Design for Change in Practice
Evidenced based practice (EBP) is an empowering process for improvement in the health care professions. Rosswurm and Larrabee (1999) credit the research studies which used meta – analysis, randomized clinical trials and systematic studies of patient outcomes over the last few decades as having started this shift from the “tradition of intuition – driven practice…to the new paradigm of evidenced based practice” (p.318). However, evidence has encountered a certain amount of difficulty being implemented into practice, thereby necessitating the use of a model when implementing a change based on evidence into practice. This paper will discuss the six steps in the Rosswurm and Larrabee (1999) model for implementing change as they apply to the necessary change of mitigating lateral violence in the nursing work place. Step 1: Assess
This step of the change process begins with the identification of a problem. For the purposes of this paper the problem identified is lateral violence in the workplace. Rosswurm and Larrabee (1999) discuss this process to include comparing the internal data with external data and involving the shareholders. There is much evidence to support the fact that lateral violence is a real and troubling problem in the nursing profession. The external data of evidence spans over twenty – years’ worth of documented research that describes and proves the presence of lateral violence in the world of professional healthcare particularly as it pertains to nurses (Griffin, 2004). Lateral violence is known by many names; psychological terrorism, nurse – to – nurse aggression, and bullying (Griffin, 2004; Jennings, 2008; Embree & White, 2010); however, the essence is the same.
This author was interested in assessing the relevance and importance of this evidence due to an overwhelmingly evident trend in the emergency department in question. The internal data suggested that the high turn – over rate and many unexplained absences that plagued the ED were due in part to factors outside of the short staff and long hours. The shareholders gathered to discuss the problem and initiate a positive change, included all levels of emergency room management, a select group of staff members, and hospital administrators. Step 2: Link Problem with Interventions and Outcomes
During the second step in the Rosswurm and Larrabee (1999) model for change, the shareholders are directed to define their problem in standardized language for the purpose of identifying relevant research, and linking the problem with outcomes. This part of the process resulted in the formation of a PICO formatted question: Will the nursing staff of an Emergency Department benefit from a comprehensive morale program versus the singular MAGIC program by experiencing a decrease in unexplained absences and nursing staff turnover? This question was developed because the shareholders had identified lateral violence as a problem in the work place directly related to the high level of unexplained absences and nursing staff turnover. The comprehensive morale program present in the PICO question was the intervention decided upon by the shareholders. This program would include education for both management and staff about lateral violence and conflict management, because comprehensive educational initiatives for both management and staff have proven effective in the mitigation of lateral violence (Griffin, 2004; Apker et al., 2009; Embree & White, 2010). The program would also include a multi- level mentorship program including mentorships for new hires and coaching for staff of all experience levels. New nurses are particularly vulnerable to lateral violence (Griffin, 2004) and mentorship has been a proven improvement technique for enabling and empowering new nurses, but mentorship at all levels can help to increase team cohesion by improving relationships and increasing morale (Stapleton et al., 2007). Finally a comprehensive reward and acknowledgement program will be implemented and given high visibility because this will help to establish a supportive environment (Roberts, Demarco & Griffin, 2009). The outcome would be measured in two primary ways.
First over the course of a six month probationary period would the turnover and unexplained absences decrease. More specifically after the first three months would all turn – over, not related to hours or pay, stop. Unexplained absences are much harder to assess due to the nature of unexplained absences; however, the shareholders decided on a statistical reduction of 50% by the end of the six month probationary period as an indication of success. The second type of measurable assessment of the outcomes of the comprehensive morale program would be the use of anonymous surveys and brief in – person interviews during the bi – annual review. These surveys would assess the identification of team in terms of the individual to the larger group, the over – all job satisfaction, the presence or absence of lateral violence, and the opinion of each employee regarding the morale program. The brief interviews serve a two – fold purpose; first they continue to foster and develop open lanes of communication between staff and management, and second they provide an environment for feedback directly related to the performance being evaluated. These surveys and interview sessions would be analyzed by the shareholders for language that could be categorized and used to improve or change the morale program for increased benefit. Step 3: Synthesize Best Evidence
This step in the Rosswurm and Larrabee (1999) model involves refining the variables and outcomes even further through research. The shareholders perform a literature review based on their variables and desired outcomes and find evidence to support the change they are proposing. For this project, several computer databases were mined for the relevant research: CINAHL, Medline, and Ovid. A comprehensive literature review was performed for the problem of lateral violence and there was strong evidence supporting education (Griffin, 2004; Apker et al., 2009; Embree & White, 2010), mentorship (Griffin, 2004), and acknowledgement/team building (Stapleton et al., 2007) as useful tools for mitigating lateral violence. These were therefore the elements chosen for the comprehensive morale program. Step 4: Design a Change in Practice
This step in the model involves the delineation of the details of the proposed change or changes generally through protocols or processes implemented by the management. During this step needed resources are identified, a plan is developed, and measureable outcomes are defined. Tools for measuring the outcomes are also chosen or designed. Because of the multi faceted nature of the comprehensive morale program, the shareholders identified several critical resources essential to the success of the six month trial period. Educational materials related to lateral violence, conflict management and effective mentoring would need to be found and procured. Budget would need to be allocated for the once monthly mandatory meetings regarding mentorship, because unpaid extra hours would have a negative impact on the over – all morale of the ED. Also, gift certificates or other prizes would need to be secured for the acknowledgement program.
Time was also noted as a needed resource. The plan begins with the dissemination of two assessment tools, Lateral Violence in Nursing Survey and the Nurse Workplace Behavior Scale (Griffin, 2004; Apker et al., 2009; Embree & White, 2010 which will be used to generate awareness and begin group buy – in amongst the staff regarding the presence of lateral violence. A mandatory staff meeting will then be held to introduce the new reward and acknowledgement program which will have built in milestones, for example employee of the month, and bi weekly employee appreciation days. During this staff meeting mentors will be assigned to small groups. After the implementation of the education program more specific and individualized mentorships will be established. The education program will begin within the framework already established in the ED. New hires will train in the manner indicated by Griffin (2004) as a part of their orientation and existing staff members will be educated about lateral violence as a part of their continuous learning credits. Leadership will begin a bi – weekly mentorship training program focusing on conflict management, building cohesive teams, and active listening. During the six month trial period, the assessment survey and the interview questions will be designed by the shareholders and used to determine the success of the trial period. Also the much more concrete outcomes of reduced unexplained absences and halted turn-over will be monitored and assessed. Step 5: Implement and Evaluate the Practice Change
The fifth step in the Rosswurm and Larrabee (1999) model is the implementation of the proposed change and the evaluation of the results. Rosswurm and Larrabee (1999) suggest a pilot program for a finite period of time during which an assessment can be made as to the success of the change and whether or not it should be implemented permanently. For the purposes of this paper the implementation and evaluation of outcomes will be anticipated because the change for practice is still in the planning stages.
Research suggests that education initiatives designed to teach responses to lateral violence have significantly increased the subjects’ ability to mitigate lateral violence acted against them (Griffin, 2004). Education also has proven effective in conflict management and team building (Apker, Propp & Ford, 2009). Survey results are anticipated to reveal that subjects feel more able to communicate in conflict and also that management is more receptive to feedback and more proactive regarding team building and conflict management. Mentorship groups will participate in brainstorming activities regarding team building and will also discuss strategies for conflict resolution. Wherever possible these strategies will be implemented and the surveys and interviews are anticipated to reveal this involvement in the change will increase each staff member’s identification with the team and investment in the change process (Stapleton et al., 2007). The much more clearly defined and well-ordered acknowledgment program will also be assessed through the surveys and interviews and anticipated results include more positive attitudes and pride in the staff. Finally, the reduction of unexplained absences and the turn – over not related to money and hours are anticipated as well. Step 6: Integrate and Maintain the Change in Practice
Rosswurm and Larrabee (1999) warn that during the sixth step of the model, if the results of the pilot program indicate that the changes should be implemented permanently, that there will be some resistance to change because all change can be seen as disruptive. The shareholders for this study hope to overcome some of this resistance through implementing some of the suggestions of the staff as ascertained in the mentorship groups. However, during this step the shareholders look at the results of the outcomes and decide whether or not the change in practice should be implemented permanently. Because the shareholders will be involved in every step, in fact the representatives of the shareholders will be serving in the committee actively involved in the implementation of the change, little extra work will be necessary regarding informing them. They will however seriously review the outcomes and it is anticipated that they will implement the program. The implementation will include periodic reviews of processes and modifications where necessary. The pilot program strategies will be made available to other floors and departments in the hospital as well to be modified for their needs and implemented as well.
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