decision making as the need for adjustments arises. Nurse champions can effectively identify necessary real-time modifications to the implementation plan because they are directly involved at the bedside. Nurse champions are best suited to provide input for practice changes on individual units. Adjustments were needed for the nurse-led mobility program to address differences in healthcare service areas because different patient populations had specialty needs. For example, nurses on the neurovascular acute care unit needed a higher level of education and training regarding mobility techniques for patients who have physical neurovascular deficits. This was imperative to ensure the safety of both the neurovascular patients and the staff.
INSTITUTIONALIZING CHANGE Accountability is the key to sustained change. The nurse leader is predominately responsible for maintaining the institutional change to ensure adherence to clinical practice standards. Nurse champions are positioned to identify staff who are resistant to change and recognize behavior trends. However, it is the nurse leader’s responsibility to hold staff accountable for practice changes. The peer relationship between nurse champion and staff functions best with collaboration and mentoring versus a disciplinary approach. Open communication between nurse leaders and nurse champions facilitates this dialogue throughout the change process.
OUTCOMES Early results from the nurse mobility program show a positive response from both patients and staff, with over 2000 nursedriven mobility encounters. Although nurses recognized the importance of mobility and its benefits for patients, they acknowledged that patient activity was not being maximized. Continued auditing by nurse champions demonstrated that the mobility initiative is sustainable, with patient progression documented in the medical record. This represented a culture change for the bedside nurse because nurses are now identifying patient mobility as a basic nursing function rather than the responsibility of physical therapy. Nurses express more confidence in their ability to mobilize patients using safe patient handling techniques. A sense of urgency and heightened awareness surrounding patient activity
38
Nurse Leader
has contributed to increased collaboration and communication among disciplines. Additionally, the facility has experienced an overall 6.8% decreased length of stay. Quality metrics continue to improve as nurses prioritize mobility and incorporate patient activity as a standard of practice.
CONCLUSION As nurse leaders rise to the challenge of addressing constant practice changes, using a structured change model can assist in achieving sustained change. Because nurse-led mobility represented a major practice change, Kotter’s change model was ideal to provide a framework for nurse leaders to create sustained change. As organizations seek to improve quality metrics, implementation of a nurse-led mobility program can be a dynamic intervention to improve patient outcomes. When nurse leaders use nurse champions as a component of structured change, current staffing resources are maximized without incurring additional costs. Additionally, bedside nurses are empowered through peer-to-peer collaboration throughout the change process. Therefore, the nurse champion role is an effective tool for nurse leaders to apply when seeking to facilitate change. NL References 1. Strech S, Wyatt DA. Partnering to lead change: nurses’ role in the redesign of health care. AORN J. 2013;98:260-266. 2. Pollack J, Pollack R. Using Kotter's eight stage process to manage an organizational change program: presentation and practice. Syst Pract Action Res. 2015;28:51-66. 3. Tieman J. Affordable Care Act: we can do this. Health Prog. 2013;94(6):84-86. 4. Kavanagh KT, Cimiotti JP, Abusalem S, Coty M. Moving healthcare quality forward with nursing-sensitive value-based purchasing. J Nurs Scholarsh. 2012;44:385-395. 5. Burnett M, Lewis M, Joy T, Jerrett K. Participating in clinical nursing research: challenges and solutions of the bedside nurse champion. Medsurg Nurs. 2012;23:309-331. 6. Callen BL, Mahoney JE, Wells TJ, Enloe M, Hughes S. Admission and discharge mobility of frail hospitalized older adults. Medsurg Nurs. 2004;13:156-164. 7. Kalisch BJ, Lee S, Dabney BW. Outcomes of inpatient mobilization: a literature review. J Clin Nurs. 2014;23:1486-1501. 8. Dammeyer JA, Baldwin N, Packard D, et al. Mobilizing outcomes: implementation of a nurse-led multidisciplinary mobility program. Crit Care Nurs Q. 2013;36:109-119. 9. Martin J, McCormack B, Fitzsimons D, Spirig R. The importance of inspiring a shared vision. Int Pract Dev J. 2014;4:1-15. 10. Bareil C. Two paradigms about resistance to change. Organ Dev J. 2013;31:59-71. 11. Kotter JP. Leading change. Harv Bus Rev. 2007;85:96-103. 12. Mento AJ, Jones RM, Dirndorfer W. J Change Manag. 2002;3:45. 13. Tobias RM. Why do so many organizational change efforts fail? Public Manag. 2015;44:35-36.
April Mount, MSN, RN, RNC, is the Director of Professional Practice at WellStar Kennestone Regional Medical Center in Marietta, Georgia. She can be reached at [email protected]. Ida Anderson, MSN, RN, ONC, is Nurse Manager of the Orthopedic Unit at WellStar Kennestone Regional Medical Center in Marietta, Georiga. She can be reached at [email protected]. 1541-4612/2014/ $ See front matter Copyright 2015 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2015.06.003
August 2015
I
f the one constant in professional nursing is
they are able to assist staff in navigating clinical
change, then change management becomes sig-
practice changes and professional development.1
nificant to nurse leaders. Nurse leaders must focus
Change models are widely recognized to provide a
on managing change to achieve desirable patient out-
useful
framework
in
the
change
management
2
comes and promote the success of their staff. A
process. This article describes one hospital’s experi-
leader’s personal response to change can be a defin-
ence in navigating a major practice change by using
ing leadership trait, either positive or negative. As
Kotter’s 8-step change model as implemented by
nurse leaders develop change management skills,
designated nurse champions.
36
Nurse Leader
August 2015
W
ith the advent of the Affordable Care Act (ACA), health systems are focusing on value through quality, cost, and patient outcomes.3 Value-based purchasing is an ACA program designed to improve patient safety and patient care quality.4 Value-based purchasing establishes benchmark scores for patient satisfaction and quality outcomes, and ties hospital scores directly to Medicare and Medicaid reimbursement.3 Lean processes are now a mandatory element of any healthcare organizational change. Utilization of existing resources can be the biggest challenge to implementation of change. Nurse champions represent an untapped resource vital to change management in today’s metric-driven culture. When bedside nurses are identified as champions, it can be a powerful and rewarding experience for professional growth.5
BACKGROUND For a large level II trauma center, improving length of stay and quality outcomes can be a daunting task. If nursing can improve processes and positively affect quality outcomes by decreasing overall length of stay, both patients and organizations will benefit. Mobility was identified as a clinical practice change with the potential for global impact on hospital quality performance, including length of stay. Mobility has historically been an established preventative nursing intervention for hospitalized patients.6 However, in recent years, nurse-led mobility has come to be seen as a low nursing priority and is the one nursing intervention most frequently missed.7 Establishing mobility as a fundamental nursing clinical practice now requires a cultural change within the organization to return nursing focus back to basic patient care needs. A nurse-led mobility program was formulated to assist the hospital in achieving the overall goal of decreasing length of stay. Kotter’s 8-step process for organizational change has been proven to be effective in achieving sustained change, and nurse leaders chose this as a framework to facilitate the nurse-led mobility initiative. Interestingly, the steps were introduced in multiple layers of the project throughout the change implementation.
CREATING A SENSE OF URGENCY Nurse leaders set the tone for establishing the urgency surrounding the need for change. Urgency was created by identifying the key stakeholders and educating staff on the benefits of nurse-led patient mobilization. It is important to note that a sense of urgency does not equate to reactionary behaviors. A systematic plan that involves frontline nurses as champions is essential in this stage of the process to obtain staff buy-in and engage frontline staff early. Nurse champions assisted nurse leaders in reinforcing the need for their peers to accept patient mobilization as an important intervention in a patient’s plan of care. Maximizing mobility for the hospitalized patient is critical to decreasing risk of complications such as falls, venous thromboembolism, pressure ulcers, and pulmonary function.8 These factors contribute to both increased length of www.nurseleader.com
stay and healthcare costs.6 Organizational performance and financial benefits are a direct reflection of patient quality indicators. To remain competitive, organizations must adopt methods to improve their efficiency while achieving positive patient outcomes.
CREATING A GUIDING COALITION To create a unified approach, a guiding coalition promotes collaboration among disciplines as staff partner in their efforts to meet patient needs. Many organizations have established guiding coalitions in the form of shared governance councils at both unit and system levels. For the nurse-led mobility project, unit-based nurse champions were recruited to participate in action planning, lead peers, monitor unit progress, and collect data. These champions were nominated by their nurse leader based on their informal leadership skills and their ability to positively influence their peers. Nurse champions are singularly effective in effecting change because of their ability to promote peer-to-peer accountability without a punitive dynamic.
VISION FOR CHANGE A strong vision helps leaders inspire their team to commit to a shared goal.9 Additionally, a clear vision provides meaningful purpose and can help nurses to remain focused on the transformation of the practice.10 The vision for the nurse-led mobility initiative was to increase daily patient mobilization and achieve 100% unit compliance. As nurses developed consistency in their practice and saw positive trends, performance stabilized, which maintained the new expectation as a standard of care. Nurse champions played a vital role in engaging team members in a shared vision by reinforcing goals and recognizing positive performance. Peer-to-peer accountability empowered the team to achieve the desired goal.
COMMUNICATION Communicating the vision for the initiative is often where the change process breaks down.11 Consistency and frequency of communication are important components for the process. Ensuring that the delivery of the message is clear and concise promotes understanding of expectations.12 The communication plan for the nurse-led mobility program began with a meeting for nurse champions and then included mandatory educational in-services for all staff, visual cues, and leader rounding. Nurse champions were responsible for posting weekly results in the form of a graph to track individual unit progress and to promote transparency of metric data.
EMPOWERMENT Staff becomes empowered when organizations use internal resources.9 Additionally, staff relates well to their own team members. Because nurse champions belong to their individual nursing units, there is a history of trust between nurse champions and their peers before the project even begins. Empowerment is created when successful outcomes and meaningful patient experiences are accomplished.
Nurse Leader
37
CELEBRATING SHORT-TERM WINS Transparency of compliance allows units to easily see results. Quality metrics must be posted in a common area where all staff can see performance outcomes. This will help motivate staff and maintain focus on the initiative. When consistent positive trends occur, both nursing units and individual staff can be recognized for their contributions to the success of the program. The nurse champion played a pivotal role in celebrating short-term gains by developing quality competitions to enhance comradery and reward success.
CONSOLIDATING IMPROVEMENTS All organizational change implementations require adjustments over time.13 Transparency of metric data through discussion and posted results helps promote shared decision making as the need for adjustments arises. Nurse champions can effectively identify necessary real-time modifications to the implementation plan because they are directly involved at the bedside. Nurse champions are best suited to provide input for practice changes on individual units. Adjustments were needed for the nurse-led mobility program to address differences in healthcare service areas because different patient populations had specialty needs. For example, nurses on the neurovascular acute care unit needed a higher level of education and training regarding mobility techniques for patients who have physical neurovascular deficits. This was imperative to ensure the safety of both the neurovascular patients and the staff.
INSTITUTIONALIZING CHANGE Accountability is the key to sustained change. The nurse leader is predominately responsible for maintaining the institutional change to ensure adherence to clinical practice standards. Nurse champions are positioned to identify staff who are resistant to change and recognize behavior trends. However, it is the nurse leader’s responsibility to hold staff accountable for practice changes. The peer relationship between nurse champion and staff functions best with collaboration and mentoring versus a disciplinary approach. Open communication between nurse leaders and nurse champions facilitates this dialogue throughout the change process.
OUTCOMES Early results from the nurse mobility program show a positive response from both patients and staff, with over 2000 nursedriven mobility encounters. Although nurses recognized the importance of mobility and its benefits for patients, they acknowledged that patient activity was not being maximized. Continued auditing by nurse champions demonstrated that the mobility initiative is sustainable, with patient progression documented in the medical record. This represented a culture change for the bedside nurse because nurses are now identifying patient mobility as a basic nursing function rather than the responsibility of physical therapy. Nurses express more confidence in their ability to mobilize patients using safe patient handling techniques. A sense of urgency and heightened awareness surrounding patient activity
38
Nurse Leader
has contributed to increased collaboration and communication among disciplines. Additionally, the facility has experienced an overall 6.8% decreased length of stay. Quality metrics continue to improve as nurses prioritize mobility and incorporate patient activity as a standard of practice.
CONCLUSION As nurse leaders rise to the challenge of addressing constant practice changes, using a structured change model can assist in achieving sustained change. Because nurse-led mobility represented a major practice change, Kotter’s change model was ideal to provide a framework for nurse leaders to create sustained change. As organizations seek to improve quality metrics, implementation of a nurse-led mobility program can be a dynamic intervention to improve patient outcomes. When nurse leaders use nurse champions as a component of structured change, current staffing resources are maximized without incurring additional costs. Additionally, bedside nurses are empowered through peer-to-peer collaboration throughout the change process. Therefore, the nurse champion role is an effective tool for nurse leaders to apply when seeking to facilitate change. NL References 1. Strech S, Wyatt DA. Partnering to lead change: nurses’ role in the redesign of health care. AORN J. 2013;98:260-266. 2. Pollack J, Pollack R. Using Kotter's eight stage process to manage an organizational change program: presentation and practice. Syst Pract Action Res. 2015;28:51-66. 3. Tieman J. Affordable Care Act: we can do this. Health Prog. 2013;94(6):84-86. 4. Kavanagh KT, Cimiotti JP, Abusalem S, Coty M. Moving healthcare quality forward with nursing-sensitive value-based purchasing. J Nurs Scholarsh. 2012;44:385-395. 5. Burnett M, Lewis M, Joy T, Jerrett K. Participating in clinical nursing research: challenges and solutions of the bedside nurse champion. Medsurg Nurs. 2012;23:309-331. 6. Callen BL, Mahoney JE, Wells TJ, Enloe M, Hughes S. Admission and discharge mobility of frail hospitalized older adults. Medsurg Nurs. 2004;13:156-164. 7. Kalisch BJ, Lee S, Dabney BW. Outcomes of inpatient mobilization: a literature review. J Clin Nurs. 2014;23:1486-1501. 8. Dammeyer JA, Baldwin N, Packard D, et al. Mobilizing outcomes: implementation of a nurse-led multidisciplinary mobility program. Crit Care Nurs Q. 2013;36:109-119. 9. Martin J, McCormack B, Fitzsimons D, Spirig R. The importance of inspiring a shared vision. Int Pract Dev J. 2014;4:1-15. 10. Bareil C. Two paradigms about resistance to change. Organ Dev J. 2013;31:59-71. 11. Kotter JP. Leading change. Harv Bus Rev. 2007;85:96-103. 12. Mento AJ, Jones RM, Dirndorfer W. J Change Manag. 2002;3:45. 13. Tobias RM. Why do so many organizational change efforts fail? Public Manag. 2015;44:35-36.
April Mount, MSN, RN, RNC, is the Director of Professional Practice at WellStar Kennestone Regional Medical Center in Marietta, Georgia. She can be reached at [email protected]. Ida Anderson, MSN, RN, ONC, is Nurse Manager of the Orthopedic Unit at WellStar Kennestone Regional Medical Center in Marietta, Georiga. She can be reached at [email protected]. 1541-4612/2014/ $ See front matter Copyright 2015 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2015.06.003
August 2015