Discussion

I am using Lewin’s theory of planned change to guide the change process in this field experience rotation. The first stage of Lewin’s theory is the unfreezing phase whereby a change agent recognizes a problem, identifies the need for change, and determines the differences between the current and desired state (Shirey, 2013). The second stage is the moving phase which involves viewing the change as a process rather than a single event (Shirey, 2013). The change agent creates a solid plan for change, ideally consisting of actionable items that engage people to attempt the proposed change (Shirey, 2013). Finally, the refreezing phase involves solidifying the process(es) and creating policies such that the change becomes the new normal (Shirey, 2013).

According to Schwartz, Spencer, Wilson, and Wood (2011), an essential element of organizational effectiveness is the accessibility to leaders, and for leaders to provide opportunities for horizontal and vertical communication. It is imperative that frontline nursing staff and formal leaders provide input into the types of changes that will ultimately impact unit-level and organizational decisions (Schwartz et al., 2011). The A3 problem-solving method is the intervention I am using to guide my work at this field site. The A3 tool was adopted from the Toyota Corporation as a method to systematically address the Plan-Do-Study-Act cycle for change. The A3 form consists of the following categories: issue, background, current condition, root cause analysis, target condition, countermeasures, test, implementation, cost analysis, and follow up (Bassuk & Washington, 2013).

The first example illustrates all the best practices identified above. The operating room (OR) nurse manager identified many different performance improvement goals for 2019; however, she has struggled with creating a plan of how to achieve them. Upon meeting with her I identified that she was in Lewin’s unfreezing phase. She recognized that OR first-case start times were often delayed and identified the need for change. However, she was struggling with how to use the data she had available in a meaningful way. Additionally, she felt the vertical communication with her director was lacking. The A3 problem-solving method is the ideal intervention for this scenario. Through data mining and conducting process observations, we were able to uncover a few root causes to OR first-cases starting late. As we proceed into Lewin’s moving phase, the frontline staff, providers, and the OR manager’s formal leaders will need to be involved in determining the countermeasures that will effectively address the root causes. Because the OR manager is the process owner for this project, she will need to lean heavily on vertical and horizontal communication skills to make this change successful.

The second example involves the infusion center (IC) nurse manager. Upon meeting with the IC manager, I identified that she was not in any phase of Lewin’s change theory. She was speculative of a problem, but struggled to know if a problem truly existed. She knew that several months ago one of the patient satisfaction scores she tracks had dropped. However, she struggled identifying a true problem and visualizing a target condition. We used the same intervention of the A3 method; however, the process observations were very different than the OR nurse’s approach. The nurse manager interviewed the patients to obtain qualitative data that we would later analyze for recurring themes. Based on the qualitative data, we determined that the root causes and proposed countermeasures involve several different areas outside of the infusion center, including the cancer clinic and lab. Horizontal communication and collaboration amongst many stakeholders will be essential as we enter into Lewin’s moving phase.

How does the evidence-based strategies assist in meeting the DNP essentials and individual learning objectives?

The individual learning objective surrounding this project is to evaluate methods to enhance nursing leaders’ knowledge and skills in process improvement. I am using different approaches of process observations because the clinical areas are different, and the nurse manager’s leadership styles are different. Each manager is in a different phase of Lewin’s change theory also. I am leveraging their strengths and professional interests as I work to enhance the managers’ knowledge and skills throughout the process.

The strategies also align with DNP Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking. The guiding principles of DNP Essential II ensure accountability for quality of healthcare by utilizing advanced processes to lead quality improvement and patient safety initiatives (American Association of Colleges & Nurses (AACN), 2006). Additionally, DNP Essential II employs business acumen and health policy alignment to develop practice-level or system-wide practice initiatives to improve the quality of care (AACN, 2006). As we begin to uncover the countermeasures, design an implementation plan, and begin tests of change, additional DNP Essentials can be applied.

Comparisons between this field experience with previous experiences:

Overall, I feel the nurse managers are much more engaged this rotation than the last. Some of this is due to me working one-on-one with the nurse managers rather than in a group setting. Also, the nurse managers have a better understanding of my role as a DNP student. My preceptor continues to be exceptional in that she works alongside me but does not micromanage my work. Also, she is very good at diagnosing problems in the clinical areas that lie within her span of control; however, she lacks time to work with the managers to address them. I am filling a much-needed void by helping build the skillset of the nurse managers so that they can lead future process improvement work.

References

American Association of Colleges of Nurses. (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf

Bassuk, J. A., & Washington, I. M. (2013). The A3 problem solving report: A 10-step scientific method to execute performance improvements in an academic research vivarium. PLoS ONE, 8(10), 1-5. doi:10.1371/journal.pone.0076833

Schwartz, D. B., Spencer, T., Wilson, B., & Wood, K. (2011). Transformational leadership: Implications for nursing leaders in facilities seeking magnet designation. AORN Journal, 93(6), 737-748. doi:10.1016/j.aorn.2010.09.032

Shirey, M. R. (2013). Lewin’s theory of planned change as a strategic resource. Journal of Nursing Administration, 43(2), 69-72. doi:10.1097/NNA.0b013e31827f20a9