Leadership and Management
Numerous individuals who experience cardiopulmonary arrest have discernable neurological deficits that may affect his or her quality of life. Preservation of a patient’s neurological brain function is critical during the first twenty-four hours after insult. As healthcare clinicians, we can potentially preserve and decrease discernable neurological deficits with therapeutic hypothermia post cardiopulmonary arrest. The aim of reducing core temperature is to decrease the body’s metabolic rate and the amount of oxygen the body demands to improve survival and neurological outcomes post cardiac arrest (Mathieseon & Smith, 2015, p. e2). Therapeutic hypothermia maybe induced and maintained internally with an endovascular catheter placed by a physician or externally with surface cooling pads for a period of twenty-four hours.
Describing the Problem and Importance for Nurse Leader to Implement Change
Targeted temperature management within our healthcare organization is most often accomplished by external cooling mechanisms. In clinical practice, endovascular or internal cooling mechanisms are presently only used in the patient population with high body mass indexes. This is mainly due to surface cooling pads not adequately covering the individual’s body surface area allowing for ineffective temperature management. After research, evidence suggests that internal or endovascular-cooling devices are more effective at achieving rapid cooling and tighter maintenance of temperature with less shivering. With this knowledge, nurse leaders can close the gap between best evidence and existing clinical practice to improve patient outcomes within the healthcare system. Numerous medicines are used throughout the course of therapeutic hypothermia. These medications may include: vasopressors, sedatives, paralytics or anti-shivering medications. Internal cooling measures can produce hypothermia quicker, thus creating more cost-effective patient care. By implementing more frequent use of endovascular cooling mechanism may allow nurse leaders to provide more efficient induction and temperature management during therapeutic hypothermia, theoretically creating more cost-effective care.
Key Roles of Nurse Leaders, as Change Agent in Healthcare Settings
Leaders are an indispensable part of change within a health care system. Nurse leaders may take on numerous of roles during the course of transformation. Nurse administrators and executives provide a visualization of desired future, initiating change, and help guide the direction of a change within a healthcare organization. While middle level and first-level managers and staff may also take roles in introducing and sustaining change. According to Hubler (2018), “nurses in variety of roles from educators to clinical specialist to staff nurses, may take on roles of change agents, opinion leaders, and earlier adopters of innovations” (p. 40). Change agents or nurse leaders should be precise about the requirement for and the benefit of change within a healthcare organization. While change is infrequently an easy process, implementation of change creates greater autonomy for nurses, superior safety and quality, or improved effectiveness in regards to patient care. Change may be perceived as unwarranted, coerced from higher-level nurse leaders, and may threaten a workers’ sense of refuge within the healthcare organization. The progression of change becomes even more challenging for those implementing a changing within clinical practice. Nurse managers and leaders must require methodical understanding of change supported in theory, pertinent research, and reports of effective change processes to lead the transformation process.
Method Utilized to Assess the Health Care Organizations Readiness for Change
Many methods may be utilized to assess a health cares organizations readiness for change. A leader must create urgency or have an open dialogue about external and internal realities supporting the need for change. A core group of change advocates can help build momentum and support individuals throughout the change and should be utilized to support the change. As a nurse leader, we must create a vision for change and consistently communicate this vision of change continuously. While barriers and processes that limit the ability of change should be addressed; success motivates future successes, thus creating short-termed successes and celebrating accomplishments enables nurse leaders to foster change within the health care organization. Change is ongoing, a nurse leader must identify when the change is effective, discuss the difference the change is making, and honor the people who helped make the change possible. Resistance is a common obstacle of change. An individual or change agent must recognize that resistance is a normal response to change and must not waste time or energy attempting to eliminate it. Involvement and education and training are key guidelines to implementing a successful change. The use of change theories to plan for the implementation of organizational change allows for readiness for change within a healthcare organization.
Identify Evidence and Gaps in Literature Between Current Practice and Best Practice
Internal and external cooling devices are accessible for healthcare provider use to induce and maintain therapeutic hypothermia, but only a small number of studies have compared the performance of these two devices. Evidence suggests that internal or endovascular-cooling devices are more effective at achieving rapid cooling and tighter maintenance of temperature with less shivering. Look et al. (2018) conclude, “internal cooling showed tighter temperature control compared to external cooling. Internal cooling can potentially provide better survival to hospital discharge outcomes and reduce cardiac arrhythmia complications in carefully selected patients as compared to normothermia” (p. 66). This evidence supports the use internal or endovascular cooling mechanisms during therapeutic hypothermia post cardiopulmonary arrest. Not only does other research support internal cooling mechanism, but also argues internal cooling mechanisms provide more rapid induction and management of temperature. Sonder et al. (2017) concluded, “endovascular cooling and gel-adhesive pads provide more rapid hypothermia induction and more effective temperature maintenance compared to water-circulating cooling blankets. Not only does it apply to induction speed, but also to time within target range” (Sonder et al., 2017, p. 14). All scholarly research concludes the same finding; that therapeutic hypothermia post cardiopulmonary arrest is correlated with superior neurological outcomes and preservation of neurological brain function. In current clinical practice, internal or endovascular cooling devices are presently only used in the patient population with high body mass indexes. This is mainly due to surface cooling pads not adequately covering the individual’s body surface area allowing for ineffective temperature management. A health care organization may implement more frequent use of endovascular cooling mechanisms allow nurse leaders to provide more efficient induction and temperature management during therapeutic hypothermia, theoretically creating more cost-effective care.
Change Theory Utilized as a Framework for Process Improvement
Lewin’s force field analysis can be compared with the nursing process. Unfreezing is similar to assessing and problem identification and definition. The second stage of moving is similar to the planning and implementation process and similar to analysis and seeking alternative solutions. Finally, refreezing is like the evaluation aspect of the nursing process and similar to the implementation and evaluation in the problem solving process.
Lewin’s force field analysis allows us to look at all elements in a situation to determine what barriers we must overcome and how quickly a change can occur. The first stage of change in Lewin’s force field analysis is unfreezing. This stage is the cognitive familiarity to the change, diagnosis of the problem, and the effort to create alternative resolutions to the problem. Unfreezing encourages motivation and readiness for change. This stage is finalized when those involved within the change process welcome and accept the requirement of the suggested change. During this stage, assessing for readiness for change is showing problem awareness and make it possible for individual to let go of old ways. Educating, communicating, and setting the scene for is crucial in preparing those for change. The second change stage of Lewin’s force field analysis is moving. During this stage, the healthcare organization can move forward with the suggested change. Persons involved collect information to clarify and identify the problem, thus allow planning and implementation of such change. Implementing the actual change occurs during this stage. Moving allows for individuals seek alternatives, demonstrate benefits of change, and decrease forces that affect change negatively. During this stage, brainstorming, presenting new ideas, role modeling new ways, and stakeholder engagement can help nurse leaders push in the direction of change.
The final stage of Lewin’s force field is refreezing. During this final stage, new changes are assimilated and stabilized within current practice. Reinforcement of behavior is essential as individuals assimilate change into practice. Refreezing allows for organizational readiness by integrating and stabilizing the new change of internal cooling mechanisms into the healthcare organization so it becomes habit and resists further change.
Describing the Change Process Using Change Theory Framework
The first step of Lewin’s Analysis involves identifying the change focus; specifically, implementing internal or endovascular cooling mechanisms regularly into clinical practice. Key components of this step are communicating with all stakeholders including frontline nurses, physicians, program managers, clinical nurse educators, managers and administration. The inclusion of frontline staff allows for empowerment, which may help to overcome resistance to the change, thus enabling them to understand the importance of the change and how it might create more cost effective nursing care. During the unfreezing stage, discussion about restraining forces can help identify barriers that may need to be overcome before implementation. The moving stage represents the phase of actual change including the planning and implementation stages of the project. Implementing endovascular or internal cooling mechanisms require continuous effort from various teams, of which include; physicians, nursing, program managers, clinical nurse educators and administrators. In this final stage of Lewin’s theory, the process of refreezing the changed practice occurs and leads to a time of stability and evaluation. Refreezing allows for organizational readiness by integrating and stabilizing the new change of internal cooling mechanisms into the healthcare organization so it becomes habit and resists further change. There must be ongoing support of the nurses on the frontline and support from all stakeholders and this support should continue until the change is deemed complete and all users are comfortable with the evidence-based practice change. Once the change is successful within the health care organization, an evaluation and summary of problems met, successes realized, and challenges confronted throughout the change should be done, for future reference.
Objective of Planned Process Change
The objective of planned change would be to implement endovascular or internal cooling mechanisms regularly into clinical practice. Registered nurses within the cardiac intensive care unit will start implementing more frequent use of intravascular cooling mechanisms resulting in one-third of cardiac arrest patients being cooled by endovascular or internal mechanisms within one year of implementation. To clarify achievably, a unit champion will be appointed to serve as a liaison between the implementation team and the unit staff. The unit champion should be familiar with program goal, bundles of care, and outcome data that will be used. Two champions should be appointed per shift. This ensures that a champion should always be available to assist with succession planning if one person leaves. Most importantly, the unit champion often encourages staff during the implementation process.
Identification of Facilitators and Barriers to Proposed to Change
Change is often seen as complex and irrational, which makes the implementation of a propose change in clinical practice difficult. Facilitators of change may include adequate leadership support, adequate training, persistence and oversight on the part of the unit champion, and supporting results to research. While barriers to proposed change may include the complexity of the change, resistance to change, lack of resources, lack of leadership support, and technical problems. While resistance to change is seen as a barrier to a propose change, it is important to understand the positive effects resisters may have. According to Hubler (2018), “re-conceptualizing staff and others as the co-creators of change instead of resisters not only provides an alternative view of change and resistance but also can point to new strategies for moving organizations toward change” (p. 38). While implementation of a proposed change may be difficult end results of a clinical practice change allow nurse leaders to provide more efficient induction and temperature management during therapeutic hypothermia, theoretically creating more cost-effective care.