A team of community nurses was encouraged to adapt an electronic patient caseload tool by making sure they were all involved in its development and implementation
In this article…
- Why nurses need to adapt to new ways of working
- Approaches to implementing structured changes at work
- Predicting how people will react to change
- How to encourage people to embrace change in daily practice
Ben Bowers is community charge nurse, Cambridgeshire Community Services Trust, and a Queen’s Nurse.
Bowers B (2011) Managing change by empowering staff. Nursing Times; 107: 32/33, early online publication.
Nurses must constantly adapt to a variety of radical and incremental changes in the way they work, but their emotional responses can inhibit changes from being sustained in practice.
Implementing sustainable and meaningful change means supporting each individual to find value in new ways of working. This article shows how a team of community nurses were empowered to improve their practice by using an electronic caseload tool. This was done in a structured and supportive way by using Lewin’s change management process, an approach that has benefits for supporting and sustaining changes in practice.
Keywords: Change process, Empowerment, Sustainable change
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article
5 key points
- Changes in practice always create emotional responses in employees
- Planning change in an open, structured way aids communication and staff participation
- Natural resistances to change must be addressed to be able to progress
- Involving everyone in the process from the start enables resistances to be examined and constructively addressed
- Change is only sustainable if everyone involved psychologically owns the new ways of working
Changes in the workplace naturally create uncertainty and can be emotionally challenging for employees. Change, particularly when it is unexpected, can undermine confidence and threaten sense of purpose (Holbeche, 2006).
The demands of healthcare mean nurses work in constantly changing environments; they must continually adapt to different demands, new technologies, government policies and other innovations.
Although commitment to new ways of working is crucial to delivering high- quality healthcare, nurses often say they feel change is imposed on them and that their views are not taken into consideration. This perception does little to empower them to own changes occurring and to adapt behaviours to sustain practice improvements.
When managing change it is important to identify with people and reduce the possible resistances they will have in accepting new ways of practising (Holbeche, 2006). Baulcomb (2003) found that successfully leading change means helping people to embrace the challenges to the point where they positively accept and psychologically own new ways of practising.
This article examines how a team of community nurses was supported as the nurses adapted to using an electronic patient caseload tool. Rather than being expected to adjust to a management-led change, the team was encouraged to own this new way of working through a structured change management process (Lewin, 1951).
Reason for change
The team of seven community nurses sees housebound patients, many of whom have complex nursing needs. Before the change, each patient’s personal details and planned visit dates were held in a handwritten visit folder. Due to space constraints, any
special instructions for the next visit would be written by hand in the team’s shared daily diary. Information on each patient’s nursing needs was often in separate, handwritten nursing notes. Each nurse would return from visits and individually update the daily diary and visit folder with future visit information.
In practice, nurses often lacked the time to do this promptly and information would become confusing. Cross-referencing all this information to allocate work was time consuming, complicated and open to errors. The system relied on the same nurses being around to hand over any important information that was not contained within the visit folder.
As team leader, I audited the time it took to organise the daily diary and visit folder as well as plan and allocate the next day’s work over the course of a week. It took an average of 40 minutes each day – not an effective use of busy nurses’ time.
About a month before making the changes, we looked at alternative options. I discussed the problems associated with the existing system with individual team members to find out their views. Each said we needed a more effective caseload management system that would be easy to use and enable any nurse to walk in and understand what was needed.
During daily team handovers, we discussed alternative methods of planning patient visits and continuity of care. Several team members said the logical answer was to use an electronic caseload Excel spreadsheet
to manage all future visit information in one place.
We set up a spreadsheet that enables the nurses to highlight any day of the week and instantly see and alter which visits are planned. Information on nursing needs is available next to the patients’ details. Any specific future interventions, such as changing a wound treatment, can be added electronically as a comment attached to the next scheduled visit. This removes many of the problems and work associated with maintaining separate handwritten systems.
Several years ago, our team had created an electronic caseload system but subsequently reverted to the handwritten version. This was mainly due to staff changes within the team; when staff moved on, fewer members of the team were comfortable using the electronic system, so nurses went back to the old, familiar paper systems. This time, we needed to ensure the change would be sustainable.
Most changes in practice fail because nurses are not supported and empowered to adjust emotionally to new ways of working (Holbeche, 2006).
Balfour and Clarke (2001) highlighted how it is tempting to revert back to familiar ways of working once those instigating pressure to adopt changes have moved on; they described a situation where a change to self-medication in an inpatient setting lasted only while the team leader was driving it. They said that, for change to be embraced and sustained, people must identify with, and value, the new ways of working.
To bring about a sustainable change in using an electronic caseload system, the whole team needed to own the change in their practice. Lewin (1951) offered a
three-step approach to implementing structured changes in the workplace. Adopting this enabled the whole team to psychologically identify with and sustain the change.
Lewin proposed that bringing about meaningful structured change meant supporting employees in psychologically “unfreezing” from a point of comfort with the current state of affairs. “Moving” can then occur, as team members are encouraged to alter their values and ideally gain ownership of the change, exploring the alternatives and defining and implementing solutions. “Refreezing” occurs once the change has become integral and established.
In the NHS, change often never truly reaches the stage of refreezing because the next change tends to interrupt or affect previous ones. Nurses often talk of “change fatigue”, viewing their professional life as being subject to unremitting changes.
For change to be embraced, it needs to be planned and implemented in a way that responds sensitively to people’s emotional reactions (Curtis and White, 2002). Lewin’s change model lends itself to healthcare practice – its three stages are comparable to the processes of planning, implementing and evaluating care.
Lewin’s “force field” analysis offers a way of analysing and predicting how people will react to a given change during the unfreezing period (Cook et al, 2004). This involves assessing the current situation and what is needed to achieve the best outcome. The assessment makes it possible to identify the driving forces for the change and the likely resisting forces against it (Fig 1).
Lewin (1951) found that ensuring staff actively participated in analysing opportunities was vital to identifying and compensating for resistant behaviours. This approach is a useful way to consider how any changes affect people emotionally and what needs addressing to help implement the changes.
Unfreezing in practice
As team leader, before instigating the change, I talked openly to everyone individually about the problems with the current caseload management system and the benefits of adopting the electronic tool.
By listening and discussing its strengths and weaknesses, I could gauge people’s perspectives. Some team members were unsure about their ability to use an electronic system, while others felt it would initially create more work or that all the data could be lost. However, everyone recognised the system would help communication and reduce duplication.
Although the process of discussing the proposed change was time consuming, it proved indispensable in involving everyone and respecting any concerns (Cook et al, 2004). This reduced uncertainty about what the change would involve (Curtis and White, 2002).
One common concern was that staff would need support in learning how to use the spreadsheet as a caseload management tool. Although all the nurses were able to use computers, their IT skills varied – some were inexperienced while others were not. To provide effective support in the first month that the new system was in place, we ensured someone experienced at using Excel spreadsheets was working alongside less-experienced colleagues every day.
We agreed we would all take turns to update the caseload to boost everyone’s confidence in taking the lead.
Resistance to change was already reduced as people could see they would be supported through the process. The team members who were more IT literate felt their skills were valuable in helping their colleagues to adapt (Holbeche, 2006).
Having identified the obstacles to and opportunities for altering practice, we began using the electronic caseload management tool; on the same day, we removed the handwritten visit folder. As Holbeche (2006) suggests, change can only be sustained while the driving forces propelling it outweigh the resistant forces against it.
The team had previously reverted to using handwritten caseload management tools because the driving forces behind the change had subsided, while the resisting forces had continued. Not everyone had been trained to use the system confidently and, once most of the individuals skilled in using the electronic caseload had moved on, the team no longer had a critical mass of people able to use the system.
Getting everyone to participate in and shape ongoing change is essential to reducing resistance (Curtis and White, 2002). As a team, we agreed on what information we wanted on the new system, and continually adapted the information, based on users’ feedback. For example, we added patients’ telephone numbers and altered how we recorded comments so everyone could easily find them. However, adaptations were limited by the software we were using and the range of IT user skills (Warm et al, 2008).
At first, some team members were reluctant to add and delete data from the caseload. Some lacked the IT skills to do this while others felt they would hold their colleagues up by taking too long or that they could inadvertently lose all the data. If these concerns about change had not been addressed, we would have had an ineffective caseload management tool in place –an unsustainable system relying on a few individuals to maintain it.
The single biggest reason technology-related healthcare projects fail is because users lack the suitable IT skills and experience (Warm et al, 2008). To boost team members’ confidence, we made the electronic caseload the focal point of daily team handovers. It is updated as patient care outcomes are discussed and future input is planned. We take turns updating the caseload during handover. This has helped to build everyone’s confidence and develop their IT skills and familiarity with the system.
The electronic caseload quickly ceased to be a metaphorical white elephant and has become an integral part of our communication culture. Supporting all members of the team as they learnt to use
the system has taken time and the commitment of everyone to support their colleagues (Cook et al, 2004).
Within four weeks of instigating the change, every nurse in the team felt confident enough to update the electronic caseload independently. Indeed, the member of the team who had been the most reluctant to update the caseload is now the first to volunteer for the role during handover. While all of us can forget to update comments from time to time, we support each other constructively to ensure the system is updated.
Through open communication and team involvement, everyone has been empowered to embrace and embed the change. Allocating patient visits now takes an average of 10 minutes a day, freeing up a substantial amount of nurses’ time.
This experience has been positive and change has been sustainable because we engaged the team and worked as a team (Baulcomb, 2003). Using an electronic caseload management tool has become an intrinsic part of our work culture.
The team has experienced being able to influence changes to their practice, which helps them to feel they will be able to influence and make the most of the opportunities from future changes.
Staff are not always actively involved in the inception and implementation of change. If behavioural resistance is not identified and worked with, they can reverse even the best-intended change projects. Equally, they may resist change because it can damage care.
Open discussions are needed to identify if change is realistic and will benefit patients and staff. Lewin’s process of managing structured change is one way in which busy leaders and practitioners can mentally step back and identify how sustainable changes can be achieved (Lewin, 1951). By helping nurses to psychologically own changes, leaders are more likely to see changes become sustained and embedded in practice.
Balfour M, Clarke C (2001) Searching for sustainable change. Journal of Clinical Nursing; 10: 1, 44-50.
Baulcomb J (2003) Management of change through force field analysis. Journal of Nursing Management; 11: 4, 275-280.
Cook S et al (2004) Change Management Excellence: Using the Four Intelligences for Successful Organisational Change. London: Kogan Page.
Curtis E, White P (2002) Resistance to change: causes and solutions. Nursing Management; 8: 10, 15-20.
Lewin K (1951) Force Theory in Social Science. New York, NY: Harper and Row.
Holbeche L (2006) Understanding Change: Theory, Implementation and Success. Oxford: Elsevier.
Warm D et al (2008) Benefits of information technology training to National Health Service staff in Wales. Learning in Health and Social Care; 8: 1, 70-80.