For the purpose of this assignment the practice initiative for consideration will be the redesign and management of a practice nurse led baby immunisation clinic within a general practice surgery. The background for the reason of choice will be established within this written work, and will then demonstrate areas for improvement and change from a practice nurse team leader perspective. A rationale for change will be presented. The issues surrounding change within the practice initiative will be linked to current theories within change management and discussed.
Leadership qualities and communication in the general practice environment will be analysed in relation to theoretical views. To conclude the challenges of change within General Practice will be demonstrated and critically evaluated from a practice nurse team leader perspective. The practice nurse’s traditional role as a caring, task orientated person carrying out doctors orders has progressed beyond recognition (Norman, 2005). Since the development of General Practitioner (GP) fund holding, the practice nurse role has rapidly grown (Carey, 2000).
This combined with the establishment of integrated nursing teams in community health provision (DOH, 2005), has lead to the vast evolvement of the practice nurse and their contribution made to the health of the practice population. The National Health Service (NHS) plan (DOH, 2000) outlined the development of “clinical leaders” to deliver organisational change and quality to service users. A further Department of Health (DoH) white paper, Liberating the Talents (2002) took this further, placing great importance to improve leadership and change within the roles of primary care nurses.
Practice nurses’ are now encouraged to take responsibility for assessment, planning, care and management of patients that were previously the domain of medical staff. The advent of nurse led clinics and advanced nursing roles have led to the inevitable evolution of nursing leadership roles (Norman, 2005). The general practice surgery in question currently recognises the importance and significance of the role of the practice nurse and utilises their leadership skills to run nurse led clinics.
At present, the baby immunisation clinic is nurse led, running on the same day every week, for one afternoon, by the same practice nurse. The practice nurse who runs the clinic is very experienced and has assisted and subsequently run the clinic over a period of 20 years. Each patient is allocated a time slot of 10 minutes, irrespective of where they are on the immunisation schedule, from first immunisations to pre school booster. The clinic rarely runs overtime.
Vaccination is the most effective public health intervention in the world, after clean water, saving lives and promoting good health (Health Protection Agency, 2006). Nonetheless, in recent years vaccine uptake has declined, mostly due to public alarm fuelled by anti-vaccination forces and news stories about the purported adverse effects of vaccinations (Campbell, 2004). The evidence supporting the efficacy and safety of vaccinations and immunisations is extremely strong (McCarthy, 2000). The research data, however, is not always easy to interpret.
Health professionals, particularly those with a public health perspective should have the skills to understand this data. Parents may very well not as such data can be confusing. According to McCarthy (2000) there are risks with vaccines, which are infinitely smaller than the risks of the diseases but from the perspective of the parents today, the vaccine risk is real, more real than the disease. Therefore, when once our mothers and grandmothers beat a path to have their children vaccinated, today’s changing society sees a greater reluctance and a public that necessitates information.
Government policy (DoH, 2000, DoH, 2006) has been clear that it expects the front line practitioner, and patients themselves, to be more active about the care they give and the care the patient wants to receive. In other words, passive acceptance that the care the nurse is giving is the right care needs to be questioned by the giver and the receiver. Practice nurses are now at the forefront in promoting and delivering immunisations (Kassianos, 2001). This places the practice nurse with an ideal opportunity to promote and educate her practice population, to maintain the uptake of immunisations.
Recently after a media leak in February 2006, the DOH (2006) announced that important changes will be made to the childhood immunisation schedule later this year. These changes will ensure that young children in the United Kingdom (U. K. ) have the best possible coverage against disease via the inclusion of pneumococcal vaccine, and modification of the existing schedule (Appendix 1) based upon the best evidence in practice. The changes will have implications for both clinical practice and the patient.
The proposed schedule will mean the administration of more routine vaccines and subsequently ensuing workload this produces. For the parents it will mean the increased need for education and information on the vaccines being given, thus enabling practitioners to achieve informed consent and maintain adherence to the uptake of immunisations. For babies being immunised, they will be receiving more vaccines and rather than 2 needles they will be having 3 injections during periods within the schedule. Due to the forthcoming changes in the immunisation schedule the rationale for change was decided.
For the purpose of change to be made a reflective approach has been adopted. Reflective practice of a practice nurse new to immunisations, bought about the notion of researching the possibility of changing the way in which the nurse led baby clinic was run. According to Blackie (1998) reflection is a key concept available to nurses, to assist them to develop and advance practice. The outcomes of reflection depend on the individuals’ capacity to explore their own experiences. Handy (1993, cited in Hewison, 2004) defines change as a progressive and adaptive individual or organisational condition.
In light of changes that will occur with the implementation of the new schedule, it was therefore obvious that this had implications for leadership and change management issues within the general practice organisation. According to Blackie (1998) for change to succeed, the manager is required to understand the organisation they are submerged in and to know how to use this understanding to initiate and manage change. Although currently the baby immunisation clinic runs to time, the implementation of the new schedule will increase the work load required.
Therefore, providing possibilities for change to be explored. The aim of change proposed is the implementation of two nurses in conducting the baby immunisation clinic. The two nurses can provide simultaneous injections to babies to reduce pain, based upon best evidence and practice (RCN, 2001), check vaccines together, provide education and information to parents, complete all relevant documentation and work within the patient group directives (PGD’s). With any planned change some preparatory work needs to be undertaken to predict the relative success of that change (Tiffany and Lutjens 1998).
According to Carney (2000), and Tiffany and Lutjens (1998), planned change theories provide a theoretical sequence that helps change agents to choose, develop and order activities that are essential to bring about planned change episodes. Lewin (1951, cited in Blackie, 1998) identified three stages of planned change. The first step in introducing a change plan and developing an initiative is to diagnose the problem, or ‘unfreeze’ the current system of practice. During this stage forces which maintain the past behaviours are reduced and the need for change established (Hewison, 2004).
In practice this may be translated into recognising that the immunisation schedule will inevitably change how the nurse led clinic continues. At this stage of the change process past efforts used by the nursing team to manage the nurse led clinic can be acknowledged and recognition given. Change cannot be introduced successfully unless there is shared understanding about how it can be achieved and commitment to common goals (Henderson, 2003). To initiate the change process a SWOT analysis (Appendix 2) may be used. Adams (2000) states that by using a SWOT analysis (Ansoff, 1987) practitioners can consider the perceived benefits of change.
SWOT stands for strengths, weaknesses, opportunities and threats (Hewison 2004). Authors such as Iles (1997) have criticised SWOT analysis stating that making lists under the aforementioned headings is of little use to an organisation. However, a SWOT analysis is felt to be of benefit to make change within the general practice surgery. A SWOT analysis can be conducted with all practice staff to look at the present situation and analyse influences that affect the running of the clinic. This may help to draw attention to practice staff for the need to change and identify positive areas of working.
Swage (2001) concurs stating that a SWOT analysis can help to formulate arguments and portray a picture of change to a team. Within the change process Lewin (1951, cited in Cork, 2005) acknowledged that when implementing any change there are a number of factors that help to achieve change (drivers) as well as factors that may impede change (restrainers). Lewin (1951) developed a tool called the force field analysis. A force field analysis was devised to establish the restraining and driving forces that would be involved in implementing change to the immunisation clinic (Appendix 3).
Having identified the forces, positive factors can be taken advantage of and negative factors can be worked on and reduced. By using the SWOT analysis tool, positive and negative factors may have been identified by staff, and can be used to develop the force field analysis. The force field analysis identified that a resisting factor maybe that practice staff are resistant to change. Iles (1997) compares the change process with the grief process and that any change will ultimately mean the disappearance or refinement of one thing and the introduction of something new.
According to Deegan et al (2004) implementing change can quickly move to resistance when external and internal values conflict. The practice nurse currently conducting the immunisation clinic may have different values to that of the new nurse steering change. To manage change successfully therefore, McKay (1993) stresses the importance of taking personal values into account, while Robbins (1991) suggests that, where it affects personal and social values, resistance to change can be overt, covert, implicit, immediate or deferred.
Resistance to change may also come about due to staff resistance. Mullins (2002) suggests that some of the reasons individuals have resistance to change include the perception of the current situation and anxieties relating to effects on security and lack of control. Fretwell(1985 cited in Cork, 2005)) argues that nurses appear to have an inherent resistance to change and questions whether they are in a position to effect change. However, Ewles et al. (1999) states that educating and communicating to people about change before it happens can limit resistance.
However, Ewles et al. (1999) goes on to caution that often this can be a time consuming process. However, writers (Sullivan and Decker 1997, Pryjmachuk, 1996) on change management theory have recognised that the utmost influence on change is achieved when group members discuss issues that are perceived as important and make relevant central decisions based on those discussions. By involving staff from the outset of the change, such as with the SWOT analysis, may allow them to have perceived ownership of the change process.
Subsequently this may motivate them to accept the changes (Upton and Brooks, 1995). Another driver of resistance may prove to be financial constraints. Within the U. K. the DoH sets immunisation targets, or Quality Outcome Frameworks (QOF) to maintain the U. K’s high uptake of the vaccination programme. Financial rewards are given in general practice if targets are reached. (Chiodini, J. , 2000). The provision of vaccination and immunisation services is funded in two ways. The infrastructure costs are included in the global sum under the General Medical Services (GMS) contract.
In addition the general practice surgery receives a payment through a Directed Enhanced Service (DES) in line with the current scheme if they achieve either the lower or the higher target thresholds. Currently the general practice achieves 90% uptake on immunisations in the under two year olds, thus receiving the maximum payment. (PCC, 2006). The practice management may be reluctant to fund a second nurse for the clinic. However, it may be argued that in consideration of the implementation of the new schedule and partnership working with patients, the maintenance of the practices 90% achievement may be threatened.
One driving force in the force field analysis is the use of evidence based practice to improve patient outcomes. The use of evidence-based practice supports the commitment of key stakeholders and the integration of research findings to plan effective change (Cummings et al. , 2005). Practice management may well need to consider these factors when issues of financial resources are addressed. Evidence based practice is a key element of clinical governance. Within the framework of clinical governance (DoH, 1999) decisions for clinical practice must be based upon the most up to date evidence (Chilton et al. 004).
Clinical governance is also about changing the way people work; demonstrating that leadership, teamwork and communication is as important to high quality care as risk management and clinical effectiveness. According to Major (2002) and Bulley, (2005) by influencing the team and developing staff, direct influence and change can be made on the quality of patient care. If driving forces of change proved greater than the resisting forces the second stage, within Lewin’s (1951, Hewison, 2004) planned change, the moving process, could be implemented.
During this stage new attitudes and behaviours can be developed and the planned change implemented (Hewison, 2004). New skills may be learnt by practice staff in regard to giving vaccinations simultaneously, based on the best evidence (RCN, 2001). The implementation of the use of two nurses within the clinic may commence. Prymachuk (1996) questions that often when a change in organisations is necessary, it is usually imposed from the top down rather than engendered from the bottom up, often demoralising staff.
The origin of change in this scenario stems from proposals by the DoH (2006) in amending policy on immunisations. However, the nurse leading change in the general practice surgery may have a positive influence on how change is received from practice staff. The National Health Service (NHS) recognises the need for clinical nurses to be equipped with leadership skills. The clinical leader’s role is central to meeting the needs of patients, the team they lead and meeting organisational goals (Bulley, 2005).
According to Blackie (1998) to deliver innovations in practice effective leadership must come from those possessing emotional intelligence. Emotional intelligence is associated with transformational leadership (Blackie, 1998) Transformational leadership is the ability to raise both levels of motivation and morality in the leader and there follower (Norman, 2005). The nurse would attempt to adopt a transformational style of leadership to boost moral and motivation of their staff and aid reduction in resisting forces.
Leadership can shape the system, alter the climate, balance resources, implement new programs, structures, and roles, and thereby facilitate change (Cummings et al, 2005). However, Carey (2000) warns that historically GP’s have often been seen as the leaders, often due to the hierarchal power they are perceived to hold over their nursing colleagues. Therefore it may be possible to say that the dominance of GP’s as leaders in general practice has possibly seen a more authoritarian style of leadership. Ewles et al. 1999) describes this style of leadership as directive, the leader is source of expertise. However, this may possibly lead a paternalistic partnership and demotivation of staff. Conversely, Norman (2005) asserts that with the implementation of the new GMS contract to prevent practice nurses becoming a task orientated profession; they need to become leaders in delivering patient care. Therefore the nurse leader must be permitted personal and professional development, while maintaining a patient centred focus to their work.
Once the change has been put into practice the final stage of Lewin’s (1951, cited in Hewison, 2004) model of planned change, refreezing, can be implemented. During the refreezing stage new behaviours are consolidated and the change is stabilised (Hewison, 2004). If the clinic has become successful with two nurses then a level of stability may continue. Protocols and policies may be structured to formalise the change to the clinic. According to Rumbold (1995) overlooking this stage could lead to the return of the original position held by the organisation.
King et al (1995) states that regular communication, constructive feedback to staff and team evaluation of the changes at this stage are effective. Evaluation of change is fundamental to the process to assess whether or not the change is working in practice (Cork, 2005). Broome (1998) states that formative and summative evaluations are necessary to the change management process. Throughout the change process formative evaluation can be utilised. This may be done by holding regular team meetings to monitor effectiveness and the change management process.
Repeating the SWOT analysis (Ansoff, 1987, cited in Hewison, 2004) may also assist in reflecting on the occurring change and provide a means for making relevant amendments to the process. Summative evaluation may include auditing information from computer held records to ascertain the level of uptake of immunisations. Also patients may be asked to participate in questionnaires to establish their level of satisfaction with the clinic and the care they received. Staff may reflect on practice and the outcomes of which may develop new notions for change and improvement, which can be explored through the ongoing process of change management.
To conclude, it has been shown that change is an inevitable part of organisations, yet it frequently causes problems. By using change management models proactively rather than retrospectively, some of the dimensions and consequences of change can be considered and acted on. The practice nurse was able to consider through the use of change management tools, possible resisting factors and minimise these. However, such considerations do not guarantee the success of future change, nor does it spur nurses on to become innovative and generate new ways of working.
However, it may simplify the process and allow nurses to become more receptive to change. It imperative that practice nurses participate in decisions about the management and implementation of patient care (Norman, 2005). Exploration of change management in general practice has highlighted to the practice nurse a need to make a stand in what appears to be a tradition dominated and target orientated culture, and has fuelled the fire to drive change forward with an interest to improving their patients care.