The Virtual Garden of Change


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The Virtual Garden of Change

  1. 1. Presented by: Simmi Prasad
  2. 2. The Target Group: Critical Care Nurses
  3. 3. The Target Group: Critical Care Nurses Critical care nurses ensure the provision of clinically effective care, which is the trademark of evidence- based practice. These practitioners recognize clinical effectiveness as “doing the right thing in the right way for the right patient at the right time” (Royal College of Nursing, 1996, p. 3), in the evaluation of patient care delivery. Furthermore, critical care nursing practice is embedded with evidence-based practice, which is a framework for clinical decision-making in the provision of patient care, and utilizes a problem- solving approach that incorporates the best evidence drawn from research, clinical expertise, and patient preference. (Porter-O’Grady, 2006)
  4. 4. Critical Care Nurses Consequently, recognizing the interplay of perspectives from numerous sources when utilizing evidence-based practice, nurses employ the processes of systematic inquiry, collaboration (for example, the collaboration between the nurse and the physician to decide the clinical relevance of this evidence for the patient), and reflective critical thinking to ensure “the nature of the evidence” is definable and defendable as clinically effective, while meeting patient care standards within the organization and optimizing patient outcomes (Fulbrook, 2003, p. 97). Thus, critical care nurses use these guiding principles to ensure clinical effectiveness is sustained in patient care delivery and quality practice environments. (Fullbrook, 2003)
  5. 5. The Context: Organizational Culture
  6. 6. The Context: Organizational Culture The organization is the most momentous contextual factor in the promotion and utilization of evidence- based practice, with an assurance for quality practice environments enforced by policies (Royle, Blythe, Ciliska, & Ing, 2000). Hence, organizations implementing evidence-base practice are considered “‘learning organizations’ … [that] are more conducive to facilitating change because they create learning cultures that pay attention to individuals, group processes, and organizational systems” (Rycroft- Malone, 2004, p. 299).
  7. 7. Organizational Culture This learning culture steps forward to meet the requirements of the “individual (personal mastery and mental stimulation), group processes (having a shared vision), and organizational systems (systems thinking)” (McCormack, Kitson, Harvey, Rycroft- Malone, Titchen, & Seers, 2002, p. 97). Consequently, the “culture is what the organization is” in terms of its vision, values, and behaviors demonstrating commitment to evidence-based practice (Scott- Findlay, 2005, p. 360). As a driving force, organizational culture adopts daily challenges and the change process to provide work environments that empower its clinicians and patients in the clinical decision-making process (Dale, 2006).
  8. 8. What needs to change? Clinical Practice Resulting in Moral Distress
  9. 9. What needs to change? Clinical Practice Resulting in Moral Distress Adversely, organizational culture can not streamline effective patient care delivery, when critical care nurses are experiencing moral distress in their endeavor to achieve optimal patient outcomes; this has been evidenced by research. These situations arise “when the nurse knows the moral value at issue, knows the ethical principles that ought to guide action and has chosen the right course of action based on these values and principles” (Fry, & Luce, 2002, p. 166). Unfortunately, these nurses are inhibited by constraints, and are unable to implement the appropriate interventions for their patients (Fry, & Luce, 2002).
  10. 10. Clinical Practice Resulting in Moral Distress For example, Meltzer and Huckabay (2004) found “the frequency of moral distress situations that are perceived as futile or non-beneficial to their patients has a significant relationship to the experience of emotional exhaustion, a main component of burnout [for critical care nurses]” (p. 202). Furthermore, McClendon and Buckner (2007) recognize that critical care nurses experience the most moral distress while caring for “critically ill patients whose families wished to continue aggressive treatment when it probably would not benefit the patient in the end” (p. 199).
  11. 11. Clinical Practice Resulting in Moral Distress Fry and Luce (2002) also admit that nurses experience moral distress as a result of constraints, such as “a lack of power or decision-making authority, institutional rules and authority over the nurse, or even lack of respect for the nurse’s role in decision making” (p. 166). Moreover, Sundin-Huard and Fahy (1999) have identified while “attempts at advocacy were unsuccessful, the nurses experienced intensified moral distress, frustration and anger” (p. 8). Moreover, Corley (2002) correspondingly notices “when a health care organization does not provide a policy that guides practice for ethically complex care, nurses experience moral distress [ 42]” (p. 641).
  12. 12. Clinical Practice Resulting in Moral Distress Corley (2002) makes the following proposition regarding the benefits of possessing an organizational culture that hinders institutional constraints, and minimizes moral distress, while ensuring effective patient care delivery:  Nurses who have high levels of ethics work satisfaction and believe that they are in a more constructive work culture[ 34] will have lower levels of moral distress.  Nurses who have good relationships with their peers, patients, managers, the hospital administration and physicians[ 39] will have less moral distress.
  13. 13. Clinical Practice Resulting in Moral Distress  Nurses who have more influence in their work environment and thus are more likely to take action to resolve ethical dilemmas[ 40] will have less moral distress.  Nurses who work in health care organizations that do not provide policies that guide practice,[ 41] provide a supportive environment,[ 42, 46] guide ethically complex care,[ 67, 68] and provide a mechanism for addressing complex conflicts with physicians[ 26, 46] will experience more moral distress.
  14. 14. Clinical Practice Resulting in Moral Distress  Nurses who work in health care organizations that encourage collaboration with physicians and the development of trust with them will experience less moral distress in ethically complex situations.[ 46]  Nurses will resort to lesser degrees of responsible subversion if the work environment supports nurse autonomy and nurses' participation in decisions.[ 41] (p. 648) Thus, organizational culture needs to eradicate constraints and change clinical practice to effectively resolve the moral distress experienced by critical care nurses working in the intensive care unit.
  15. 15. Strategies for Change: Applying Lewin’s Change Theory
  16. 16. Strategies for Change: Applying Lewin’s Change Theory In order to deal with the moral distress experienced by critical care nurses, organizations need to assess the causes of this distress, and thereafter, implement changes to end these causes; change is “the process of making something different from what it was” (Sullivan, & Decker, 2005, p. 217). This change process can be facilitated by the application of Lewin’s change theory; Lewin identifies this assessment as a force field analysis that recognizes the driving and the restraining forces involved in this change process.
  17. 17. Applying Lewin’s Change Theory Lewin understands:  behavior as a dynamic balance of forces working in opposite directions within a field (such as an organization. Driving forces facilitate change because they push participants in the desired direction. Restraining forces impede change because they push participants in the opposite direction . To plan change, one must analyze these forces and shift the balance in the direction of change through a three- step process: unfreezing, moving, and refreezing. … Basically, strategies for change are aimed at increasing driving forces, decreasing restraining forces, or both. (Sullivan, & Decker, 2005, p. 217-218)
  18. 18. Applying Lewin’s Change Theory: The Virtual Garden of Change
  19. 19. Applying Lewin’s Change Theory: Restraining Forces
  20. 20. Applying Lewin’s Change Theory: Driving Forces
  21. 21. Applying Lewin’s Change Theory For example, a change agent (“one who works to bring about change”) such as a critical care nurse can develop a survey that identifies the causes and the level of moral distress experienced by critical care nurses working in the intensive care unit (Sullivan, & Decker, 2005, p. 217). In this case, the change agent surveys her colleagues in the intensive care unit, and recognizes situations involving medical futility to be the leading cause of moral distress among respondents, practicing in Vancouver Coastal Health; medical futility is observed when certain medical treatments will provide no significant benefit to particular patients and should therefore be withheld in the treatment plan (Angelucci, 2006).
  22. 22. Applying Lewin’s Change Theory Thereafter, the change agent identifies restraining forces that will disallow critical care nurses to effectively intervene in situations involving medical futility, such as:  nurses who believe that futile care can not be successfully resolved in clinical practice using the means of organizational culture,  nurses who lack the skills of being an effective change agent,  nurses who feel threatened to change values around family-centered care (respecting the family’s wishes to avoid any unpleasant situations, and supporting them through the patient’s hospitalization, which takes precedence when planning the patient’s care),
  23. 23. Applying Lewin’s Change Theory  families who feel threatened by these health care professionals’ decision-making abilities in respect to the patients’ end-of-life issues,  physicians who believe they should have complete authority to decide when a situation is considered futile and intervene when they see fit on their patient’s behalf,  inadequate time in clinical practice to address these situations involving medical futility,  physicians who believe they should have complete authority to decide when a situation is considered futile and intervene when they see fit on their patient’s behalf,
  24. 24. Applying Lewin’s Change Theory  inadequate time in clinical practice to address these situations involving medical futility,  organizational policies that address do-not- resuscitate orders and pay no attention to situations involving medical futility,  a perceived lack of support from members of their hospital management, the interdisciplinary team, or the ethics committee to deal with this issue. Incidentally, the change agent can acknowledge the driving forces that support critical care nurses in dealing with these situations involving medical futility,
  25. 25. Applying Lewin’s Change Theory such as:  management who choose to empower critical care nurses while preventing burnout,  nursing educators who teach critical care nurses how to take ownership of their clinical practice and become effective change agents,  the involvement of the ethical committee who take the time to individually interview critical care nurses regarding this issue,
  26. 26. Applying Lewin’s Change Theory  critical care nurses that believe change is possible in clinical practice using the means of organizational culture,  critical care nurses who believe patient-centered care and patient safety is the highest priority in the intensive care unit,  members of the interdisciplinary team who also voice being morally distressed in situations involving medical futility,  physicians who value sharing the responsibility for patient care decisions with nurses,  patients who share their reasons for not prolonging their own suffering.
  27. 27. Applying Lewin’s Change Theory Consequently, while implementing Lewin’s three-step process, the change agent can now identify and implement strategies for change in organizational culture that will minimize these restraining forces and support these driving forces: 1. Unfreeze the existing equilibrium. Motivate participants by getting them ready for change. Build trust and recognition for the need to change. To thaw attitudes, actively participate in identifying problems and generate alternative solutions.
  28. 28. Applying Lewin’s Change Theory 2. Move the target system to a new level of equilibrium. Get participants to agree that the status quo is not beneficial to them. Encourage participants to view the problem from a new perspective. Stimulate identification by linking group views to those of a respected or powerful leader who supports the change. Help them scan the environment to search for relevant information. 3. Refreeze the system at the new level of equilibrium. Reinforce the new patterns of behavior. Institutionalize them through formal and informal mechanisms (e.g., policies, communications channels). (Sullivan, & Decker, 2005, p. 218-219)
  29. 29. The Unfreezing Stage, as seen in the Virtual Garden of Change:
  30. 30. The Moving Stage, as seen in the Virtual Garden of Change:
  31. 31. The Freezing Stage, as seen in the Virtual Garden of Change:
  32. 32. Applying Lewin’s Change Theory The change agent can identify strategies for change in organizational culture, to relieve moral distress among critical care nurses practicing in Vancouver Coastal Health’s intensive care unit; “strategies, such as education and communication; participation and involvement; facilitation and support; negotiation and agreement; and manipulation, cooptation, and coercion, can be used individually or in combination with each other (Kotter & Schlesinger, 1979)” (Menix, 2003, p. 131). For example, in the unfreezing stage, the change agent can have a staff meeting where group discussion can address medical futility (Menix, 2003).
  33. 33. Applying Lewin’s Change Theory Furthermore, in order to create a mutual vision and an empowering environment, the change agent can identify critical care nurses who will be able to participate in a clinical conference, a case study presentation, an ethics round, or an ethics committee where this issue can be discussed with members of the interdisciplinary team; institutional policies can be reviewed by all participants, while policy recommendations can be made to prevent future cases of medical futility and empower critical care nurses to overcome this matter (Fry, & Luce, 2002).
  34. 34. Applying Lewin’s Change Theory The lead change agent can now identify all participants as change agents taking part in this change process, while the nursing educator teaches these nurses to become effective change agents. The lead agent should also identify an efficient timeline to monitor this change process; for example, the unfreezing stage of this change process should be expected to take three month.
  35. 35. Applying Lewin’s Change Theory Secondly, in the moving stage, the lead change agent can have all participants sign a petition that addresses the need for change in institutional policies to deal with these situations involving do-not-resuscitate orders and medical futility; this petition makes evident the severity of this issue, and should be presented to the unit manager and clinical educators, who are in authoritative positions within the organization to become effectual change agents regarding this issue.
  36. 36. Applying Lewin’s Change Theory In tandem, the lead change agent can assist participants to draft regional policies that efficiently deal with this issue in organizational culture; these policies should:  Implement interdisciplinary strategies to recognize and name the experience of moral distress.  Establish mechanisms to monitor the clinical and organizational climate to identify recurring situations that result in moral distress.  Develop a systematic process for reviewing and analyzing the system issues enabling situations that cause moral distress to occur and for taking corrective action.
  37. 37. Applying Lewin’s Change Theory  Create support systems that include:  Employee assistance programs  Protocols for end-of-life care  Ethics committee  Critical stress debriefings  Grief counseling
  38. 38. Applying Lewin’s Change Theory  Create interdisciplinary forums to discuss patient goals of care and divergent opinions in an open, respectful environment.  Develop policies that support unobstructed access to resources such as the ethics committees.  Ensure nurses’ representation on institutional ethics committees with full participation in all decision making.  Provide education and tools to manage and decrease moral distress in the work environment. (American Association of Critical Care Nurses, 2008, p. 2)
  39. 39. Applying Lewin’s Change Theory The lead agent should also monitor the moving stage of this change process so that it does not take longer than six months. Thereafter, this policy can be presented to the organization’s regional policy development committee, such as the Regional Policy Team at Vancouver Coastal Health, for review; if additional assistance is required during this change process, the manager can assist these nurses by having a policy consultant and ethics committee available during these clinical conferences.
  40. 40. Applying Lewin’s Change Theory Thirdly, in the refreezing stage, the change agent can have this policy endorsed by Health Authority Groups (Health Authority Interprofessional Advisory Council, Health Authority Medical Advisory Council/Quality Care Council, and Health Authority Professions Specific Advisory Council) in Vancouver Coastal Health. Subsequently, this policy must be signed by the Vice-President (Health Services Networks, Clinical Quality and Safety) or Executive Lead for Professional Practice and Chief Nursing Officer of Vancouver Coastal Health and officially posted on the website for Vancouver Coastal Health by the Regional Policy Team; the Professional Practice Office will communicate this policy as being immediately effective in all intensive care units.
  41. 41. Applying Lewin’s Change Theory This policy can be formally communicated to nurses using the unit’s communication book, having a poster in the staff room, during a staff meeting or an education meeting, utilizing the Vancouver Coastal Health newspaper, or creating a posting on the Vancouver Coastal Health website. Furthermore, the interdisciplinary team can be formally advised of this new policy with an email or a memorandum from the unit manager or department head. Moreover, informal communication channels may involve discussing medical futility during patient rounds to ensure physician compliance with these new standards of patient care.
  42. 42. Applying Lewin’s Change Theory Lastly, the lead change agent must ensure the freezing stage of this change process should be implemented within three months. Consequently, this entire group of change agents can successfully initiate and implement change in organizational culture to reduce any moral distress experienced by critical care nurses, in cases of medical futility in the intensive care unit.
  43. 43. Now it’s time to pick those roses!
  44. 44. References  American Association of Critical Care Nurses. (2008). Position statement. Moral distress.Retrieved October 10, 2008, from  Angelucci, P. A. (2006). Grasping the concept of medical futility. Nursing Management, 37(2), 12-14. Retrieved October 10, 2008, from Academic Search Premier Database with Full Text.  Corley, M. C. (2002). Moral distress: A proposed theory and research agenda. Nursing Ethics, 9(6), 636-650.
  45. 45. References  Dale, A. E. (2006). Determining guiding principles for evidence-based practice. Nursing Standard, 20(25), 41-46.  Fry, S. T., & Luce, H. R. (2002). Appendix 1 Teaching ethics to nurses. In S. T. Fry, & M. Johnstone (Eds.) Ethics in nursing practice: a guide to ethical decision making (2nd ed., pp. 162-172). Malden, MA: Blackwell Science.  Fulbrook, P. (2003). Developing best practice in critical care nursing: knowledge, evidence and practice. Nursing in Critical Care, 8(3), 96-102.
  46. 46. References  McClendon, H., & Buckner, E. B. (2007). Distressing situations in the intensive care unit. Dimensions of Critical Care Nursing, 26(5), 199-206. Retrieved October 10, 2008, from CINAHL Database with Full Text.  McCormack, B., Kitson, A., Harvey, G., Rycroft-Malone, J., Titchen, A, & Seers, K. (2002). Getting evidence into practice: the meaning of ‘context.’ Journal of Advanced Nursing, 38(1), 94-104.  Meltzer, L. S., & Huckabay, L. M. (2004). Critical care nurses' perceptions of futile care and its effect on burnout. American Journal of Critical Care, 13(3), 202-208. Retrieved October 10, 2008, from CINAHL Database with Full Text.
  47. 47. References  Menix, K. D. (2003). Leading change. In P. S. Yoder-Wise (Ed.) Leading and managing in nursing (3rd ed., pp. 121-137). St. Louis, MO: Mosby.  Porter-O’Grady, T. (2006). A new age for practice: creating the framework for evidence. In K. Malloch, & T. Porter- O’Grady (Eds.) Introduction to evidence-based practice in nursing and health care (pp. 1-29). Sudbury, MA: Jones and Bartlett.  Royal College of Nursing. (1996). Clinical effectiveness: a Royal College of Nursing guide. London: RCN.
  48. 48. References  Royle, J., Blythe, J., Ciliska, D., & Ing, D. (2000). The organizational environment and evidence-based nursing. Canadian Journal of Nursing Leadership, 13(1), 31-37.  Rycroft-Malone, J. (2004). The PARIHS framework - a framework for guiding the implementation of evidence- based practice. Journal Of Nursing Care Quality, 19(4), 297-304.  Scott-Findlay, S. (2005). Understanding how organizational culture shapes research use. Journal of Nursing Administration, 35(7-8), 359-365.
  49. 49. References  Sullivan, E. J., & Decker, P. J. (2005). Effective leadership & management in nursing (6th ed.). Upper Saddle River, NJ: Pearson Education.  Sundin-Huard, D., & Fahy, K. (1999). Moral distress, advocacy and burnout: Theorizing the relationships. International Journal Of Nursing Practice, 5(1), 8-13. Retrieved October 10, 2008, from MEDLINE Database with Full Text.