Product Focus feature title to go here
Clinical focus
S14
A framework for challenging deficits in compression bandaging techniques Abstract Northern Irish (and all UK-based) health care is facing major challenges. This article uses a specific theory to recommend and construct a framework to address challenges faced by the author, such as deficits in compression bandaging techniques in healing venous leg ulcers and resistance found when using evidence-based research within this practice. The article investigates the challenges faced by a newly formed community nursing Key words:
Compression bandaging
team. It explores how specialist knowledge and skills are employed in tissue viability and how they enhance the management of venous leg ulceration by the community nursing team. To address these challenges and following a process of reflection, Lewin’s forcefield analysis model of change management can be used as a framework for some recommendations made.
Lewin’s Theory of Change
Marianne Tinkler email: [email protected] Community Nurse, Northern Health and Social Care Trust
Leontia Hoy Lecturer (Education), School of Nursing and Midwifery, Queen’s University Belfast
Daphne Martin Lecturer (Education), School of Nursing and Midwifery, Queen’s University Belfast
Patient outcomes
If compression bandaging in the management of venous leg ulcers is not implemented according to protocol, this will result in increased workload and use of resources and delayed healing. In addition, implementation creates a need for change within the community nursing team dynamic. This article explores how specialist knowledge and skills are employed in tissue viability and how they enhance the management of venous leg ulceration by the community nursing team. To address these challenges and following a process of reflection, Lewin’s forcefield analysis model of change management (Lewin, 1951) can be used as a framework for some recommendations in this article.
Background
Accepted for publication 23 JUNE 2014
C
ommunity nursing within the NHS is undergoing immense change, and demand for services has never been greater. Northern Ireland has the fastest-growing ageing population in the UK (Health and Social Care Board, 2011). The first-named author is a community nurse in health and social care in Northern Ireland and is cognisant of the need to provide care based on evidence, alongside best practice (Nursing and Midwifery Council (NMC), 2008). The focus of this article is to investigate the challenges faced by a newly formed community nursing team.
The community nursing service is situated within the NHS and can be interpreted as a bureaucratic organisation. The management of change in the NHS within Northern Ireland is in a state of flux with the implementation of the Transforming Your Care strategy (Health and Social Care Board, 2011), and the reduction from 18 health-care trusts to 5 trusts in the past 7 years. Northern Irish health care is facing major challenges, namely, the impact of developments in information technology (for example, nursing referrals and ordering of equipment). Within new integrated community nursing teams, staffing is significantly reduced, yet needs to cope with an increase in complex cases, along with external factors such as the economic downturn and an ever-increasing
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Community Wound Care March 2014 Community Wound Care September 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 5, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus: Compression bandaging techniques
ageing population. The Health Minister for Northern Ireland has stated that ‘by 2025 the number of people aged 85 and over will increase by 83%’ (Northern Ireland Executive, 2012). Hence, change is a constant challenge for all health-care staff while striving to deliver patient-centred care. The community nursing team has faced major organisational change, with the amalgamation of two nursing teams and the addition of new employees to a new team structure. This has resulted in different ways of working, differing management styles and a ‘bedding down’ period—with the intention that the teams will unite as one, delivering patient-centred care that is evidence based.
Quality The Scottish Intercollegiate Guidelines Network (SIGN) (2010:2) states that ‘compression bandaging should be routinely used for the treatment of venous leg ulcers’. It goes on to say that ‘compression bandaging should only be applied by staff with appropriate training’. Nelson et al (1995) suggest that compression bandaging is the single most important method in healing venous leg ulcers. Dowsett and Scanlon (2001) agree that chronic venous leg ulceration increases with age, especially in those over 65 years of age. Penn (2002) comments that all clinicians within clinical governance are accountable to improve the quality of patient care. Quality is closely linked to the management of risk factors and resources available. Posnett and Franks (2007) calculate that the cost of recurring venous leg ulcers in the UK is approximately £200 million per year. Brooks et al (2004) suggest that improving the quality of education in staff and patients is required to reduce recurrence rates of venous leg ulceration.
Reflective practice The majority of patients on the nursing caseload in the present initiative had compression bandaging applied for recurring chronic venous leg ulceration for a few years. Patients’ healing rates were questioned using reflection. Jasper (2012) comments that reflective practice is a way in which we learn from our experience. Reflection uprooted the possible lack of adherence to guidelines and protocols (for example, Clinical Resource Efficiency Support Team (CREST) (1998) guidelines and the management of venous leg ulceration. Observation supported these reflections when a full lowerlimb assessment was completed and compression bandaging applied. Subsequent visits demonstrated that recommendations were not followed through.
Cost Patients with chronic venous leg ulceration are at risk of reduced mobility due to pain and inability to wear appropriate footwear due to bandaging. Resources affect the cost of having a venous leg ulcer that is not healing, incurring
nurse time, dressing costs and personal costs to the patient, such as quality of life—from being housebound. StephenHaynes (2010) believes that community nursing contains an element of de-skilled nurses, resulting in reduced quality of care for the patient and escalating cost implications. This supports observations in the community nursing team in this initiative in relation to chronic venous leg ulcer management. A change to practice was therefore highlighted and action was required of the whole team.
Changing practice Makinson (2001:598) states that
‘major organisational changes are being implemented to improve quality of care more effectively and efficiently.
’
He also believes it is vital that managers learn how to deal with change and implement it effectively. Manning and Robertson (2011) suggest that having effective leadership behaviour within an organisation is vital. This includes having vision, good interpersonal skills and creativity. Daft (2000) agrees that there are four major roles for change to be managed: the inventor, who understands the technical side of the idea; the champion, who believes in the idea and questions the organisation on issues such as cost and resources; the sponsor, such as the manager who removes obstacles in the organisation; and the critic, the realist who is aware of pitfalls to the eventual success of change (see Figure 1). To conclude the above, Grohar-Murray and Langan (2011) point out that change agents need experience and respect, alongside management competency. The change agent does not have to be the manager. Martin (1989) maintains that an entrepreneur is a person who has created their own idea, alongside managing some risk. They need to have a vision, be captivating, work alone and be accountable. Many nurses, depending on their personality and motivation, could be nurse entrepreneurs who have been successful in being cost-effective within the health service. However, organisational restraints can prevent the nurse entrepreneur role from being successful, with funding problems and scepticism from colleagues such as medical staff (Elango et al, 2007). Boyett (1997:77) agrees that
‘within the public sector we are seeing a new birth of an entrepreneurial leader.’ Lewin’s 1951 model of change The community nurse in the present initiative considered applying Lewin’s (1951) model of change to a change proposal to generate solutions and improve evidence-based practice. This could reduce the number of patients with chronic venous leg ulceration on the nursing caseload. Lewin’s (1951) model of change management, although seminal, is based on the participation of people in all aspects of change, to increase
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Community Wound Care September 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 5, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus: Compression bandaging techniques
their acceptance and execution of that change. Many modern change theories are based on this classic model. Lewin argued that time and a sequence of stages must be implemented before change can take place; these are known as the unfreezing, moving/changing and refreezing stages.
Figure 1. Four major roles of change to be managed (Daft, 2000)
Stages of change Critic Realist
Unfreezing stage In the unfreezing stage, colleagues were given guidance on the need for change in leg ulcer management practices and implementation of the CREST (1998) guidelines to underpin their knowledge and practice of compression bandaging technique. At monthly community nursing staff meetings, it was decided, compression bandaging techniques could be discussed. If there are gaps in education and training, these must be addressed—by focusing on any deficits in knowledge and theory of compression bandaging techniques, poor practices can be addressed and adjusted. Tagney and Haines (2009) support the above and argue that upgrading clinical knowledge and skills can help practitioners with the fast-moving pace of new initiatives highlighted in nearly all major Department of Health documents (Health and Social Care Board, 2011). They also add that barriers to major change, such as increased acute care being administered in the community, will have an impact on available time in a nurse’s working day to enable them to access evidence-based practice resources.
Moving/changing stage In the moving or changing stage, attitudes and behaviour can be altered towards a new idea, thereby modifying and standardising practice. For example, it may be beneficial to review current guidelines, policies and organisational protocols on the management of venous leg ulceration. Discussion of research articles and journals on evidence-based practice for better outcomes and improved quality of patient care can be encouraged, thereby increasing confidence in best practice. Further tissue viability specialist training can be initiated if needed or suggested in this instance, and the firstnamed author’s knowledge and skills in tissue viability could be used to assist colleagues in improving their compression bandaging techniques and increasing knowledge in this area.
Refreezing stage The refreezing stage will take more time as new skills are established, for example, a full, detailed lower-limb assessment may take 1–1.5 hours at the first or second contact with the patient. This includes holistic assessment, Doppler ultrasound, wound assessment, blood testing and a new dressing regime. Lack of competence, knowledge and understanding of compression bandaging techniques can be identified to allow new or existing staff to gain confidence, and take up further supervision and training in this skill, which can be audited over time.
Sponsor Removes barriers
Inventor Understands technical side
Champion Believes in the idea. Questions the organisation
Audit Clinical audit will also play a part at the refreezing stage of Lewin’s (1951) model. Auditing current practice to evaluate whether or not care is working is key. Penn (2002) advises that patient questionnaires on the effectiveness of treatment while using compression bandaging may be useful, and may help to determine how the patient’s quality of life has been affected. Reinforcing the change at this stage is valuable, communicating the results of the audits to the team and encouraging discussion on the positive and negative effects of this change on the patient and workload. Closing the knowledge and skill deficit will enhance staff confidence, enabling them to make more informed, accountable decisions with existing evidence.
Driving and restraining forces Lewin’s (1951) model of change reminds us that driving and restraining forces will always exist, and the scrutiny of such forces is essential. Drivers in compression bandaging techniques for venous leg ulceration management are: guidelines, policies and organisational protocols, as mentioned above. There is a need for training, improvement of quality and patient-centred care, setting goals and achieving outcomes and targets. Restraining forces could be: the demand of workload in a busy community nursing team and lack of time to carry out supervised practice and available training sessions in compression bandaging. Welford (2006) notes that
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Clinical focus: Compression bandaging techniques
other restraining forces might be lack of respect for or faith in managers or colleagues who are planning and implementing the change. Welford argues that in order for change to come about and be beneficial to staff, everyone onvolved needs to be more positive, motivated and have belief. Lawrence-Parr (1999) also agrees that positive thinking and questioning the best ways of achieving change for better outcomes will then help to achieve the vision that has been set.
Nursing team environment Underpinning the above, it is important to take into account the way in which colleagues work as a team. Conflict within that team will create barriers to the success of change. In this case, the large team (totalling 22 nurses) emerged from three separate teams, which naturally led to conflict. The first team is a group of nurses who had been a team for 20 years and whose office is the main base for the new larger team. Another group is from a nearby health centre. Finally, a third group was a newly recuited group of six new employees. Hence, the team is very diverse in nature and has three separate dimensions. In addition to this, three new team managers have been appointed. Stonehouse (2011) prompts us to believe that conflict will definitely occur in any team at certain times, but also supports the fact that, without it, nursing teams would not be exciting and visionary. In support of the team environment, Grohar-Murray and Langan (2011) propose that enhanced communication helps to build connections which will then underpin the leader to better oversee and motivate. Bolden (1996) confirms that various positive mechanisms such as discussions, regular appraisals, granting study leave and expressing thanks benefit the process of change, which can otherwise be sadly lacking with resistance then occuring. Eve (2004) concurs that if constant enthusiasm is devoted to sustaining team equilibrium, this can create a positive change management experience within the clinical setting. Through reflection we are able to ask a number of questions about compression bandaging techniques in healing chronic venous leg ulcers. Schon’s (1987) text Educating The Reflective Practitioner suggests that, as clinicians, thinking is more intellectual as emotions and feelings are involved. Cowan (2003) agrees—as a nurse, it is important to regularly ask oneself how well change is implemented, whether anything has been learned, and whether it could have been managed differently. The aim in this initiative was to educate, update and improve compression bandaging techniques, thereby improving quality of life for this client group and hopefully enhancing healing. Furthermore, the application of specialist knowledge of tissue viability provides a possibility of the latter being achieved. The consequences will mean increased time and possible conflict within the team, due to complacency and resistance from other colleagues. It was envisaged that this change would be time consuming. Notably, the team is in the process of the moving stage of Lewin’s (1951) change management theory.
Patient quality of life On a positive note, patients that were fully assessed felt as though they were ‘finally’ going to get out of compression bandaging. They commented that ‘eventually’ something was moving forward with their care. Carers noted that the small advancement and reassessment of the lower limb with a new plan of care was beneficial. It was questioned whether the change could have been carried out in any other manner. In hindsight, it was noted that, due to time and workload constraints, it was difficult to keep continuity of care viable. Discussions with line managers and the establishment of a plan to allocate time in the week to focus on relevant client groups could have benefited the process further.
Conclusion Lewin’s (1951) theory of change was used to provide a framework for the improvement of bandaging techniques in patients with venous leg ulceration, within a busy, new community nursing team. On an organisational level, the Department of Health (2011) proposes a new plan for more patients in our ageing population to be cared for in their own homes. This comes within an environment of reducing resources and continual improvements in quality of patient care, where practitioners are accountable for risk and resource management. There is a responsibility for each nurse to maintain his or her knowledge and to keep skills current and evidence-based. Recommendations for practice may include the need to use Lewin’s theory of resistance to change within a team. Consider change agents within a nursing team to highlight proactive thinking, which can help the team implement new government initiatives without barriers. Within the tissue viability nursing environment, improvement in overall patient healing rates and reducing nursing workload is the role of the change agent.
Recommendations for practice Initiating change is not only the manager’s responsibility but is the domain of all employees. The emergence of change agents, champions and nurse entrepreneurs allows visions to be achieved with improved quality of care—a central component to decisions made in the change process. This initiative realised through using Lewin’s (1951) model of change management that the moving stage was going to take a while, due to workload and time constraints. In hindsight, it might have been worthwhile to consult with management in planning time during the working week to facilitate this change. On further reflection, colleagues sometimes lacked vision and participation within the team, which made the process more difficult. The greatest advantage in using the model was that it gave focus to a major issue within a very busy community caseload. This, ultimately, will improve care and quality of life for the patient group. CWC
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Clinical focus: focus: Clinical Compressionbandaging bandaging techniques techniques Compression
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KEY POINTS
Disclaimer The authors declare that this piece of work has not been submitted for publication elsewhere. Ethics committee approval was not required for publication. There were no competing interests and/or declaration of interests for all authors. Bolden K (1996) Communication: theory and practice. Pract Nurs 7(17): 19–21 Boyett I (1997) The public sector entrepreneur: a definition. Int J Entrepreneur Behav Res 3(2): 77–92 Brooks J, Ersser SJ, Lloyd A, Ryan TJ (2004) Nurse-led education sets out to improve patient concordance and prevent recurrence of leg ulcers. J Wound Care 13(3): 111–6 Cowan T (2003) Reflection is the precursor to change. J Wound Care 12(1): 3 Clinical Resource Efficiency Support Team (CREST) (1998) Guidelines for the Assessment and Management of Leg Ulceration. http://tinyurl.com/nm6uvp9 (accessed 24 June 2014) Daft RL (2000) Management, 5th edn. Dryden Press, London Dowsett C, Scanlon L (2001) Compression bandaging and the clinical governance agenda. Br J Community Nurs 6(9): 17–21 Elango B, Hunter GL, Winchell M (2007) Barriers to nurse entrepreneurship: a study of the process model of entrepreneurship. J Am Acad Nurs Pract 19(4): 198–204 Eve JD (2004) Sustainable practice: how practice development frameworks can influence team work, team culture and philosophy of practice. J Nurs Manag 12(2): 124–30 Grohar-Murray M, Langan J (2011) Leadership and Management in Nursing, 4th edn. Pearson, New Jersey NJ Health and Social Care Board (2011) Transforming Your Care. A Vision to Action: Improving Northern Ireland’s Health and Social Care. Department of Health, Social Services and Public Safety, Belfast. http://tinyurl.com/q3zrjnu (accessed 24 June 2014) Jasper M (2012) Beginning Reflective Practice, 2nd edn. Seng Lee, Singapore Lawrence-Parr C (1999) Manage change by positive thinking. Pract Nurs 10(15): 41–4 Lewin K (1951) Field Theory in Social Science. Harper and Row, New York NY Makinson G (2001) Managing change. NRC 3(12): 506–98 Manning T, Robertson B (2011) The dynamic leader revisited: 360 degree assessments of leadership behaviours in different leadership situations. Industrial Commercial Training 13(2): 88–97 Martin BA (1989) Gender differences in salary expectations when current salary information is provided. Psych Womens Quart 13(1): 87–96. doi: 10.1111/j.1471-6402.1989. tb00987.x Nelson EA, Ruckley CV, Barbenal JC (1995) Improvements in bandaging technique following training. J Wound Care 4(4): 181–4 Northern Ireland Executive (2012) Who Cares? The Future of Adult Care and Support in Northern Ireland. http://tinyurl.com/pmv2xs6 (accessed 25 November 2012) Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. http://tinyurl.com/p2t85dx (accessed 24 June 2014) Penn E (2002) Nurses’ education and skills in bandaging the lower limb. Br J Nurs 11(13): 164–70 Posnett J, Franks P (2007) The cost of skin breakdown and ulceration in the UK. In:
Community nurses should consider change agents within their nursing team to encourage proactive thinking, which could help implement new government initiatives without resistance The improvement of community nurses’ knowledge and skills in the techniques of compression bandaging directly influences patient outcomes and their quality of life The greatest advantage in using Lewin’s 1951 Theory of Change model was that it brought focus to a major issue within a busy community caseload Person-centred assessment is essential if patients with chronic venous leg ulceration are to benefit from good compression bandaging; this will eliminate the risk of reduced mobility due to pain and inability to wear the appropriate footwear
Smith & Nephew Foundation, Skin Breakdown: The Silent Epidemic. Smith & Nephew Foundation, Hull Schon DA (1987) Educating the Reflective Practitioner, Jossey Bass, San Francisco CA Scottish Intercolligate Guidelines Network (2010) Management of Chronic Venous Leg Ulcers. http://tinyurl.com/oqhgyq4 (accessed 24 June 2014) Stephen-Haynes J (2010) Professional accountability and outcomes in tissue viability. Br J Community Nurs 15(supp. 8): S29 Stonehouse D (2011) Conflict at work: how support staff can handle it. Br J Healthcare Assistants 5(11): 557–9 Tagney J, Haines C (2009) Using evidence-based practice to address gaps in nursing knowledge. Br J Nurs 18(8): 484–9 Welford C (2006) Change management and quality. Nurs Manag 13(5): 23–5
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Community Wound Care September 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 5, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus
S14
A framework for challenging deficits in compression bandaging techniques Abstract Northern Irish (and all UK-based) health care is facing major challenges. This article uses a specific theory to recommend and construct a framework to address challenges faced by the author, such as deficits in compression bandaging techniques in healing venous leg ulcers and resistance found when using evidence-based research within this practice. The article investigates the challenges faced by a newly formed community nursing Key words:
Compression bandaging
team. It explores how specialist knowledge and skills are employed in tissue viability and how they enhance the management of venous leg ulceration by the community nursing team. To address these challenges and following a process of reflection, Lewin’s forcefield analysis model of change management can be used as a framework for some recommendations made.
Lewin’s Theory of Change
Marianne Tinkler email: [email protected] Community Nurse, Northern Health and Social Care Trust
Leontia Hoy Lecturer (Education), School of Nursing and Midwifery, Queen’s University Belfast
Daphne Martin Lecturer (Education), School of Nursing and Midwifery, Queen’s University Belfast
Patient outcomes
If compression bandaging in the management of venous leg ulcers is not implemented according to protocol, this will result in increased workload and use of resources and delayed healing. In addition, implementation creates a need for change within the community nursing team dynamic. This article explores how specialist knowledge and skills are employed in tissue viability and how they enhance the management of venous leg ulceration by the community nursing team. To address these challenges and following a process of reflection, Lewin’s forcefield analysis model of change management (Lewin, 1951) can be used as a framework for some recommendations in this article.
Background
Accepted for publication 23 JUNE 2014
C
ommunity nursing within the NHS is undergoing immense change, and demand for services has never been greater. Northern Ireland has the fastest-growing ageing population in the UK (Health and Social Care Board, 2011). The first-named author is a community nurse in health and social care in Northern Ireland and is cognisant of the need to provide care based on evidence, alongside best practice (Nursing and Midwifery Council (NMC), 2008). The focus of this article is to investigate the challenges faced by a newly formed community nursing team.
The community nursing service is situated within the NHS and can be interpreted as a bureaucratic organisation. The management of change in the NHS within Northern Ireland is in a state of flux with the implementation of the Transforming Your Care strategy (Health and Social Care Board, 2011), and the reduction from 18 health-care trusts to 5 trusts in the past 7 years. Northern Irish health care is facing major challenges, namely, the impact of developments in information technology (for example, nursing referrals and ordering of equipment). Within new integrated community nursing teams, staffing is significantly reduced, yet needs to cope with an increase in complex cases, along with external factors such as the economic downturn and an ever-increasing
© 2014 MA Healthcare Ltd
S14
Community Wound Care March 2014 Community Wound Care September 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 5, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus: Compression bandaging techniques
ageing population. The Health Minister for Northern Ireland has stated that ‘by 2025 the number of people aged 85 and over will increase by 83%’ (Northern Ireland Executive, 2012). Hence, change is a constant challenge for all health-care staff while striving to deliver patient-centred care. The community nursing team has faced major organisational change, with the amalgamation of two nursing teams and the addition of new employees to a new team structure. This has resulted in different ways of working, differing management styles and a ‘bedding down’ period—with the intention that the teams will unite as one, delivering patient-centred care that is evidence based.
Quality The Scottish Intercollegiate Guidelines Network (SIGN) (2010:2) states that ‘compression bandaging should be routinely used for the treatment of venous leg ulcers’. It goes on to say that ‘compression bandaging should only be applied by staff with appropriate training’. Nelson et al (1995) suggest that compression bandaging is the single most important method in healing venous leg ulcers. Dowsett and Scanlon (2001) agree that chronic venous leg ulceration increases with age, especially in those over 65 years of age. Penn (2002) comments that all clinicians within clinical governance are accountable to improve the quality of patient care. Quality is closely linked to the management of risk factors and resources available. Posnett and Franks (2007) calculate that the cost of recurring venous leg ulcers in the UK is approximately £200 million per year. Brooks et al (2004) suggest that improving the quality of education in staff and patients is required to reduce recurrence rates of venous leg ulceration.
Reflective practice The majority of patients on the nursing caseload in the present initiative had compression bandaging applied for recurring chronic venous leg ulceration for a few years. Patients’ healing rates were questioned using reflection. Jasper (2012) comments that reflective practice is a way in which we learn from our experience. Reflection uprooted the possible lack of adherence to guidelines and protocols (for example, Clinical Resource Efficiency Support Team (CREST) (1998) guidelines and the management of venous leg ulceration. Observation supported these reflections when a full lowerlimb assessment was completed and compression bandaging applied. Subsequent visits demonstrated that recommendations were not followed through.
Cost Patients with chronic venous leg ulceration are at risk of reduced mobility due to pain and inability to wear appropriate footwear due to bandaging. Resources affect the cost of having a venous leg ulcer that is not healing, incurring
nurse time, dressing costs and personal costs to the patient, such as quality of life—from being housebound. StephenHaynes (2010) believes that community nursing contains an element of de-skilled nurses, resulting in reduced quality of care for the patient and escalating cost implications. This supports observations in the community nursing team in this initiative in relation to chronic venous leg ulcer management. A change to practice was therefore highlighted and action was required of the whole team.
Changing practice Makinson (2001:598) states that
‘major organisational changes are being implemented to improve quality of care more effectively and efficiently.
’
He also believes it is vital that managers learn how to deal with change and implement it effectively. Manning and Robertson (2011) suggest that having effective leadership behaviour within an organisation is vital. This includes having vision, good interpersonal skills and creativity. Daft (2000) agrees that there are four major roles for change to be managed: the inventor, who understands the technical side of the idea; the champion, who believes in the idea and questions the organisation on issues such as cost and resources; the sponsor, such as the manager who removes obstacles in the organisation; and the critic, the realist who is aware of pitfalls to the eventual success of change (see Figure 1). To conclude the above, Grohar-Murray and Langan (2011) point out that change agents need experience and respect, alongside management competency. The change agent does not have to be the manager. Martin (1989) maintains that an entrepreneur is a person who has created their own idea, alongside managing some risk. They need to have a vision, be captivating, work alone and be accountable. Many nurses, depending on their personality and motivation, could be nurse entrepreneurs who have been successful in being cost-effective within the health service. However, organisational restraints can prevent the nurse entrepreneur role from being successful, with funding problems and scepticism from colleagues such as medical staff (Elango et al, 2007). Boyett (1997:77) agrees that
‘within the public sector we are seeing a new birth of an entrepreneurial leader.’ Lewin’s 1951 model of change The community nurse in the present initiative considered applying Lewin’s (1951) model of change to a change proposal to generate solutions and improve evidence-based practice. This could reduce the number of patients with chronic venous leg ulceration on the nursing caseload. Lewin’s (1951) model of change management, although seminal, is based on the participation of people in all aspects of change, to increase
© 2014 MA Healthcare Ltd
S16 S16
Community Wound Care September 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 5, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus: Compression bandaging techniques
their acceptance and execution of that change. Many modern change theories are based on this classic model. Lewin argued that time and a sequence of stages must be implemented before change can take place; these are known as the unfreezing, moving/changing and refreezing stages.
Figure 1. Four major roles of change to be managed (Daft, 2000)
Stages of change Critic Realist
Unfreezing stage In the unfreezing stage, colleagues were given guidance on the need for change in leg ulcer management practices and implementation of the CREST (1998) guidelines to underpin their knowledge and practice of compression bandaging technique. At monthly community nursing staff meetings, it was decided, compression bandaging techniques could be discussed. If there are gaps in education and training, these must be addressed—by focusing on any deficits in knowledge and theory of compression bandaging techniques, poor practices can be addressed and adjusted. Tagney and Haines (2009) support the above and argue that upgrading clinical knowledge and skills can help practitioners with the fast-moving pace of new initiatives highlighted in nearly all major Department of Health documents (Health and Social Care Board, 2011). They also add that barriers to major change, such as increased acute care being administered in the community, will have an impact on available time in a nurse’s working day to enable them to access evidence-based practice resources.
Moving/changing stage In the moving or changing stage, attitudes and behaviour can be altered towards a new idea, thereby modifying and standardising practice. For example, it may be beneficial to review current guidelines, policies and organisational protocols on the management of venous leg ulceration. Discussion of research articles and journals on evidence-based practice for better outcomes and improved quality of patient care can be encouraged, thereby increasing confidence in best practice. Further tissue viability specialist training can be initiated if needed or suggested in this instance, and the firstnamed author’s knowledge and skills in tissue viability could be used to assist colleagues in improving their compression bandaging techniques and increasing knowledge in this area.
Refreezing stage The refreezing stage will take more time as new skills are established, for example, a full, detailed lower-limb assessment may take 1–1.5 hours at the first or second contact with the patient. This includes holistic assessment, Doppler ultrasound, wound assessment, blood testing and a new dressing regime. Lack of competence, knowledge and understanding of compression bandaging techniques can be identified to allow new or existing staff to gain confidence, and take up further supervision and training in this skill, which can be audited over time.
Sponsor Removes barriers
Inventor Understands technical side
Champion Believes in the idea. Questions the organisation
Audit Clinical audit will also play a part at the refreezing stage of Lewin’s (1951) model. Auditing current practice to evaluate whether or not care is working is key. Penn (2002) advises that patient questionnaires on the effectiveness of treatment while using compression bandaging may be useful, and may help to determine how the patient’s quality of life has been affected. Reinforcing the change at this stage is valuable, communicating the results of the audits to the team and encouraging discussion on the positive and negative effects of this change on the patient and workload. Closing the knowledge and skill deficit will enhance staff confidence, enabling them to make more informed, accountable decisions with existing evidence.
Driving and restraining forces Lewin’s (1951) model of change reminds us that driving and restraining forces will always exist, and the scrutiny of such forces is essential. Drivers in compression bandaging techniques for venous leg ulceration management are: guidelines, policies and organisational protocols, as mentioned above. There is a need for training, improvement of quality and patient-centred care, setting goals and achieving outcomes and targets. Restraining forces could be: the demand of workload in a busy community nursing team and lack of time to carry out supervised practice and available training sessions in compression bandaging. Welford (2006) notes that
© 2014 MA Healthcare Ltd
S18 S18
Community Wound Care September 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 5, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus: Compression bandaging techniques
other restraining forces might be lack of respect for or faith in managers or colleagues who are planning and implementing the change. Welford argues that in order for change to come about and be beneficial to staff, everyone onvolved needs to be more positive, motivated and have belief. Lawrence-Parr (1999) also agrees that positive thinking and questioning the best ways of achieving change for better outcomes will then help to achieve the vision that has been set.
Nursing team environment Underpinning the above, it is important to take into account the way in which colleagues work as a team. Conflict within that team will create barriers to the success of change. In this case, the large team (totalling 22 nurses) emerged from three separate teams, which naturally led to conflict. The first team is a group of nurses who had been a team for 20 years and whose office is the main base for the new larger team. Another group is from a nearby health centre. Finally, a third group was a newly recuited group of six new employees. Hence, the team is very diverse in nature and has three separate dimensions. In addition to this, three new team managers have been appointed. Stonehouse (2011) prompts us to believe that conflict will definitely occur in any team at certain times, but also supports the fact that, without it, nursing teams would not be exciting and visionary. In support of the team environment, Grohar-Murray and Langan (2011) propose that enhanced communication helps to build connections which will then underpin the leader to better oversee and motivate. Bolden (1996) confirms that various positive mechanisms such as discussions, regular appraisals, granting study leave and expressing thanks benefit the process of change, which can otherwise be sadly lacking with resistance then occuring. Eve (2004) concurs that if constant enthusiasm is devoted to sustaining team equilibrium, this can create a positive change management experience within the clinical setting. Through reflection we are able to ask a number of questions about compression bandaging techniques in healing chronic venous leg ulcers. Schon’s (1987) text Educating The Reflective Practitioner suggests that, as clinicians, thinking is more intellectual as emotions and feelings are involved. Cowan (2003) agrees—as a nurse, it is important to regularly ask oneself how well change is implemented, whether anything has been learned, and whether it could have been managed differently. The aim in this initiative was to educate, update and improve compression bandaging techniques, thereby improving quality of life for this client group and hopefully enhancing healing. Furthermore, the application of specialist knowledge of tissue viability provides a possibility of the latter being achieved. The consequences will mean increased time and possible conflict within the team, due to complacency and resistance from other colleagues. It was envisaged that this change would be time consuming. Notably, the team is in the process of the moving stage of Lewin’s (1951) change management theory.
Patient quality of life On a positive note, patients that were fully assessed felt as though they were ‘finally’ going to get out of compression bandaging. They commented that ‘eventually’ something was moving forward with their care. Carers noted that the small advancement and reassessment of the lower limb with a new plan of care was beneficial. It was questioned whether the change could have been carried out in any other manner. In hindsight, it was noted that, due to time and workload constraints, it was difficult to keep continuity of care viable. Discussions with line managers and the establishment of a plan to allocate time in the week to focus on relevant client groups could have benefited the process further.
Conclusion Lewin’s (1951) theory of change was used to provide a framework for the improvement of bandaging techniques in patients with venous leg ulceration, within a busy, new community nursing team. On an organisational level, the Department of Health (2011) proposes a new plan for more patients in our ageing population to be cared for in their own homes. This comes within an environment of reducing resources and continual improvements in quality of patient care, where practitioners are accountable for risk and resource management. There is a responsibility for each nurse to maintain his or her knowledge and to keep skills current and evidence-based. Recommendations for practice may include the need to use Lewin’s theory of resistance to change within a team. Consider change agents within a nursing team to highlight proactive thinking, which can help the team implement new government initiatives without barriers. Within the tissue viability nursing environment, improvement in overall patient healing rates and reducing nursing workload is the role of the change agent.
Recommendations for practice Initiating change is not only the manager’s responsibility but is the domain of all employees. The emergence of change agents, champions and nurse entrepreneurs allows visions to be achieved with improved quality of care—a central component to decisions made in the change process. This initiative realised through using Lewin’s (1951) model of change management that the moving stage was going to take a while, due to workload and time constraints. In hindsight, it might have been worthwhile to consult with management in planning time during the working week to facilitate this change. On further reflection, colleagues sometimes lacked vision and participation within the team, which made the process more difficult. The greatest advantage in using the model was that it gave focus to a major issue within a very busy community caseload. This, ultimately, will improve care and quality of life for the patient group. CWC
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Clinical focus: focus: Clinical Compressionbandaging bandaging techniques techniques Compression
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Community nurses should consider change agents within their nursing team to encourage proactive thinking, which could help implement new government initiatives without resistance The improvement of community nurses’ knowledge and skills in the techniques of compression bandaging directly influences patient outcomes and their quality of life The greatest advantage in using Lewin’s 1951 Theory of Change model was that it brought focus to a major issue within a busy community caseload Person-centred assessment is essential if patients with chronic venous leg ulceration are to benefit from good compression bandaging; this will eliminate the risk of reduced mobility due to pain and inability to wear the appropriate footwear
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