The Nurse as Change Agent and Advocate

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The Nurse as Change Agent and Advocate

• Chapter 8

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Origins of Change

• Began in the 1990s
• Continuing increase in health care costs
• Employees expected to become multiskilled
• Presents challenges for both providers and
  consumers

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Types of Change

• Developmental change-
• changes or improvements in currently used
  processes and operations
• Transitional change-
• Moves into a different pattern of operation and
  structure
• Transformational change-
• creates a whole new set of attitudes and
  appproaches

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Change

• Driving forces for change
• See page 300 for examples of driving and
  restraining forces
• External forces
• Insurance companies
• Government
• New technology
• See page 300 for examples of
• Internal forces
• Strategy for success
• New philosophy
• Planned deliberate and conscious
• Unplanned- reactive change

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Theories of Change

• Bridges transformational change
• Focuses on transitions of attitudes and beliefs
• Old must be given up
• Lewins force field theory of change
• Moving from one state to a new desired state
• Unfreezing, movement, and refreezing
• Coghlan and McAuliffe
• 5 tasks of change- determining the need,
  defining the desired state, assessing,
  implementing and managing it, and consolidating it

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Question

• Change in our health care delivery system is an
  ongoing process. The view that stability in any
  organization or system is achieved through a
  balance or equilibrium of forces acting on the
  situation is a component of which theory of
  change?
• A. Coghlan and McAuliffe
• B. Bridges
• C. Lewin
• D. Bennis and Chin

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Answer

• C. Lewin
• Rationale another theory of change is the
  force-field analysis described by Lewin.
  Force-field analysis begins with the view that
  stability in any organization or system is
  achieved through a balance or equilibrium of
  forces acting on the situation (Lewin, 1951).

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Strategies for Creating Change

• Environmental and adaptive strategy
• Power-coercive strategy
• Leader orders change
• Empirical-rational strategy-
• Change will be accepted if seen as desirable
• Normative-reeducative strategy (most common)
• Change will take place only after attitudes,
  values, skills etc. change

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Leading and Managing Change

• Role of the change agent
• The person who seeks to lead or create change
• Demonstrate your commitment to change
• Believe in the necessity for planned change
• Managers of change
• Quality patient care continues
• Staff feel supported in doing their jobs
• Adverse effects of the change are mitigated

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Facilitating the Change Process

• Assessing the situation
• Identifying driving and restraining forces
• Understanding losses associated with change
• Recognizing resistance to change
• Lack of trust can be key
• Fear and loss of control
• Change fatigue- feel overwhelmed by the
  expectations and lose enthusiasm
• Self-assessment

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Facilitating the Change Process (contd)

• Planning for change
• Developing trust
• Listening is very important
• Planning a response to concerns
• Fostering involvement
• Timing the change

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Facilitating the Change Process

• Implementing the change
• Using a pilot project
• Providing resources and supports for change
• Managing the time frame
• Interpersonal processes for change
• Negotiation- find areas both sides can give
• Co-optation- enlist key people from opposition
• Coercion- threat of adverse effects
• Sustaining the change- refreezing
• Monitoring and evaluating the change process-
  story board

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Question

• Is the following statement true or false?
• One reason that change fails is recognizing the
  losses inherent in change.

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Answer

• False.
• Rationale as mentioned earlier, Bridges (2003)
  suggests that there are many losses in any change
  and failure to acknowledge that loss is present
  is one reason for the failure of change.

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Effectively Participating in Change

• Understanding the change
• Why it should occur
• Who it will benefit
• What is required for success
• What is your place in the change?
• Viewed as positive or negative
• Participation is essential

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Change Through Advocacy

• Definitions
• Pleading or arguing in favor of something
• Mediation- helping 2 parties work out an
  agreement
• Broker or responsible model- negotiation,
  compromise and persuasion
• Adversarial model or legalistic- focus on rights
  of the client without concern for others
• Empowerment of individual- advocate for self
• Background
• Ombudsman program (1978 Nursing Homes)
• American Nurses Association- ethical standard

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Change Through Advocacy (contd)

• Prerequisite to effective advocacy
• Identify and define your own beliefs and values
• Avoid paternalism- making decisions for the
  person
• Clinical competence
• Believe that you have the right to speak up

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Change Through Advocacy (contd)

• Assessing the need for advocacy
• Those who lack knowledge
• Those with little power
• Those who need to make decisions
• Those who receive inadequate care
• Those who are unable to communicate for themselves

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Question

• What is a prerequisite to being an effective
  advocate?
• A. Believe you know what is best for your
  client.
• B. Define your own beliefs and values.
• C. Identify what family members believe and
  value.
• D. Be supportive of other health care personnel.

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Answer

• B. Define your own beliefs and values.
• Rationale before being a client advocate, you
  must identify and define your own beliefs and
  values.

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Advocacy Goals
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Advocacy Outcomes
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Advocacy Actions

• Preventing the need for advocacy
• Providing information and education
• Assisting and supporting clients decision making

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Communicating with Health Care Professionals

• Demonstrate knowledge and tact
• Include information about the clients concerns,
  questions, and expectations
• Call the appropriate physician
• Encourage direct communication between the client
  and the appropriate health care providers

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Working for Changes in the Health Care System

• Advocate through understanding
• Organizational structure
• Volunteer for ethics committee
• Make sure resources are available
• Clients need to select options that fit their
  values and choices
• Community services

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Being Involved in Public Policy Formulation

• Expertise to be an advocate for the health care
  needs
• Support legislation that benefits health care
  consumers or makes needed services available
• ANA encourages nurses to step forward as the
  experts they are to speak to the media

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Question

• One of the ways to be actively involved in the
  formulation of public policy is
• A. Networking with other professionals at a
  social level
• B. Volunteering for planning committees in
  professional organizations
• C. Knowing who your congressional
  representatives are
• D. Being actively involved in nursing
  organizations that work for programs and services
  for clients

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Answer

• D. Being actively involved in nursing
  organizations that work for programs and services
  for clients
• Rationale the best ways to be actively involved
  in formulation of public policy is through
  nursing organizations that work for programs and
  services for clients, and network through
  professional organizations, alumni groups,
  friends, and coworkers.

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Advocating for Other Staff Members

• Managers must address
• Staff needs
• Staff requests
• Staff problems
• Staff rights
• Requires careful judgment relative to the staff
  members situation and the needs of the
• agency

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Constraints and Supports

• Constraints
• Conflict with other staff
• Lack of supports
• Bucking the system
• Supports
• Legal mandate for client rights
• Personal reward for quality care