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Discussion

Reflections by clinical nurse specialists on changing ward practice

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Changing practice can be difficult to implement and sustain. Clinical nurse specialists should work with ward managers and need effective change management skills

 

In this article…

  •  How nursing competencies can be used to change practice
  •  Leadership styles and their influence on successful change
  • How leadership styles affect changes to practice

 

Author

Catherine Thomas and Angie Ramcharan are both palliative care clinical nurse specialists at North Middlesex University Hospital Trust

Abstract

Thomas C, Ramcharan A (2011) Reflections by clinical nurse specialists on changing ward practice. Nursing Times; 107: 30/31, early on-line publication.

In September 2010, palliative care clinical nurse specialists at North Middlesex University Hospital Trust introduced competencies for all nurses in setting up and using syringe drivers.

This was done after the trust identified a high level of clinical incidents involving syringe drivers.

This article discusses how the competencies were implemented and assessed, explores the importance of understanding change management to achieve change, and how different leadership styles affect changes to practice.

Keywords: Leadership, Change, Competencies, Syringe driver

  • This article has been double-blind peer reviewed

  

5 key points

  • Clinical nurse specialists must work closely with ward managers to implement new policies across a hospital
  • The relationship between the ward managers and the CNS is a key to successful change in practice
  • When planning change, prepare staff through launch events or focus groups
  • The CNS must appreciate the demands made on nurses trying to implement new policies
  • It is essential that nurses have knowledge and understanding of leadership theories, and adapt and apply these when managing change

 

In September 2010, palliative care clinical nurse specialists (CNSs) at North Middlesex University Hospital Trust introduced competencies for all nurses in setting up and using syringe drivers.

Syringe drivers deliver continuous subcutaneous infusions. One type of device had been removed from practice following an increase in clinical incidents but the trust continued to have a high level of clinical incidents involving syringe drivers. This highlighted a need for education and training in their use.

The CNS who had been trained by the device manufacturers educated ward managers and senior staff nurses, who then trained other ward staff. After this had taken place, an audit established how many staff were competent in setting up and using syringe drivers.

Although some clinical areas met the required standards, the audit results showed others did not (Fig 1). We wanted to find out why there was such a variation.

Explaining the audit

The reasons why some areas were not meeting the standards were analysed by the palliative care CNS team. Each clinical area had different daily workload demands. They were also short-staffed through sickness absence, annual and maternity leave and staff shortages.

Although staff felt they had the necessary skills for setting up and using syringe drivers, the audit demonstrated significant variances in competency depending on the clinical area. Staff also felt the change had been imposed on them needlessly.

The relationship between the ward managers and the palliative care CNSs was key to successful change in practice. Managers who were more experienced in their roles appeared to be more committed to ensuring their staff were competent. Those who used syringe drivers infrequently appeared to see the training less of a priority as they had other educational requirements simultaneously.

The CNS recognised the need to appreciate the demands made on nurses, and where adaptations and innovations would be required to improve service delivery.

It was evident that the ward managers and CNSs had different leadership styles and this led the palliative care CNS to explore the literature about change. The aim was to understand the concepts of leadership, and its implications for successful change management.

Defining clinical leadership

Differentiating between leadership and management styles is essential to understand how these styles apply to change management in practice.

Bernhard and Walsh (1995) said leadership is a process that influences groups in setting and attaining goals. Govier and Nash (2009) argued that management is about “doing things right”, and leadership is about “doing the right things”.

Clinical leadership has been identified as a major factor influencing the quality of care. However, there is a lack of preparation for this significant role (Dierckx de Casterlé et al, 2008).

Harper (1995) defined a clinical leader as one who is proficient in their area of practice, and use interpersonal skills to enhance care. Cook and Leathard (2004) identified attributes of effective clinical leaders, such as creativity, being influential, and respecting and supporting others. Senior nurses should apply these characteristics to their work to be clinically credible in practice development.

Discussion

Planned change is a sequence of events implemented to achieve goals. The audit demonstrated that we had not achieved this.

Change involves preparing an organisation to accept that it is necessary, and involves breaking down the status quo before a new way of operating can be built (Barr and Dowding, 2009).

Table 1 shows how many RGNs achieved competence after receiving syringe driver training; our aim was that all nurses in all wards would have been signed off as competent. Our audit suggests we should have used a structured framework to facilitate a more seamless transition during the change process.

On reflection, Lewin’s theory (1951) would have been an appropriate model to use. The palliative care team appreciated that the task they set out to achieve was huge and staff already had the pressure of other compulsory training programmes.

Staff had said this change was imposed on them needlessly. They had felt that they were competent in the skills to set up and use these devices, but the audit demonstrated that competency depended on the area they worked in.

The first stage in Lewin’s change theory is to “unfreeze” behaviours so the need for change can be accepted. Change involves overcoming inertia and dismantling the existing “mindset”; defence mechanisms have to be challenged.

The unfreezing process is often the most difficult and stressful as it may evoke strong reactions in individuals. This occurred as staff questioned why they needed to be assessed.

In the second stage of Lewin’s theory, change occurs. This transition may be fraught with confusion and uncertainty. The palliative care team had clear aims and objectives to standardise the competencies for all nurses in the organisation but this had met resistance on some wards.

The third and final stage of Lewin’s theory is called “refreezing”. This occurs when those involved alter the status quo to create a new culture.

On some wards, this may not have been achieved. The palliative care CNS needed to maintain vigilance and check whether staff were completing workbooks and that ward managers were setting timescales for staff to achieve competencies. Whether the training was linked to individuals’ professional review very much depended on the ward managers’ assistance.

It became apparent that individual managers and CNSs had different styles of leadership, which may have contributed to variation in performance. The relationship between the ward managers and the palliative care CNS was a key issue in successful change.

Kerfoot (1996) suggested there is a need to recognise the emotional needs of self and others to become more proficient in practice. Moreover, successful partnerships are built on a foundation of ongoing dialogue (Tornabeni and Fitzgerald Miller, 2008). It was evident that the CNSs needed to recognise and appreciate the demands of clinical care.

Relationship-building is essential and emotional intelligence plays an important part in forming successful human relationships. Emotional intelligence is identified by Goleman (1998) as interpersonal intelligence that consists of self-awareness, self-regulation, motivation, empathy and social skills; these are relevant to nurses because they interact with others.

Emotional intelligence requires that emotions are recognised. The concept provides understanding of how the emotions experienced by individuals affect the work of the team (Druskat and Wolff, 2001). We hope that by building on relationships with ward staff, we will promote effective communication and this will lead to successful change management.

Conclusion

Nurses need to know about and understand leadership theories, and learn to adapt and apply them when managing change.

The knowledge gained from the audit has provided an insight into the “balancing act” required in today’s healthcare. While our primary aim is providing quality care, the political, financial and organisational demands faced by staff need to be recognised and addressed before any planned changes to practice can be effective.

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