- Email: [email protected]
Translating change: The development of a person-centred triage training programme for emergency nurses
International Emergency Nursing (2009) 17, 31–37
www.elsevierhealth.com/journals/aaen
Translating change: The development of a person-centred triage training programme for emergency nurses Barry McBrien MSc (Hons), BSc (Hons), PG Dip., PG. Cert., RGN (Co-ordinator Post Graduate Diploma in Emergency Nursing) * Centre for Nurse Education, Mater Misercordiae University Hospital, Nelson Street, Dublin 7, Ireland Received 25 January 2008; received in revised form 18 July 2008; accepted 27 July 2008
KEYWORDS
Within health care, there has been a change in practice from an illnessorientated service to one that is more health-focused and person-centred. The concept of person-centredness is frequently espoused by practitioners as being not only a desirable, but a necessary element of health care provision. Indeed, nationally and internationally, person-centred care has underpinned many healthcare documents and policies. Person-centred practice focuses on providing care, utilising a variety of processes that operationalise person-centred nursing and include working with patients0 beliefs and values, engagement, presence, sharing decision-making and providing for physical needs. In the field of emergency nursing, the incorporation of person-centred care and its holistic foundation may require a significant shift in practice. There is evidence to suggest that emergency nurses view their role as one, which is predominantly concerned with providing urgent physical care, rather than one, which espouses the theories of holistic healthcare. To this extent, being person-centred in the context of emergency care, requires the nurse to move beyond the traditional notions of his/her role and to embrace the more holistic aspects of patient care. The aim of this article is to critically analyse how a change in nurse-led triage training in one Irish Emergency Department facilitated an improved person-centred approach in practice. c 2008 Elsevier Ltd. All rights reserved.
Abstract
Change; Lewin0 s model of change; Person centeredness; Triage
Introduction
* Tel.: +353 1 8032648. E-mail address: [email protected]
While change is a constant in the health care field, it is faster and more complex than ever before (Mannion, 1994; White, 1998). Poggenpoel (1992)
1755-599X/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2008.07.010
32 affirms that change may lead to real innovation, providing abundant opportunities for creating a better way forward. However, the process of leading successful change requires effective communication, wide participation, facilitation and manipulating different interests towards the agreed goal (McLaren and Ross, 2000). Indeed, the ability to manage and lead change has become an essential skill for all nurses (Dampour, 1987; Glynn, 1989; Zukowski, 1995; Pryjmachuk, 1996). The overall aim of this paper is to critically analyse how a change in nurse-led triage training in one major Emergency Department (ED) facilitated an improved people-centred approach in practice. Firstly, a rationale will be presented for changing the current triage training programme. Various definitions of the terms ‘people-centeredness’ and ‘change’ will then be explored, followed by an analysis of the contemporary literature on these issues. A discussion will then follow, outlining the obstacles the author encountered in changing the triage training system. The paper will conclude with an evaluation of the change process involved and how it enhanced care in the ED.
B. McBrien delays in women with myocardial infarction, revealed that triage nurses experience significant difficulties in assessing women with the symptoms of myocardial infarction, with a resulting delay in their pathway to reperfusion therapy. Whilst these difficulties in assessment can, in part, be attributed to the atypical presentation of women experiencing a myocardial infarction, nevertheless, the authors state that inappropriate decisions by triage nurses can expose women to a greater rate of life-threatening complications and less favourable outcomes. Furthermore, anecdotal evidence would suggest that nurses feel a need for continuing education about triage. This indicates that existing education regarding nurse triage may be inadequate and may not equip nurses with the necessary skills to perform triage properly. In order to bridge this practice-totheory gap, the writer has introduced a mandatory triage study day. It is hoped that this change initiative will help ED nurses to develop the necessary skills to triage competently and, ultimately, to make an important contribution to improving patients’ experience of attending ED’s.
People-centred care Rationale for changing triage training Triage is defined as the process of sorting and prioritizing patients for care (Estrada, 1981; Thompson and Dains, 1982; Reed et al., 1992; Handysides, 1996; Manchester Triage Group, 1997). Implementation of nurse-led triage systems in emergency departments began in the early 1960s, when the demand for emergency services exceeded resources (Gerdtz and Bucknall, 2001). When performed in the ED, the aim of triage is to ensure that patients are treated in the order of their clinical urgency and that they receive treatment in a timely and appropriate manner (Australian College for Emergency Medicine, 2000). To triage appropriately, the practitioners need to have an understanding of the triage process, and nurse education should equip them with this knowledge (Gerdtz and Bucknall, 2001). Recent research, in conjunction with anecdotal evidence, suggests that nurse education may be falling short in this regard (Clarke et al., 2006). Accordingly, Goransson et al. (2005) investigated how nurses performed triage in Swedish ED’s. Results revealed that there was considerable diversity in the way in which triage nurses assessed and prioritized patients pointing to a significant safety risk for patients. Moreover, in an Irish context, a study by O’Donnell et al. (2005) investigating in-hospital
People-centred care has exerted a considerable influence on policy, practice and academic literature, particularly in nursing (McCormack, 2004). Concomitantly, in an Irish context, people-centredness is one of the four principles that have underpinned the Government’s Health Strategy (Department of Health, 2001). Despite this proliferation of activity and the ensuing political discourse, there is still a great deal of ambiguity surrounding the meaning of people-centred care (McCormack, 2004). Winefield et al. (1996) describe people-centred care as the optimum way of delivering healthcare and is defined as ‘valuing people’. More recently, it has been depicted as care that respects others as individuals and is organized around their needs (DoH, 2002). Elsewhere, Kitwood (1997), describes the concept as a standing or status that is bestowed upon one human being, by others, in the context of a relationship and social being. People-centredness is therefore the application of healthcare that focuses on individuality. It implies mutuality as central to its philosophy in terms of the healthcare provider and healthcare consumer. In order to be people-centred and to value individuals, there is a requirement to appreciate the totality of the individual and not merely to concentrate on a specific role (Williams and Grant, 1995). Adopting a people-centred approach to practice re-
Translating change: The development of a person-centred triage training programme quires that health professionals think beyond concepts of cure based on scientific facts and technical competence, to the adoption of a more holistic approach that also incorporates values (Hope and Fulford, 1994). In the field of ED nursing, the incorporation of people-centred care and its holistic underpinnings may require a significant shift in practice. There is evidence to suggest that ED nurses view their role as one which is predominantly concerned with providing urgent physical care, rather than one which espouses the theories of holistic healthcare (Byrne and Heyman, 1997; Dolan, 1998; Wiman and Wikblad, 2004). Moreover, Wilkin and Slevin (2004) aptly suggest that while establishing physical priorities acts as a coping mechanism for the nurse, this practice may ultimately result in the neglect of the patient’s psychological well-being. To this extent, being people-centred in the context of the ED, requires the nurse to move beyond the traditional notions of their role and to embrace the more holistic aspects of patient care.
Change The concept of change may simply be defined as ‘to make or become different0 (Mc Leod and Hanks, 1982, p. 72). Planned change represents an intentional attempt to improve operational and managerial effectiveness (Baulcomb, 2003). Although the focus of this paper is on planned change, it is important to note that change often unfolds in an apparently spontaneous and unplanned way. Tappen (1995, p. 108) refers to unplanned change as ‘‘emergent change’’ and describes it as a sudden, forceful break in continuity. Indeed, in a healthcare context, change rarely occurs in a linear fashion and often displays the properties of emergence (Boshoff, 2005). Change is therefore fundamentally a process of making different, in an attempt to improve the organisational effectiveness. It is characterised by planned change or unplanned change which is often embraced by an organisation as complex as the healthcare service. Undoubtedly, EDs have undergone significant change in recent years. Accordingly, the throughput and acuity of patients have increased, while concomitantly, the technical and clinical management of these patients has improved (Dolan, 1998). Managing change is seen as being skilled at creating, acquiring and transferring knowledge, thereby modifying its behaviour to reflect new knowledge and insights (Garvin, 1993). Therefore, an effective manager needs insight and knowledge into change theories (Mc Phail, 1997). Poggenpoel
33
(1992) states that for nurses to view change as a challenge and to manage it pro-actively and creatively, they need to understand change as a phenomenon, identify the key emotional reactions associated with change and know how to manage change in a positive manner. Moreover, if change is approached with a certain level of excitement and enthusiasm, it will create opportunities that will make the lives of patients better (Muller, 1992). The force field model described by Lewin (1951) appears to be the most favoured approach in the nursing literature. This method divides the change process into three phases: unfreezing, changing and refreezing (see Fig. 1). It emphasises the need to ensure that the driving forces outweigh the resisting forces. Lewin (1951) argued that the nature and pace of change depends upon the balance of driving and restraining forces, in relation to a particular change. In spite of this, Rogers (1983) claims that the process of adopting any change is more complex than the three steps outlined by Lewin (1951). Conversely, Rogers’s rational model describes a five-stage process in the cycle of change (Rogers, 1983). This step-by-step, logical approach allows the agent to optimise and tailor his/her change programmes in order to maximise the chances of success. Tross and Cavanagh (1996) refute this position and assert that change is not a sequential process. Additionally, Roger’s model is built on the premise that people and organisations are capable of acting in a completely rational and logical manner (McWhinney, 1992). Lewin’s seminal model was chosen to underpin the change initiative, presented by the author. In conjunction with this model, a normative re-educative approach was utilised and this enables the individuals undergoing the change to participate in identifying the problem, choosing the solutions and implementing the change (Haffer, 1986).
Implementation of the change process Overall, most nurses were keen to be involved in the change initiative as they hoped that it would
Unfreezing
Figure 1
Changing
Refreezing
Lewins model of change.
34
B. McBrien
benefit them. A focus group was established consisting of staff nurses and clinical nurse managers. The two main benefits they perceived were that they could be involved in identifying any education gaps in the current programme by their participation and that they could become involved in developing a programme which would address their individual triage training needs. The focus group interview facilitated a partial diagnosis of the problematic areas of the triage training system. On the other hand, it was difficult to explore the inherent issues in totality as initially a number of senior nurses had declined to participate. However, involvement of all grades of staff in this change process was a central tenet of this project. In addition, a number of these senior nurses had been identified as driving forces in the force field analysis (see Fig. 2). To this extent, Kennedy (2000) asserts the importance of active involvement of all necessary stakeholders, in order for the change to be successful and lasting. In order to develop a greater collaboration, a meeting was held with senior nurses, junior nurses and the author as change agent. Fitzgerald (2002) argues that, to enhance motivation and commitment to change, a supportive atmosphere of collaborative working is imperative. Likewise, Smale (1998) highlights the benefits of actively involving staff that are closest to the problems, by explaining that they are closest to the solution. On this occasion, information concerning the change was provided through a discussion and presentation of research findings regarding ED nurses’ triage practices. In this respect, educating people about the need for the change and its potential benefits is vital and may potentially help to overcome resis-
tance (Griffin, 1993). Indeed, this increased knowledge about triage served to create dissatisfaction with the current triage training system. Tross and Cavanagh (1996) claim that dissatisfaction with the status quo is the most influential factor in the initiation of change. However, rather than being an education issue, two nurses claimed that it was an experiential issue and subsequently suggested that it was a lack of experience that was causing the difficulties in triage. Cognisant of the normative re-educative strategy that was employed in the change process, provision was made to listen to and validate the resistors’ feelings. Nonetheless, it was asserted that if nurses did not have the theoretical knowledge, which underpins the skill of triage, they would be unlikely to be competent practically in this area (Reece and Walker, 1997). Accordingly, the resistors’ position was weakened by providing them with copious amounts of evidence to support the introduction of the project. A consensus was then reached and actions were prioritised for the change initiative in triage training. In line with the force field analysis, resources had been identified as a restraining force in the implementation of this change project. For example, administrative support was essential to the success of the triage training program. Other necessary resources included equipment and sufficient time to train staff. Accordingly, a proposal was compiled and sent to the nursing management of the ED. A subsequent meeting was arranged with the senior nurse manager and the Co-ordinator of Practice Development. Whilst, overall, the nurse managers were positive towards the change, the focus appeared to concentrate on funding issues
Force against Change
Forces for Change Dissatisfaction with current triage training.
Cost
Promote patient centred . approach
Plan:To develop a person-centred triage training programme.
Human and Physical Resources
Nursing staff resistance to the change in triage training.
Promote patient satisfaction with Triage
Improve nurses’ decisionmaking skills regarding
Time
Figure 2
Force field analysis.
Translating change: The development of a person-centred triage training programme rather than on improving the quality of the triage service. Moreover, it was articulated that the author required more support to implement the change successfully. Haynes (1992) suggests that it would be useful if all nurses could act as change agents. However, Jackson (2000) affirms that the way in which new ideas are accepted is very dependent on the status of the person who suggests the change. Therefore, in order to overcome this resistance, the author enlisted the support of a Lecturer in Emergency Nursing to act as an external change agent. White (1998) suggests that having an objective person from outside the department taking on responsibility for introducing the change, may help facilitate the introduction of the change. Perhaps, not unsurprisingly, with the participation of the external change agent, the ED managers endorsed the implementation of the triage training programme. In addition, the external change agent was instrumental in securing funds for resourcing the programme.
Evaluation The quality of the triage training was evaluated throughout the programme and one month following its completion. This concurs with Coghlan and Mc Auliffe’s (2003) view, where they identify the need to evaluate the process as well as the product, of the change. Elsewhere, Koch (1992) suggests that defining quality is a fruitless debate, as quality is a social construct influenced by an individual’s values, expectations and the role of the health care system. In other words, quality can mean different things to patients, healthcare providers and organisers (Ludwig-Beymer et al., 1993). Furthermore, it has been claimed that it is necessary to combine the perspectives of patients and healthcare providers when evaluating quality (Ashley, 2000). In order to ensure the change initiative facilitated an improved people-centred approach, both nurses’ and patients’ views were ascertained on triage practices. Patient evaluation has become a key component in the assessment of healthcare quality (Williams et al., 1998). Indeed, the importance of patients as evaluators of the quality of care is increasingly emphasized by health policy and recent government legislation (Department of Health UK, 2002; Staniszewska and Henderson, 2005). The central themes emerging from these different initiatives have been the need to place patients central to healthcare provision and, subsequently, to re-design the service delivery according to their needs.
35
Patient satisfaction with health care services reflects the quality of care provided and is frequently considered an important indicator of quality care (Redmond and Sorrell, 1999). Risser (1975) describes patient satisfaction with nursing care as the degree of congruency between a patient’s expectation of ideal nursing care and his/her perceptions of real nursing care he/she receives. However, while the employment of patient satisfaction surveys remains integral to the current Irish Health Service’s quality initiatives, their use is plagued with growing criticism (Currie et al., 2005). Specific criticisms are that they give little understanding of how patients evaluate their care (Avis et al., 1995), lack any clear conceptual or theoretical basis (Bond and Thomas, 1992) and fail to elicit patients’ feelings, values and experiences (Hiidenhovi et al., 2002). In addition, the findings are difficult to interpret, their validity is doubtful and, ultimately, they distort the actual level of satisfaction (Edwards, 2000). Therefore, rather than surveying patients’ satisfaction, the author surveyed their experiences of triage, following the change initiative. Evidence to date reveals that whilst waiting times continue to be problematic, patients’ anxieties and psychological concerns are addressed more holistically. Indeed, Stewart (1995) suggests that increased concordance and resolutions of concerns have been attributed to approaches that are more people-centred. Audit of the nurses’ triage practices was carried out concurrently, while the patients’ experiences were being surveyed. The literature contends that change is not consolidated without continuous monitoring and observation (Smale, 1998). Furthermore, Dale (1994) asserts that internal auditing, scrutiny of records and objective observation help discover what is currently taking place. Since the triage training, all participants have reported that they have developed more confident attitudes towards their role in triage decision-making. They reported that their changed concept of triage has given them more autonomy and satisfaction in performing triage. Ongoing audits have reflected that nurses are now framing their triage decisions in a humanistic context, rather than with an overreliance on a medical framework.
Conclusion The philosophy of people-centred care is constructed on the premise that the patient is not a passive recipient of care and it recognizes the importance of patients’ knowledge and experience. In the context of emergency nursing, the
36 practice of people-centred care requires a significant shift in thinking, from an over reliance on a medical model towards a more holistic approach. Consequently, the author, as change agent, initiated a change in triage training in an emergency department and discovered that the concepts and processes involved in change are challenging and complex. Lewin (1951) seminal model was used to guide the process throughout the change period. Despite the ensuing obstacles, the changes in triage training proved to enhance people-centred care, in the emergency department.
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Translating change: The development of a person-centred triage training programme Poggenpoel, M., 1992. Managing change. Nursing RSA, Verpleging 7, 28–31. Pryjmachuk, S., 1996. Pragmatism and change: some implications for nurses, nurse managers and nursing. Journal of Nursing 4, 201–205. Redmond, G.M., Sorrell, J.M., 1999. Studying patient satisfaction: patient voices of quality. Outcomes Management for Nursing Practice 3 (2), 67–72. Reed, S., George, S., Westlake, L., Williams, B., Glasgow, F., Potter, T., 1992. Piloting an evaluation of triage. International Journal of Nursing of Nursing Studies 29, 275–288. Reece, I., Walker, S., 1997. Teaching, Training and Learning. Education Publishers, Sunderland. Risser, N.L., 1975. Development of an instrument to measure patient satisfaction with nurses and nursing care in primary care settings. Nursing Research 24 (1), 45–52. Rogers, E.M., 1983. Diffusion of Innovation, 3rd ed. Free Press, New York. Smale, G., 1998. Managing Change through Innovation. The Stationary Office, London. Staniszewska, S., Henderson, L., 2005. Patients’ evaluations of their health care-the expression of negative evaluation and the role of adaptive strategies. Patient Education and Counselling 55, 185–192. Stewart, M., 1995. Effective physician patient communication and health outcomes: a review. Canadian Medical Association Journal 152 (9), 1423–1433.
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Tappen, R., 1995. Nursing Leadership and Management Concepts and Practice, third ed. F.A. Davis Company, Philadelphia. Thompson, F.D., Dains, F.E., 1982. Comprehensive Triage: a Manual for Developing and Implementing a Nursing Care System. Reston Publishing Company, Virginia. Tross, G., Cavanagh, S.J., 1996. Innovations of nursing management: professional, management and methodological considerations. Journal of Nursing Management 4, 143–149. White, G., 1998. Planned change. In: Rocchiccioli, J.T., Tilbury, M.S. (Eds.), Clinical Leadership in Nursing. WB Saunders Company, Philadelphia. Wilkin, K., Slevin, E., 2004. The meaning of caring to nurses, an investigation into the nature of caring work in an intensive care unit. Journal of Clinical Nursing 13 (1), 50–59. Williams, B., Coyle, J., Healy, D., 1998. The meaning of patient satisfaction: an explanation of high reported levels. Social Science and Medicine 47 (9), 1351–1359. Williams, B., Grant, G., 1995. Defining people centredness. Making the implicit explicit. Health Social Care in the Community 6, 84–94. Wiman, E., Wikblad, K., 2004. Caring and uncaring encounters in nursing in an emergency department. Journal of Clinical Nursing 13 (4), 422–429. Winefield, H.R., Murrell, T., Clifford, P., Farmer, E., 1996. The search for reliable and valid measures of patient-centredness. Psychology and Health 11, 811–824. Zukowski, B., 1995. Managing change before it manages you. Med-surgery Nursing 4, 325–330.
Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/aaen
Translating change: The development of a person-centred triage training programme for emergency nurses Barry McBrien MSc (Hons), BSc (Hons), PG Dip., PG. Cert., RGN (Co-ordinator Post Graduate Diploma in Emergency Nursing) * Centre for Nurse Education, Mater Misercordiae University Hospital, Nelson Street, Dublin 7, Ireland Received 25 January 2008; received in revised form 18 July 2008; accepted 27 July 2008
KEYWORDS
Within health care, there has been a change in practice from an illnessorientated service to one that is more health-focused and person-centred. The concept of person-centredness is frequently espoused by practitioners as being not only a desirable, but a necessary element of health care provision. Indeed, nationally and internationally, person-centred care has underpinned many healthcare documents and policies. Person-centred practice focuses on providing care, utilising a variety of processes that operationalise person-centred nursing and include working with patients0 beliefs and values, engagement, presence, sharing decision-making and providing for physical needs. In the field of emergency nursing, the incorporation of person-centred care and its holistic foundation may require a significant shift in practice. There is evidence to suggest that emergency nurses view their role as one, which is predominantly concerned with providing urgent physical care, rather than one, which espouses the theories of holistic healthcare. To this extent, being person-centred in the context of emergency care, requires the nurse to move beyond the traditional notions of his/her role and to embrace the more holistic aspects of patient care. The aim of this article is to critically analyse how a change in nurse-led triage training in one Irish Emergency Department facilitated an improved person-centred approach in practice. c 2008 Elsevier Ltd. All rights reserved.
Abstract
Change; Lewin0 s model of change; Person centeredness; Triage
Introduction
* Tel.: +353 1 8032648. E-mail address: [email protected]
While change is a constant in the health care field, it is faster and more complex than ever before (Mannion, 1994; White, 1998). Poggenpoel (1992)
1755-599X/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2008.07.010
32 affirms that change may lead to real innovation, providing abundant opportunities for creating a better way forward. However, the process of leading successful change requires effective communication, wide participation, facilitation and manipulating different interests towards the agreed goal (McLaren and Ross, 2000). Indeed, the ability to manage and lead change has become an essential skill for all nurses (Dampour, 1987; Glynn, 1989; Zukowski, 1995; Pryjmachuk, 1996). The overall aim of this paper is to critically analyse how a change in nurse-led triage training in one major Emergency Department (ED) facilitated an improved people-centred approach in practice. Firstly, a rationale will be presented for changing the current triage training programme. Various definitions of the terms ‘people-centeredness’ and ‘change’ will then be explored, followed by an analysis of the contemporary literature on these issues. A discussion will then follow, outlining the obstacles the author encountered in changing the triage training system. The paper will conclude with an evaluation of the change process involved and how it enhanced care in the ED.
B. McBrien delays in women with myocardial infarction, revealed that triage nurses experience significant difficulties in assessing women with the symptoms of myocardial infarction, with a resulting delay in their pathway to reperfusion therapy. Whilst these difficulties in assessment can, in part, be attributed to the atypical presentation of women experiencing a myocardial infarction, nevertheless, the authors state that inappropriate decisions by triage nurses can expose women to a greater rate of life-threatening complications and less favourable outcomes. Furthermore, anecdotal evidence would suggest that nurses feel a need for continuing education about triage. This indicates that existing education regarding nurse triage may be inadequate and may not equip nurses with the necessary skills to perform triage properly. In order to bridge this practice-totheory gap, the writer has introduced a mandatory triage study day. It is hoped that this change initiative will help ED nurses to develop the necessary skills to triage competently and, ultimately, to make an important contribution to improving patients’ experience of attending ED’s.
People-centred care Rationale for changing triage training Triage is defined as the process of sorting and prioritizing patients for care (Estrada, 1981; Thompson and Dains, 1982; Reed et al., 1992; Handysides, 1996; Manchester Triage Group, 1997). Implementation of nurse-led triage systems in emergency departments began in the early 1960s, when the demand for emergency services exceeded resources (Gerdtz and Bucknall, 2001). When performed in the ED, the aim of triage is to ensure that patients are treated in the order of their clinical urgency and that they receive treatment in a timely and appropriate manner (Australian College for Emergency Medicine, 2000). To triage appropriately, the practitioners need to have an understanding of the triage process, and nurse education should equip them with this knowledge (Gerdtz and Bucknall, 2001). Recent research, in conjunction with anecdotal evidence, suggests that nurse education may be falling short in this regard (Clarke et al., 2006). Accordingly, Goransson et al. (2005) investigated how nurses performed triage in Swedish ED’s. Results revealed that there was considerable diversity in the way in which triage nurses assessed and prioritized patients pointing to a significant safety risk for patients. Moreover, in an Irish context, a study by O’Donnell et al. (2005) investigating in-hospital
People-centred care has exerted a considerable influence on policy, practice and academic literature, particularly in nursing (McCormack, 2004). Concomitantly, in an Irish context, people-centredness is one of the four principles that have underpinned the Government’s Health Strategy (Department of Health, 2001). Despite this proliferation of activity and the ensuing political discourse, there is still a great deal of ambiguity surrounding the meaning of people-centred care (McCormack, 2004). Winefield et al. (1996) describe people-centred care as the optimum way of delivering healthcare and is defined as ‘valuing people’. More recently, it has been depicted as care that respects others as individuals and is organized around their needs (DoH, 2002). Elsewhere, Kitwood (1997), describes the concept as a standing or status that is bestowed upon one human being, by others, in the context of a relationship and social being. People-centredness is therefore the application of healthcare that focuses on individuality. It implies mutuality as central to its philosophy in terms of the healthcare provider and healthcare consumer. In order to be people-centred and to value individuals, there is a requirement to appreciate the totality of the individual and not merely to concentrate on a specific role (Williams and Grant, 1995). Adopting a people-centred approach to practice re-
Translating change: The development of a person-centred triage training programme quires that health professionals think beyond concepts of cure based on scientific facts and technical competence, to the adoption of a more holistic approach that also incorporates values (Hope and Fulford, 1994). In the field of ED nursing, the incorporation of people-centred care and its holistic underpinnings may require a significant shift in practice. There is evidence to suggest that ED nurses view their role as one which is predominantly concerned with providing urgent physical care, rather than one which espouses the theories of holistic healthcare (Byrne and Heyman, 1997; Dolan, 1998; Wiman and Wikblad, 2004). Moreover, Wilkin and Slevin (2004) aptly suggest that while establishing physical priorities acts as a coping mechanism for the nurse, this practice may ultimately result in the neglect of the patient’s psychological well-being. To this extent, being people-centred in the context of the ED, requires the nurse to move beyond the traditional notions of their role and to embrace the more holistic aspects of patient care.
Change The concept of change may simply be defined as ‘to make or become different0 (Mc Leod and Hanks, 1982, p. 72). Planned change represents an intentional attempt to improve operational and managerial effectiveness (Baulcomb, 2003). Although the focus of this paper is on planned change, it is important to note that change often unfolds in an apparently spontaneous and unplanned way. Tappen (1995, p. 108) refers to unplanned change as ‘‘emergent change’’ and describes it as a sudden, forceful break in continuity. Indeed, in a healthcare context, change rarely occurs in a linear fashion and often displays the properties of emergence (Boshoff, 2005). Change is therefore fundamentally a process of making different, in an attempt to improve the organisational effectiveness. It is characterised by planned change or unplanned change which is often embraced by an organisation as complex as the healthcare service. Undoubtedly, EDs have undergone significant change in recent years. Accordingly, the throughput and acuity of patients have increased, while concomitantly, the technical and clinical management of these patients has improved (Dolan, 1998). Managing change is seen as being skilled at creating, acquiring and transferring knowledge, thereby modifying its behaviour to reflect new knowledge and insights (Garvin, 1993). Therefore, an effective manager needs insight and knowledge into change theories (Mc Phail, 1997). Poggenpoel
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(1992) states that for nurses to view change as a challenge and to manage it pro-actively and creatively, they need to understand change as a phenomenon, identify the key emotional reactions associated with change and know how to manage change in a positive manner. Moreover, if change is approached with a certain level of excitement and enthusiasm, it will create opportunities that will make the lives of patients better (Muller, 1992). The force field model described by Lewin (1951) appears to be the most favoured approach in the nursing literature. This method divides the change process into three phases: unfreezing, changing and refreezing (see Fig. 1). It emphasises the need to ensure that the driving forces outweigh the resisting forces. Lewin (1951) argued that the nature and pace of change depends upon the balance of driving and restraining forces, in relation to a particular change. In spite of this, Rogers (1983) claims that the process of adopting any change is more complex than the three steps outlined by Lewin (1951). Conversely, Rogers’s rational model describes a five-stage process in the cycle of change (Rogers, 1983). This step-by-step, logical approach allows the agent to optimise and tailor his/her change programmes in order to maximise the chances of success. Tross and Cavanagh (1996) refute this position and assert that change is not a sequential process. Additionally, Roger’s model is built on the premise that people and organisations are capable of acting in a completely rational and logical manner (McWhinney, 1992). Lewin’s seminal model was chosen to underpin the change initiative, presented by the author. In conjunction with this model, a normative re-educative approach was utilised and this enables the individuals undergoing the change to participate in identifying the problem, choosing the solutions and implementing the change (Haffer, 1986).
Implementation of the change process Overall, most nurses were keen to be involved in the change initiative as they hoped that it would
Unfreezing
Figure 1
Changing
Refreezing
Lewins model of change.
34
B. McBrien
benefit them. A focus group was established consisting of staff nurses and clinical nurse managers. The two main benefits they perceived were that they could be involved in identifying any education gaps in the current programme by their participation and that they could become involved in developing a programme which would address their individual triage training needs. The focus group interview facilitated a partial diagnosis of the problematic areas of the triage training system. On the other hand, it was difficult to explore the inherent issues in totality as initially a number of senior nurses had declined to participate. However, involvement of all grades of staff in this change process was a central tenet of this project. In addition, a number of these senior nurses had been identified as driving forces in the force field analysis (see Fig. 2). To this extent, Kennedy (2000) asserts the importance of active involvement of all necessary stakeholders, in order for the change to be successful and lasting. In order to develop a greater collaboration, a meeting was held with senior nurses, junior nurses and the author as change agent. Fitzgerald (2002) argues that, to enhance motivation and commitment to change, a supportive atmosphere of collaborative working is imperative. Likewise, Smale (1998) highlights the benefits of actively involving staff that are closest to the problems, by explaining that they are closest to the solution. On this occasion, information concerning the change was provided through a discussion and presentation of research findings regarding ED nurses’ triage practices. In this respect, educating people about the need for the change and its potential benefits is vital and may potentially help to overcome resis-
tance (Griffin, 1993). Indeed, this increased knowledge about triage served to create dissatisfaction with the current triage training system. Tross and Cavanagh (1996) claim that dissatisfaction with the status quo is the most influential factor in the initiation of change. However, rather than being an education issue, two nurses claimed that it was an experiential issue and subsequently suggested that it was a lack of experience that was causing the difficulties in triage. Cognisant of the normative re-educative strategy that was employed in the change process, provision was made to listen to and validate the resistors’ feelings. Nonetheless, it was asserted that if nurses did not have the theoretical knowledge, which underpins the skill of triage, they would be unlikely to be competent practically in this area (Reece and Walker, 1997). Accordingly, the resistors’ position was weakened by providing them with copious amounts of evidence to support the introduction of the project. A consensus was then reached and actions were prioritised for the change initiative in triage training. In line with the force field analysis, resources had been identified as a restraining force in the implementation of this change project. For example, administrative support was essential to the success of the triage training program. Other necessary resources included equipment and sufficient time to train staff. Accordingly, a proposal was compiled and sent to the nursing management of the ED. A subsequent meeting was arranged with the senior nurse manager and the Co-ordinator of Practice Development. Whilst, overall, the nurse managers were positive towards the change, the focus appeared to concentrate on funding issues
Force against Change
Forces for Change Dissatisfaction with current triage training.
Cost
Promote patient centred . approach
Plan:To develop a person-centred triage training programme.
Human and Physical Resources
Nursing staff resistance to the change in triage training.
Promote patient satisfaction with Triage
Improve nurses’ decisionmaking skills regarding
Time
Figure 2
Force field analysis.
Translating change: The development of a person-centred triage training programme rather than on improving the quality of the triage service. Moreover, it was articulated that the author required more support to implement the change successfully. Haynes (1992) suggests that it would be useful if all nurses could act as change agents. However, Jackson (2000) affirms that the way in which new ideas are accepted is very dependent on the status of the person who suggests the change. Therefore, in order to overcome this resistance, the author enlisted the support of a Lecturer in Emergency Nursing to act as an external change agent. White (1998) suggests that having an objective person from outside the department taking on responsibility for introducing the change, may help facilitate the introduction of the change. Perhaps, not unsurprisingly, with the participation of the external change agent, the ED managers endorsed the implementation of the triage training programme. In addition, the external change agent was instrumental in securing funds for resourcing the programme.
Evaluation The quality of the triage training was evaluated throughout the programme and one month following its completion. This concurs with Coghlan and Mc Auliffe’s (2003) view, where they identify the need to evaluate the process as well as the product, of the change. Elsewhere, Koch (1992) suggests that defining quality is a fruitless debate, as quality is a social construct influenced by an individual’s values, expectations and the role of the health care system. In other words, quality can mean different things to patients, healthcare providers and organisers (Ludwig-Beymer et al., 1993). Furthermore, it has been claimed that it is necessary to combine the perspectives of patients and healthcare providers when evaluating quality (Ashley, 2000). In order to ensure the change initiative facilitated an improved people-centred approach, both nurses’ and patients’ views were ascertained on triage practices. Patient evaluation has become a key component in the assessment of healthcare quality (Williams et al., 1998). Indeed, the importance of patients as evaluators of the quality of care is increasingly emphasized by health policy and recent government legislation (Department of Health UK, 2002; Staniszewska and Henderson, 2005). The central themes emerging from these different initiatives have been the need to place patients central to healthcare provision and, subsequently, to re-design the service delivery according to their needs.
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Patient satisfaction with health care services reflects the quality of care provided and is frequently considered an important indicator of quality care (Redmond and Sorrell, 1999). Risser (1975) describes patient satisfaction with nursing care as the degree of congruency between a patient’s expectation of ideal nursing care and his/her perceptions of real nursing care he/she receives. However, while the employment of patient satisfaction surveys remains integral to the current Irish Health Service’s quality initiatives, their use is plagued with growing criticism (Currie et al., 2005). Specific criticisms are that they give little understanding of how patients evaluate their care (Avis et al., 1995), lack any clear conceptual or theoretical basis (Bond and Thomas, 1992) and fail to elicit patients’ feelings, values and experiences (Hiidenhovi et al., 2002). In addition, the findings are difficult to interpret, their validity is doubtful and, ultimately, they distort the actual level of satisfaction (Edwards, 2000). Therefore, rather than surveying patients’ satisfaction, the author surveyed their experiences of triage, following the change initiative. Evidence to date reveals that whilst waiting times continue to be problematic, patients’ anxieties and psychological concerns are addressed more holistically. Indeed, Stewart (1995) suggests that increased concordance and resolutions of concerns have been attributed to approaches that are more people-centred. Audit of the nurses’ triage practices was carried out concurrently, while the patients’ experiences were being surveyed. The literature contends that change is not consolidated without continuous monitoring and observation (Smale, 1998). Furthermore, Dale (1994) asserts that internal auditing, scrutiny of records and objective observation help discover what is currently taking place. Since the triage training, all participants have reported that they have developed more confident attitudes towards their role in triage decision-making. They reported that their changed concept of triage has given them more autonomy and satisfaction in performing triage. Ongoing audits have reflected that nurses are now framing their triage decisions in a humanistic context, rather than with an overreliance on a medical framework.
Conclusion The philosophy of people-centred care is constructed on the premise that the patient is not a passive recipient of care and it recognizes the importance of patients’ knowledge and experience. In the context of emergency nursing, the
36 practice of people-centred care requires a significant shift in thinking, from an over reliance on a medical model towards a more holistic approach. Consequently, the author, as change agent, initiated a change in triage training in an emergency department and discovered that the concepts and processes involved in change are challenging and complex. Lewin (1951) seminal model was used to guide the process throughout the change period. Despite the ensuing obstacles, the changes in triage training proved to enhance people-centred care, in the emergency department.
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