Implementing Change

JCN JCN Excellence in Practice Awards runner-up, Lorna Glenn discusses the process of change management when introducing the concept of clinical supervision within a community nursing team

CHANGE MANAGEMENT

Key words: Cflange agents Resistance to chani Leadership styles

Implementing change

Lorna Glenn Dip HE Nursing (Adult), BSc (Hons) Community Health Nursing is a District Nurse, Handsworth, Birmingham

Article accepted for publication: September 2009

H ealth professionals have beenfaced with exfraordinary changesin recent years, due to major developments in clinical practice and reorganisation within the work place (Upton & Brooks, 2000). Consequently, change can have a devastating effect on people exposing them to feelings of loss, doubt, stress and impulsiveness, as well as feelings of comfort, where they experi- ence a sense of achievement, pride or belong (Marquis & Huston, 2006). In the light of these predicaments, it is viable to adapt to being an effective change agent throughout the change process, as it is vital within the role of the leader (Marquis Sz Huston, 2006).

For these reasons, this article seeks to initiate and discuss a planned change within a district nursing team, whereby clinical supervision was introduced to the staff members in offering support and guidance, in delivering safe, effective care to patients. Although the change agent was assumed, a transformational leader- ship style and a normative-re-educative approach to change were also adopted, where all identified stakeholders were encouraged to act as change agents also. The strategies used for the change process were based upon Lewin's (1951) and Roger's (1995) theory of change. Driscoll's (2007) force field analysis was incorporated to illustrate the forces acting to promote or restrain the successful implementation of clinical supervision.

Rationale Clinical supervision within the nursing profession is a relatively recent innova- tion that found itself in publication of the Department of Health (DOH) document, A Vision for the Future (DH, 1993). More recently in documents such as 'Our NHS Our Future' and' High Qualify Care for All', the Darzi Reporf emphasises the impor- tance of patient safety as being the first element of introducing quality care by reducing avoidable harms to patients (Darzi, 2008). Furthermore, research identified key factors in improving staff engagement, by recognising the aim of clinical supervision which is to identify training needs and promote confidence through supervision (DH, 2008) which is defined as:

'An exchange between professionals to enable the development of professional skills' (Butterworth's 1998:12)

This definition shows a similarity in relationship of shared experiences between both parties involved in the dialogue, whilst learning from each other. However, Lynch et al, (2008) suggest that clinical supervision is more of an interaction between two or more professionals, whereby the focus is to provide support for supervisee(s) to promote self awareness, professional development and growth in the context of their environment. For this reason, the innovation of clinical supervision will be based around these definitions, as the supervisor and supervisee not only shares joint responsibility, but they also seek to support each other.

Often there is a theme in the literature describing what clinical supervision is not, rather than what it is. However, several authors advocate that clinical supervision is not a means of controlling individuals, nor a system intended to discipline practitioners undergoing clin- ical supervision (Lynch et al,, 2008; Fejes, 2008; Clouder & Sellars, 2004). In consid- ering the definitions highlighted earlier clinical supervision should be seen for what it is.

Organisational mapping Prior to any innovation taking place, a comprehensive analysis of the organisa- tion is essential (Cutcliff & Bassett, 1997). Upton and Brooks (2000) suggest organi- sational mapping is a necessary technique that can be used to measure the total environment influenced and affected by the system we want to change. When any change transpires there are stakeholders involved who will be affected to a greater or lesser degree. This is illustrated as concentric rings which are known as the interacting level of diagnosis (Figure 1 ),

In this particular instance, the changes that clinical supervision will affect are the district nurses (stakeholders), in terms of providing support and guidance for the team. It is important to identify people most affected by the change, since funda- mental to creating a change culture, is getting the commitment and involve- ment of the stakeholders and using their energy and expertise to generate and sustain the change (Upton & Brooks, 2000).

The community trust will also be affected by the change, in that practi- tioners who are supported will

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CHANGE MANAGEMENT

ORGANIZATION

EXTERNAL ENVIRONMENT

Figure 1: The interacting levels of diagnosis

experienced less stress and consequently have less time off work. The general practitioner will also benefit through nurses improving their standards. In addition, the patients may benefit from staff becoming more proficient in service delivery. However, one has to bear in

mind, the lack of experiential evidence highlighted within the literature pertaining to patient satisfaction (The NHS Confederation, 2008).

In order to facilitate the innovation within the district nursing team, a leader- ship role had to be assumed. Research on

leadership demonstrates that there are many styles of leadership, however, it is recommended that the approach used is appropriate to the demands of the situa- tion (Marquis & Huston, 2006; Norton, 2007). As well as possessing knowledge, energy, enthusiasm and the persistence required to drive change forward, effec- tive leaders have also been described as having the ability to help colleagues articulate and develop i(deas (Goodwin, 2006).

Managing ciiange For the purposes of managing change and innovation, Goodwin (2006) proposes two leadership styles. The transactional leader who is concerned with bargaining and focusing on management issues over a short term and the transformational leader, who has a long term focus on visions, ideas and prompting ownership whilst aiming to empower others to make changes. Conversely, the transactional approach to leadership has been criticised as it can lead to loss of vision and energy, whereas a transformational leader can keep a distance and thereby retain a view of the whole (Frankel, 2008). Nevertheless, Northouse (2007) and Goodwin (2006)

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Journal of Community Nursing September/October 2010, volume 24, issue 5 11

CHANGE MANAGEMENT

warn that although transformational qualities are highly desirable, they need to be joined with the more traditional qualities of day to day management skills, if the transformational leader wishes to avoid failure.

Considering the need to have both the vision to promote change and implement practical skills successfully, a combina- tion of the transformational and transactional leadership styles were adopted in implementing clinical super- vision. By combining these approaches to leadership, a democratic or participa- tive model was agreed, whereby team members were involved with the deci- sion making along with the team leader and their views are considered equally. Moreover, the author was able to foster staff members' ownership of the change, encouraging them to work collectively, as well as providing them with practical help and support, such as providing information on clinical supervision. Frankel (2008) recognises that this style is considered to obtain more cooperation and commitment from staff. However, the weakness of this style is that some members of staff with less experience may need more direction and stronger tactics (Northouse, 2007).

Resistance to change Driscoll (2007) identified two types of forces within an organisation described as either pushing or resisting forces (referred to as a force field analysis). The pushing forces are the strengths within the culture that aids with the implemen- tation of the change. Whilst the resisting forces are negative aspects of the culture or a weakness that can slow down or impede the change. In order to plan and implement change the manager has to examine the forces and shift the balance between these two forces.

Individuals to whom the change is presented may resist change because of the lack of knowledge about clinical supervision, anxiety about what change may bring and changes in work practices. Resistance to change is not necessarily a negative thing, because it may temper and prevent a rush into a situation without planning (Harvey, 1995). Never- theless, Buonocore (2004) observed that no matter how well planned a change may be, there will always be some resist- ance. In fact, Curtis and White (2002) proposed that change without resistance is no change at all, and so is viewed as an illusion of change. As resistance should always be expected, it is essential that nurses are able to recognise it, then plan

and implement strategies to reduce it (Upton & Brooks, 2000).

Nevertheless, the job of the change agent must be to increase the pushing forces, in ensuring that change is brought about within this particular implementa- tion of clinical supervision. This is achieved by motivating staff to take ownership, involving them in the proposed innovation and emphasise clinical supervision is about support, as opposed to a control tool to regulate prac- tice (Cutcliffe & Bassett, 1997). In line with Woodcock's (1979) theory which focuses on team development, the district nursing team is a mature team where feelings are open, a wide range of options are considered and working methods are methodical. The team leader contributes to the work of the team and all team members are seen to be fiexible. The team recognises its account- ability to the wider organisation and team members are aware of their respon- sibilities. Therefore, it is not a team that functions in isolation.

Change innovation/action plan In implementing clinical supervision into the district nursing team, a change agent is required. Flunder (2009), describes a change agent has a person who leads by example and as a result generates ideas, introduces innovation, develops an appropriate climate and then implements and evaluate the proposed change. Enfold within the description of the change agent is the person's ability to be a creative thinker, a strategic planner and one who sets the scene for the change to happen. Flunder (2009) identifies two types of change agents; these are the external and internal change agents. For this particular inno- vation the author adapted the internal change agent as this type of agent is recognised to be familiar with policies, procedures and politics of the organisa- tion (Recklies, 2001 ).

Organisational change In carrying out the organisational change, it was necessary to select a strategy for change to facilitate the change process. By choosing a change strategy, this not only reduces resistance, but it encourages commitment to the envision change (Upton & Brooks, 2000). The proposed strategies the change agent used were Lewin's (1951) change theory and Rogers (1995) diffusion theory. Lewin (1951 ) suggests that change can be brought about by a three step process: unfreezing, moving and refreezing.

Rogers (1995) describes five stages in the implementation of change, these are knowledge, persuasion, decision, imple- mentation and confirmation which is an expansion on Lewin's three phrases of change. Rogers (1995) proclaims that even if change is rejected at the first attempt, then there is no reason why it cannot be implemented again at a later stage and if a different approach is taken, it might be implemented successfully. However, Cutcliffe and Bassett (1997) recognised that if change is accepted, one cannot presume permanence, hence the reason for using both strategies.

In considering Lewin's (1951) unfreezing stage, here the motivation to create change is born. This stage is considered vital, as prior to any change occurring, the people affected by the change must believe that the change is necessary (Burnes, 2000). Therefore, it is the responsibility of the change agent to firstly build up trust, respect and moti- vate the team. Goodwin (2006) stresses that motivation is essential in promoting change and highlighted that this provides momentum to disturb the normal equilibrium of existing habitual practices. It is within this stage that present conditions are critically analysed and are assumed to be frozen. Once the present level of equilibrium is known, a plan to maximise and minimise driving forces can be undertaken (Burnes, 2000).

During the unfreezing stage the author incorporated Chin and Benne's (1976) empirical rationale approach to unfreeze individuals. This approach assumes that individuals will adapt the proposed change if it can be rationally justified and again be demonstrated. Therefore, the author proposes to carry out educational sessions as well as provide evidence base information around the importance of clinical supervision. This is identified in the first stage of Rogers (1995) theory as 'knowledge', which is making the team aware of the innovation and its purpose. Moreover, if the armouncement of the change can be made well in advance of the implementation, the team will have time to adjust to the idea of change. This view is supported by Rogers (1995) second stage 'persuasion'.

The third stage of Rogers (1995) theory is 'decision'. This is where the team comes to a decision as to whether or not to accept clinical supervision via a team meeting where their views are heard. At this stage it was useful to incorporate Chin and Benn's (1976) normative re- educative approach, as this allowed team members to participate with the change

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CHANGE MANAGEMENT

agent in identifying problems foreseen in clinical supervision. Implementing a questionnaire in conjunction with the strategy was used to determine who was desirous of implementing the change and who should be supervisor. The advan- tage of the questionnaire is that it allows anonymity, where staff can respond honestly, feeling less pressured in deciding what models to use and how clinical supervision should be imple- mented (Haffer, 1986). Lynch et ai (2008), believes that supervisors should not be hierarchical and that peers are therefore best suited to fulfil the supervisory role. Conversely, Hyrkas et al. (2005) found that staff welcomed clinical supervision when it was carried out by a line manager, nevertheless Jones (2006) argued that managers who have no clin- ical function should not be involved in clinical supervision. Erom the change agent perspective the supervisory role should be taken on by an individual who is knowledgeable and experienced in order for the benefits of this change to be maximised.

The moving phase of Lewin (1951) equates with Rogers (1995) fourth stage theory of 'implementation', which is where the change is employed. If the

equilibrium has been upset in a favourable fashion, such as the driving forces exceed the restraining forces, then change occurs (Driscoll, 2007). Analysing the results of the question- naires will enable the change agent to determine who the team would like to be supervisor, what models of clinical supervision they would prefer to use and how the team would like clinical supervi- sion to be implemented. Jones (2006) believes that clinical supervision should take place with an agreement or contrac- tual framework. The proposed contract would include a definition of supervi- sion, the time involved and the location where supervision will take place. Record keeping also needs to be discussed and guidelines drawn up as they may have to be disclosed as evidence in court (Royal College of Nursing, (RCN) 2003). Issues of confi- dentiality .should be clearly addressed in the contract to prevent either party feeling compromised by the possibility of conflict, this is particular important given the legal duty of care (Nursing & Midwifery Council 2008).

Various models can be used when carrying out clinical supervision (RCN, 2003); however the model used will

depend on who the team chooses to be supervisor, where the change agent will seek to implement one to one or group supervision. Jones (2006) believes one to one supervision offers more opportuni- ties for participants to counsel each other, whilst reflecting on practice. Alterna- tively, group supervision has greater benefits, in that a broader perspective can be gained. Although group supervision has got its advantages, one has to bear in mind that it must be well facilitated so that its effort can be constructive and objective (McBride, 2007).

Refreezing The refreezing stage is the final stage of Lewin's theory, which aims to restore the equilibrium by being supportive and listening to the group's apprehensions, following the trial period of clinical supervision. Marquis and Huston (2006) recognise that refreezing has been estab- lished when new attitude and behaviour are apparent by the team, hence positive talk about clinical supervision and actions and statements are consistent. In Rogers (1995) 'confirmation' stage, which parallels with Lewin refreezing stage, the team reinforces that the deci- sion to implement clinical supervision is

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CHANGE MANAGEMENT

acceptable. The change agent would set aside time for the team to evaluate the change through reflection on the effec- tiveness of clinical supervision and identify any problems. Subsequently, the change agent would incorporate three monthly re-evaluation of clinical super- vision. This would allow the change agent to gain overall comprehensive picture of how people are adapting to the change, giving the team members time to settle into the new way of practicing. Furthermore the change agent must be willing to take calculated risks and be able to cope when set back occurs (Timmons, 2008).

Conclusion Clinical supervision is recognised to be a valuable tool for nurses benefiting patients and NHS organisation. Before clinical supervision can be employed, however, the organisational culture must be examined. Introducing the innovation of clinical supervision can be a complex operation. Therefore, combining Lewin's (1951) and Rogers (1995) strate- gies enables the change agent to understand the process of change and to minimise resistance. Nurses taking on the role of clinical supervisor must be knowledgeable and skilled; therefore the need for ongoing training for profes- sional development is required. Furthermore, having mandatory study days to ensure that clinical supervisors and supervisee are kept updated with current trends and practices would raise the profile of clinical supervision. Addi- tionally having structures in place to monitor performances such as peer review would serve as a mechanism to ensure that clinical supervision remains an effective tool in the development of nursing practice.

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