The NHS Institute for Innovation and Improvement (2001) provides guidelines on changes in the shift handover process. The guidelines highlight several steps that should be followed when implementing the change. The first step is the preparation stage which prepares the ground for the new handover process (NHS Institute for Innovation and Improvement, 2001). The second step in the change process is the assessment stage. The aspects that should be assessed include the process involved in the handover, accidents, errors and near misses, patient experience, and staff experience. The third stage is the diagnosis stage, which involves trying out different strategies that could address the problems experienced by both the staff and patients during the handover process (NHS Institute for Innovation and Improvement, 2001). This strategy also involves the patient in the process hence the patient feels part and parcel of his care (Chaboyer, McMurray & Wallis, 2009). After diagnosing the problems and discussing the best solutions to the problems, the next step is to plan for the new handover process.
The NHS Institute for Innovation and Improvement guidelines have been used successfully to change the manner in which some wards carry out their handover processes. For instance, Rudd (2010) conducted a study to examine the change in handover implemented by University Hospitals Coventry and Warwickshire NHS Trust. The main goal of the ward’s change in the handover process was to save time that could be spent on providing care to patients. The ward manager involved all the staff of the ward in the change process, believing that the success and sustainability of the change could only be achieved if all staff members were involved. Following the NHS guidelines, such as recording the handover process and regular evaluation of performance, the team at the ward was able to increase the amount of time spent on direct patient care by 28 percent and to reduce the rate of sickness to a minimal level.
Using Kurt Lewin’s Change Theory to Implement Handover Change in the Bone Marrow Transplant Unit
The three-step change model was formulated by Kurt Lewin in 1951. According to Lewin, “behavior can be seen as a dynamic balance of forces working in opposing directions,” (Marquis & Huston, 2008, p. 168). The theory has three main stages.
According to Lewin’s three-step theory, the first step in bringing about change is known as the unfreezing stage. This implies the unfreezing or undoing of the current state or the status quo. Unfreezing is a crucial stage in defeating the limitations brought about by individual opposition and or group conformity (Marquis & Huston, 2008). Lewin’s first step of change can be used in bringing about change in the manner in which patients are handed over by the off-going nurse to the oncoming nurse. The nurse manager, acting as the key change agent, recognizes the necessity of doing things differently so as to reduce the disruptions to patient care and the communication errors that result from inaccurate information passed from one nurse to another during the change of shift. The nurse manager then creates awareness among the staff members and together they brainstorm for possible solutions to the problem (Meleis, 2007).
During the unfreezing stage, a SWOT analysis is conducted to identify the strengths, weaknesses, opportunities and threats to the proposed change.
A willing and motivated nursing team
Good working environment
Committed leadership and management
Lack of prior experience in bedside handover
Increasing pressure from patients to be involved in their care
Existence of guidelines on the implementation of bedside handovers such as NHS Institute for Innovation and Improvement
Existence of best practice studies on bedside handovers
Resistance from a few nurses to adopt bedside handover practice, claiming lack of time for meetings between the off-going and oncoming nurses
The second stage in Lewin’s theory of change is referred to as the movement stage. Roussel and Swansburg (2006) argue that “in this step, it is necessary to move the target system to a new level of equilibrium,” (p. 63). The team creates a plan of action that will be followed by the nurses and staff members involved in the handover process. The first plan of action is to improve communication between the off-going and oncoming staff members during a shift change. Rather than communicating via the telephone and fax machine, the team will meet at the bedside of each patient fifteen minutes before the beginning of the new shift. The team members will discuss the reports prepared by the off-going team and the progress of the patient. The off-going team should also introduce the oncoming team to the patients. The aim of this plan of action is to reduce communication errors that arise from incomplete and inaccurate information pertaining to the patient (Davies & Priestly, 2006; Scovell, 2010).
Management and leadership style
The success of the proposed bedside handover process depends largely on the management and leadership styles adopted by the nurse manager. To ensure the effectiveness and sustainability of the proposed change, the nurse manager should utilize a participative leadership style rather than the authoritative style. The participative style of leadership involves other members of the team in the change process whereas in the authoritarian style the leader makes all the decisions regarding the required change (Romano, 2009). Involving other staff members in such a decision is important because the leader is able to know what the others think of the proposed change, their fears, and their readiness (or lack of it) to adopt the change. The leader can then take appropriate measures to encourage the employees to adopt the proposed change, for instance, through training. This process is lacking in the authoritarian leadership style because the leader gives orders about what should be done and how it should be done without taking into consideration the feelings of the employees.
Unlike the authoritarian leadership style, participative leadership is about having a shared vision and common goal (Baker & McGowan, 2010). This leadership style is effective in motivating staff members to change the way things are done. Because the staff members are made part of the change process right from the beginning, they feel appreciated and therefore are more likely to ensure the sustainability of the change rather than when the change is pushed down their throats like in the case of the authoritarian style of leadership (Kenmore, 2008).
The third stage in Lewin’s theory of change is referred to as the refreezing stage. This stage entails incorporating novel values into the organizational culture. Swansburg and Swansburg (1995) argue that “the purpose of refreezing is to stabilize the new equilibrium resulting from the change by balancing both the driving and restraining forces” (p. 251). One strategy that can be used to achieve sustainability of change is to reinforce new behaviors and make them part and parcel of the organizational culture through both formal and informal means, for instance, through legislations, processes and organization’s policies.
One important element of the refreezing stage is the evaluation of the effectiveness of the new handover process. Evaluation can be done on a quarterly basis through surveys, patients’ records and progress reports (Maurer & Smith, 2005). The importance of evaluation is that it can bring to light the challenges facing the change implementers as well as the strengths and weaknesses of the proposed change. This can help the unit to revise the proposed change if and when the need arises (Ziegler, 2005).
Handovers play important functions such as passing on important patient information from one nurse to another. Thus said, the manner in which the handover is done has a great impact on the quality of care provided to patients. This report has proposed a change of handover style from the traditional office handover to bedside handover. The change has been proposed in accordance with the guidelines published by the NHS Institute for Innovation and Improvement. It is believed that the bedside handover process will reduce communication errors and enhance the quality of patient care through comprehensive communication of patient information between the nurses involved in the handover process. The new style will also reduce the time spent in the handing over process and increase the amount of time spent on providing care to each patient.
The success of the shift from traditional to bedside handover practice will depend on many factors. The change agent is instrumental in making this shift a success. The change agent should be internal, that is, someone who has worked in the organization for many years and knows the organizational staff well. The change agent should most likely be the nurse manager. The nurse manager has experience working in different organizational units and with nurses of a different temperaments. She is therefore in a better position to implement the proposed change successfully. The nurse manager will also lead the team in the adoption of the proposed change. As a good leader, the nurse manager should involve all the team members in the preparation, planning, implementation, and evaluation stages to ensure the sustainability of the change. The organizational unit should also conduct a SWOT analysis to identify its available resources and the resources that it lacks but yet will play a critical role in making the shift from the traditional to the bedside handover process.
The effectiveness of the proposed change in the handover from traditional to bedside handover will be determined by the results of the evaluation process. Such effectiveness will be evidenced by the positive patient and staff outcomes such as shorter hospital stays, shorter time spent in the handover process, staff satisfaction with the new handover process, and a reduction in the number of adverse events such as near misses and communication errors. However, if the evaluation shows a negative impact (or no improvement at all), the nurse manager should re-assess the proposed change and identify the weaknesses and challenges. The proposed change should then be re-designed to address the weaknesses and challenges.
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