Nursing Policy Change
I. Abstract
In the study, a fictional organization under the name of White Rock Hospital – primary health care level – has been used to apply the concepts of policy change and process. Hypothetical demographics and statistics are used creating a situation of staff disproportions in the emergency area. Change process focuses more in the aspect of staff development and education programs aiming to maximize the capacity of level B and volunteer nurses in rendering IV therapy and life support.
II. Introduction
Policy changes in the area of staff training and nursing volunteer education are one of the primary concerns that influence both health care delivery system and staffing conditions of the organization. As supported by the Joint Commission Resources (JCR;), insufficient and ineffective nurses staff and volunteer training and education commonly resort to poor staffing levels and incompetent health care delivery system (p.65). Hence, effective policy regulations on staff nurses and volunteer education programs and trainings are equally important to facilitate adequate levels of staffing conditions. According to Daly, Speedy and Jackson (2003), nursing policy change must have properly planned sequence to confront potential resistance or obstacles of change process, especially during the introduction of change propositions (p.193). In order to apply the hypothetical policy change in nursing, specifically in the field of staff training and education, a fictitious hospital situation shall be utilized to act as an object of analysis. After forming the study institution, Kurt Lewin’s three-step change theory shall be used to formulate a plan of policy change.
III. Description of Healthcare Setting
The private hospital institution – White Rock Hospital – mostly renders primary level of health care in four municipalities. White Rock Hospital is established on a rural environment surrounded by three municipalities (i.e. Greenfields, Marcos and Littlewind) with notorious reputation due to their high crime rates and Pickstone municipality that has high cases of diarrhea and respiratory-related illnesses. On the average per day patient demographics, the hospital receives approximately 150 patients for ward admissions, 240 patients for emergency care, 30 patients for surgical operations, 20 patients for maternal deliveries, and 100 patients for check-ups and clinical appointments. As a primary level health care institution, fundamental departments are present, such as neurological, cardiovascular, orthopedic, pulmonary, pediatric, obstetric, radiology, etc. In terms of nurses staffing, from the 300 total employed nurses, the breakdown involves 20 nurses for the administrative and supervisory tasks, 220 staff nurses and the rest are already volunteer nurses. From the 220 staff nurses, only 120 (referred as Level A Staffs) are licensed life support providers and IV therapists, while 40 (referred as Level B Staffs). Currently, nurse staffing conditions are as follows (Level A/ Level B/ Volunteers; shown in Table 1): (a) ward admission has 40/ 30/10, (b) emergency unit has 40/20/10, (c) 20/20/10 for surgical operations, (d) 10/10/20 for maternal deliveries and (e) 10/20/10 for clinical admissions. Based from the current demographics, patient statistics require more Level A nurses on emergency units to provide immediate care on critically injured and diseased patients. Furthermore, case demographics point out stab wounds, dehydration, punctured injuries and DOB as the most prominent admission in the emergency area.
Table 1: Healthcare Setting: Statistical Analysis
Area
Level A Staffs
Level B Staffs
Volunteer
Staff Ratio
(Staff Total/Patent total)
Emergency
(240 Patients/day)
40
20
10
Lvl A: 1 N: 6 pts
Staff-Pt: 1 N: 4-5 pts
Ward
(150 Patients/day)
40
10
10
Lvl A: 1 N: 3-4 pts
Staff-Pt: 1 N: 3 pts
Surgical Operations
(30 Patients/day)
20
20
10
Lvl A: 1 N: 1-2 pts
Staff-Pt: 1 N: 1 pt
Maternal Deliveries
(20 Patients/day)
10
10
20
Lvl A: 1 N: 2 pts
Staff-Pt: 1 N: 1 pt
Clinical Check-ups
(100 Patients/day)
10
40
10
Lvl A: 1 N: 10 pts
Staff-Pt: 1 N: 2 pts
Total
120
100
60
Staff Nurses: 220
Volunteer: 60
Based from the demographics posted above, the ratio on level A nurses to patient are at risk of suffering disproportionate staffing and might compromise the health care delivery system, especially on Emergency areas due to its criticality and high number of admissions. Under this nurse staffing conditions, Level A or nurses skilled (as well as licensed) in providing life support and IV therapy are very much needed most significantly in the area of emergency unit due to the number of cases (e.g. dehydration, stabbed wounds, punctures, etc.) requiring either blood transfusion or fluid replacement. In this scenario, it is important for the nurse to acquire skill training and compensatory education, especially in the field of life support and IV therapy in order to increase the flexibility and efficacy of staffing. In addition, volunteer nurses must have nursing skill trainings to support staffs in catering emergency care.
IV. Description of Impacted Change
Currently, the hospital institution being studied experiences the following: (a) staff –patient ratio disproportions and (b) higher population of unskilled (Life support and IV therapy) nurses. Based from the health care setting analysis, results support the need for policy change in the aspect of nursing education and training rather than imposing another segment of employment hiring, which can lead to personnel congestion and non-maximization of human resources. In order to effectively reduce the Level A staff nurse to patient nurses, trainings and educations focusing on both volunteer and Level B nurses are necessary. In the process of implementing change, initial impacts will always include (a) resistance and (b) tension. According to Lauwers and Shiskie (2004), these are natural responses usually obtained from the initial phase of change (p.485). According to Marquis and Huston (2006), change process in the area of education must use both relational and developmental components to ensure the healthier course of work force development (p.167). Based in this principle, changes in the area of education must be oriented area of workforce empowerment rather than workforces’ skill level comparisons.
Evidently, the organization requires policy changes in the area of nursing education as well as recruitment sections for upcoming hiring. For the meantime, the best change process to utilize is the training of the capable nurses (Level B) in the area of IV therapy and Life support, while maximizing the level of functioning among the volunteer nurses. As supported by Ellis and Hartley (2004), nursing care delivery system I expected to advance further if the participating members of the nursing team are fully equipped with the knowledge mandated by their patient care environment (p.225). Based from the conditions of the given institution, the most appropriate training scheme to implement follows a three-step process involving: (a) exploration of nurses’ weaknesses in the area of nursing care, (b) corporate and networked-based planning participated by both nursing supervisory representatives and nursing trainees comprising of Level B and volunteer nurses, and lastly (c), implementation of planned change with series of learning outcome evaluations. Furthermore, implementations of policy change in the field of staff nurses’ education must coincide in an evolutionary process – a gradual approach of change requiring adjustment on an incremental basis (Allender and Spradley, 2005 p.315). Evolutionary process of change may not provide immediate results; however, as supported by Bassford and Slevin (2003), nurse staff trainings may require developmental process, integration of skills and adaptation (p.311). In addition, the policy impact does not only expect cognitive-based enhancements, but also skill-based with appropriate accreditations or certifications from the organization concerned (e.g. ANCC Accreditation, ANA Certifications, etc.).
After resolving resistance to change and adjustment periods, the planned change process shall be implemented involving series of systematic sequence of activities and well-planned curriculum on skills required by Level B nurses. Following the implementation of change process, the Level B nurses are expected to (a) obtain their accreditation for IV therapy and life support, (b) provide Level A nursing care, and (c) administer flexible nursing care in different areas of the institution. On the other hand, impact of changes among volunteer nurses must be manifested in their efficiency in handling and administering fundamental nursing tasks, such as (a) medication administration, (c) wound care, (d) patient monitoring and (e) wound prep.
V. Communication Network
Progressive education among nursing staffs in practice is crucial in maintaining the needed knowledge and skills for contemporary practice. According to White (2000), “staff development typically occurs in the setting of employment and is described as the delivery of the instruction to assist the nurse to achieve the goals of the institution” (p.61). On the other hand, the goal of the institution for workforce enhancements is always in line with professional development, work attitude change and enhancement of skill-cognitive aspect (Guskey and Sparks, 2000 p.138). Considering both organization and change recipients as the main components of change process, effective networks and channels of change must be considered in order to fully direct the activities of change among the recipients (Swansburg and Swansburg, 2001 p.489). In application, communication networks responsible for channeling change among nurse recipients (Level B and Volunteers) are (a) nursing supervisors – channels of information, (b) level A nurses – channels for skill guidance and peer-mediated encouragement, and (c) hospital institution – policy source and change legislator. With these three important connections and networks of change process, staff development through nursing education can be done as planned. As supported by Cleverly (2003), staff development-often networked by higher-skilled co-staffs and educators- focuses in developing skills and knowledge within a comprehensive program jointly planned by both recipients of learning and facilitators (networks or channels) (p.58). Lastly, communication networks must emphasize the relationship of change process to the potential enhancement of healthcare delivery system, to the philosophy of the organization and to their individual career as a professional nurse (Swansburg and Swansburg, 2001 p.489).
VI. Change Process
a. Change Theory Application
In support to the planned policy change in the area of nursing education aimed at staff development, the theoretical framework of Lewin – Three-Step Change Process – has been utilized. Lewin’s theoretical model comprises of three distinct phases of change, namely (a) unfreezing, (b) movement and (c) refreezing (Marquis and Huston, 2008 p.168-169). According to Roussel, Swansburg and Swansburg (2006), the change agents– the three channels of education identified (nursing supervisor, Level A nurses and Institution) – are the actual facilitators of change according to Lewin’s three-step change process (p.63). Policy change is directed by these change agents through the development and implementation of training and staff education programs. According to the Lewin’s theory, change agents must follow three phases in order to successfully direct change: (a) unfreezing – realizing the need for change, (b) moving – forces for change are identified and altered, and (c) refreezing – establishing of a new equilibrium (Jansen and Zwygart-Stauffacher, 2006 p.48). During the unfreezing, there are three possible triggers that initiate the need for change, namely: (1) individual expectations are not meant, (2) feelings of lack or insufficient action, and (3) a former obstacle to change no longer exists (Roussel, Swansburg and Swansburg, 2006 p.63). In application, the institution has began experiencing serious staffing insufficiency whereas patients’ demographics needing emergency care admissions versus the available nurses capable of rendering full serviced nursing care management (life support and IV therapy) are no anymore in balanced proportions leaving the Level A nurses disproportionately staffed.
Applying Lewin’s theory to the formulated three-phase policy change process, both Level B and volunteer nurses need to explore and verbalize their weaknesses in the area of their nursing practice aiming to define unfreeze existing comfort zone or status quo. In the second phase, the change recipients (Level B and volunteer nurses) collaborate with the change agents (nurse supervisors, institution and Level A nurses) for planning of nursing training and education programs. Following the planning phase is the implementation phase wherein the agreed training programs and educational schemes are conducted by the change agent towards their change recipients, which significantly applies the second phase of the theory – movement. Lastly, after applying the series of training programs, change agents evaluate the learning outcomes of their change recipients, while determining as well the driving forces needed to maintain and stabilize the incorporation of change results among the recipients. Following evaluation, change recipients begin recommending accreditation and proper certification among their change recipients, which applies the last phase of the theory – refreezing stage.
According to Oermann and Heinrich (2005), applying the theory also points out the need to carefully watch the influences of (a) restraining forces – decreases the integration of change behavior, and (b) driving forces –increases the integration of change behaviors – during the process of change (p.188). Change, enforced during the three-phase process, must be maintained by the driving forces observed by the agent agents during the unfreezing and freezing stages to better stabilize and integrate the outcomes of change (Roussel, Swansburg and Swansburg, 2006 p.63). After implementing the policy changes, both Level B and volunteer nurses are expected to provide enhanced nursing skills, and knowledge in the IV therapy and life support.
b. Justification of Change
Theoretically, the formulated three-phase policy change directed in utilizing nursing education to better equip and maximum the potential of existing nurses can resolve the problem of staffing at White Rock health care institution. Since another series of nurse recruitment is not entirely feasible due to personnel congestion and limited funding of the hospital to sustain such amount of workforce, it is best to maximize the skills of the available nurses. Furthermore, given the case demographics involving high number of patients needing emergency care that utilizes life support and IV therapy, developing the existing Level B nurses to Level A standard is the most feasible policy implementation to resolve the problem on staffing. In addition, as shown in Table 1, if level B nurses shall attain the skills necessary to be level A, staff to patient ratio will drop from 1:6 to 1:4 to 5 regardless of the enhanced volunteer nurses’ contributions. With volunteer nurses fully equipped and with enhanced nursing skills, they can further alter the staffing proportions in replacement to level B nurses’ position.
VII. Managing Resources
From the given statistics and hypothetical conditions prevailing in White Rock hospital, available resources that can be used in conducting staff development trainings and education programs are (1) the training facilitators – nursing supervisors, (2) the hospital’s provided area, and (2) Level B and Volunteer’s off days. With regards to materials and miscellaneous requirements, the three-phase policy change program does not entirely require specialized gadgets or materials in conducting the trainings. Furthermore, potentially required materials, such as IV sets, life support apparatus, CPR training mannequin, are already present in the hospital’s facility. However, prior to conducting of training and education programs, certain preparations must be met, specifically the following: (a) well-planned curriculum on IV Therapy and Life Support, (b) organized schedule of trainings and educational program commencements, (c) rotational plan of the nurse trainees set appropriately according to the planned allotted hours of training, and (d) materials for demonstration and demonstration of trainings. As the primary promulgator of staff development policy change, the institution is responsible for the (a) careful assessment of the trainees’ progress, (b) ethical considerations that might breach nursing care (e.g. breach of duty if working hours conflict with training, etc.), and (c) recommendations for accreditations and certifications.
VIII. Conclusion
In conclusion, staffing problems prevailing at White Rock Primary care institution can be properly resolved by focusing on interventions utilizing nursing education and staff development. By implementing the formulated plan based on Lewin’s theoretical framework, the three-phase change policy aims to (a) maximize the skills and knowledge potentials of level B and volunteer nurses, (b) generate more level A standard nurses to compensate on the emergency patient admission ratio, and (c) increase the quality of nursing care delivery system. Utilizing this change process, nursing education and staff development may solve the problem on staff disproportions. Change process is usually confronted be series of resistance, tensions and obstacles; hence, it is always important to include the recipients of change in the planning process of change.
IX. References
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