Vera M Robinson, RN

How to initiate change in practice When you participate in a workshop or seminar, how do you incorporate your new knowledge into your nursing practice? How do you share your newly acquired skills with your colleagues? Can you use what you have learned to change the system? Continuing education (CE) in nursing is the vehicle for maintaining individual competency, for survival of the profession, and for the assurance of quality health care for the consumer. Toffler and others have pointed out that with rapid advances in technology and with new knowledge multiplying at an alarming rate, within five to ten years most professionals are consi-

Vera M Robinson, R N , EdD, is associate professor, continuing education coordinator, nursing program, California State University, Fullerton. She is a graduate of Western Pennsylvania Hospital School of Nursing, Pittsburgh. She received her B A from the University of New Mexico, Albuquerque, her MLitt in psychiatric nursing from. the University of Pittsburgh, and her EdD from the University of Northern Colorado, Greeley. Robinson presented this paper at the 1977 AORN Congress program “Shake up the workshop hideouts.” 54

dered obsolete.’ If that professional continues to operate with knowledge and skills of which an increasing percentage is no longer current or effective, it follows that the quality of service he is providing will be obsolete or ineffective. The remedy for this is lifelong learning. This concept is not new. In nursing we have consistently viewed the ultimate goal of all continuing education to be enhancing patient care, even though the immediate objectives are designed for the individual and his learning. What is new is that increasingly we are asked to document that this learning maintains the competency of the practicing nurse and has impact on the practice setting. We are consistently asked, Does continuing education really make a difference? The demand from the consumer for competent health care has pressured the basic education programs and the service system to be accountable for their endeavors. Curriculum, faculty, and student evaluations have intensified in education. In the practice setting, the result has been peer review, audits, and quality assurance programs. Criteria set by professional organizations and voluntary and mandatory agencies insure the quality of the continuing education offering. Research

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and evaluation to assess its impact on the health care system is difficult. Horn states, “Evaluative research methodologies are not well developed so that work in this area is most difficult. To test the effects on clients, settings must be controlled to a s u f f cient extent as to reduce or eliminate competing hypotheses. This is not always possible.”2 She points out the danger, with so many variables to consider, of skewed and misleading results. One variable is the individual learner. What he or she does in the practice setting with what is learned is the crucial issue. Does he or she have the opportunity to practice? Is the new input valued? Is there administrative support? Does the input get lost in the usual busy routine? The responsibility rests with the practice setting and the participant to demonstrate that continuing education does have an impact. Continuing education courses are designed to evaluate individual learning. We can evaluate the knowledge and skills and changes in attitudes. We can guarantee that the student has the ability to perform. We can guarantee learning by the end of the workshop, but we cannot guarantee consistency of that performance or application back in the work setting. Postevaluation tools will tell us what has happened but do not control what did happen. The controlling variables become the health setting and the individual learner-what he or she does with the learning, the extent to which he or she is encouraged and able to perform, and the ability to influence the system and, subsequently, the health care of the patient. There are three areas of concern the student will have: 1. how to maintain and reinforce

his own new skills, attitudes, and knowledge 2. how to share this new learning with others 3. how to incorporate this learning into the system to create change. In the ideal situation, the avenues for achieving success at these three levels would have been preplanned. That is, a n organization that conducts a n ongoing evaluation of the effectiveness of its efforts to meet its goals would have determined its need for new input. It would have selected the right person or persons to attend carefully chosen continuing education. offerings and to bring back those inputs identified as necessary to increase its effectiveness. Plans would have been made for incorporating that input at all levels with all persons ready, accepting, cooperative, and eager. Unfortunately, this idealistic situation rarely exists in organizations. Even if the intent is genuine, not everyone is ready for change in the same way and to the same extent. What we are discussing is change: change in the individual, in others, and in the system. Learning is generally defined as a change in behavior. Individual behavior change will affect the system. We know that in a n organized system, change in one part forces change in other parts because one property of systems is to maintain equilibrium. The reaction, however, may be positive or negative, adaptation or resistance. Therefore, in attempting to incorporate behavior change into a n organization, i t is important to analyze the system and to know what and where are the supports and resistances. When we know, we can develop appropriate methods and intervention strategies. Let us look a t the first level of change. How does the individual retain and reinforce his or her own new

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Workshops no longer a “hideout” As the nursing profession continues its emphasis on continuing education (CE) as a primary agent for developing nurse practitioners, are we in the operating room throwing the CE ball or are we catching it? For more years than we choose to admit, we have been content to keep the ivory tower doors closed and bolted while we did “our thing.” We never really identified, for ourselves or for anyone else, what that thing was, but we certainly spent many hours doing it. Every year on schedule, the OR supervisor took off to attend meetings usually held out-of-town. We never challenged these leaves as they gave us all a chance to relax and breathe while the “boss figure” was away. When he or she returned, it was back to the “old grind’’-same behavior-day in and day out. Administrators, for the most part, picked up the tab without too much questioning. I don’t know that a change in behavior on the supervisor’s part was expected; I do know very little was shared. In essence, the workshop became a “hideout”-away from threats to security and uncomfortablesituations. More important, the workshop became a convenient hideout from one’s self. The opportunity to attend an educational offering was seldom extended to anyone but the supervisor. As a result, effectiveness was never measured and impact never experienced. The patient certainly paid for the supervisor’s trip but no benefit was realized. Where are we now? With continuing

education becoming mandatory for relicensure, we are disturbing the “hideouts” and, as a result, exposing the “cop-outs.” The OR nurse is being forced to look to his or her supervisor for assistance in meeting professional requirements. The opportunity for continuing education will have to be offered to one and all on an equal basis. Our patients are paying plenty for care, and it is most important that health care delivery be accomplished by well-trained practitioners and knowledgeable and caring personnel who take their commitment to the patient seriously and totally. The time for telling it the way it is from an administrative viewpoint is at hand. The OR nurse’s voice must be sounded by mature nursemanagers who not only provide the opportunity to learn but also provide the opportunity to grow and modify outdated performance patterns. More and more opportunity for continuing education is being provided on company time. It is in the interest of good business that positive results are realized and improved health care delivery to our patients demonstrated. Administration, which builds these costs into charges to the patient, has every right to expect results from such an expensive proposition. A more aware, demanding public is entitled to an explanation for rising health care costs. You say you’re not allowed to attend CE offerings on company time? Administration could care less? Won’t let you go? Nonsense. Just as the OR nurse’s voice

behaviors in the practice setting? The process should begin before the individual attends the workshop. He or she should have defined the goals and reasons for participating and shared them with the inservice coordinator, the head nurse, and/or the supervisor. If possible, more than one person from the organization should attend the same conference or workshop to support and reinforce the other’s behavior.

If practice is involved, a commitment should be made with the head nurse, supervisor, or inservice coordinator for the opportunity to practice and subsequent evaluation and supervision. Peer review is another means for evaluating effective performance in the setting. Reviewing course materials and seeking out supplemental readings and audiovisual materials often suggested by the instructor will

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commodity of life so use it wisely. If you are in a session, listen and learn. Change in any system requires modified behavior on the part of those involved. Be vigilant. Seize the opportunity to share what you’ve learned. Volunteer to present recommendations for change that have been identified. It is a selling situation. Allow enthusiasm to rub off, whether it be on the supervisor, colleagues, and/or administration. With patience and persistence, the ivory tower becomes a room at the inn with an unlocked, swinging door. Make the educational experience a “workshop come-on.” Your patients will benefit, nursing will benefit, and you will benefit. A well-adjusted, enthusiastic staff becomes a productive staff, proving to hospital administration that continuing education can produce positive, tangible results.

must be sounded by mature leaders, so must that voice be carried in such a way that it is heard. This is a true challenge for OR management. However, there has to be bargaining power, and it has to be shown that quality beats quantity. Knowledgeable, capable, mature OR nurses who have faith in themselves, can think on their feet, and have as their prime goal optimum, safe patient care will contribute more to patients than twice as many lukewarm colleagues. We have to sell ourselves, keeping in mind that traditionally OR representation to workshops has produced little or no measurable improvement in patient care. Administration has a right to question, in the name of the patient dollar used for education, where the tangible evidence is of the effect of further education in your OR. A few years ago, I moderated a panel at the AORN Congress in New Orleans. The OR staff nurse was the subject and we heard from a nursing administrator, an OR supervisor, and finally a staff nurse. This intelligent young lady had the courage to say that despite attempts to improve herself, there were three Ss that kept her from modifying performance: surgical technician, surgeon, and supervisor. I am adding a fourth S-self-in that we all function within self-contained limitations-we need the job-we don’t want the hassle-we need the commitment-we don’t want the involvement. The education process has to be initiated by the learner. Time is the most precious

Shirley M Ruof, R N , MS, is associate director of nursing for operating room services at Cedars Sinai Medical Center, Los Angeles. A graduate of Buffalo General Hospital School of Nursing, Buffalo, N Y , she received a BS from the University of Buffalo, and an MS fFom the State University of New York at Buffalo. Ruof presented this paper at the 1977 AORN Congress program, “Shake up the workshop hideouts.”

add to one’s knowledge. Practice and overlearning reinforce behavior. A recent study a t the University of Texas found t h a t “when practice occurred either during or after the offering, information learned during the offering appeared to be retained.”3 Changes in performance are not always viewed favorably by others in the system, particularly by one’s peers and colleagues. In many respects, the re-

turning participant who has learned new content, new attitudes, a n d n e w values may experience a “reality shock’ s i m i l a r t o t h a t of a n e w g r a d ~ a t e .The ~ learner has acquired some values o f the educational system t h a t may be in conflict with the values of the w o r k system. Often, the learner recognizes t h a t the old system m a y n o t be as effective as thought and t h a t changes need t o be made.

Shirley M Ruof, RN

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ithout change, systems stagnate and decay.

Friends and colleagues who have not attended the educational offering, however, do not have the same insight-not because they want to be “behind,” but because they simply “don’t even know what it is they don’t know.” Consequently, their reactions may be less than positive with comments such as, “Am I glad you’re back. Ilet me tell you how much I had to do while you were gone.” “What are you gonna lay on us this time?” “Can’t be bothered with that new stuff; we need to get the work done.” There will be some, however, who will express a “show me” attitude, and others who will be receptive. How to maintain newly acquired values and behaviors without becoming immobilized and withdrawing or abandoning them is to become bicultural. Becoming bicultural means to retain one’s value system and behaviors but to seek ways to effect a viable integration of both value systems.5 The bicultural nurse understands the effect of his or her behavior on others, predicts the behaviors of others in terms of their frame of reference, and chooses appropriate avenues for operationalizing his or her goals and changing the system by working within it. What are some strategies the nurse can use to achieve this state? Building a support system and being able to express feelings and concerns is the

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first step. Meeting and communicating with other participants who attended the conference to share reactions and experiences serve to eliminate the feelings of being alone. The continuing education instructor must also incorporate into the workshop some discussion and strategies to prepare the student for this conflict and provide means for communication after the conference. Role playing, group sessions, and participant and address lists are examples. The inservice educator is also a useful ally and a resource for support to plan ways to incorporate the new behaviors and share feelings. Keys to functioning within the system are accepting the reality of the organization, retaining one’s selfconcept, having confidence in one’s ability, and finding an approach in the situation suited to one’s own personality. At the second level, how can the individual share his or her knowledge and values with colleagues and encourage changes in their performance? Because the returning participant has been part of the system, he or she has an advantage over a new person entering the situation and has empathy for fellow workers. Perhaps he or she can link the old with the new. Recognizing why negative reaction occurs is important. As professionals, we think of ourselves as competent individuals. As an example, the nurse

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who for years has been told she is doing a good job finds it frightening and deflating to suddenly face a new concept or an aggressive torchbearer who declares what is being done is all wrong or not good enough. Naturally, the nurse’s defenses are raised. It takes courage to admit we need change and have made mistakes and to accept the premise that the more we know, the more we realize we don’t know. This is a process of growth. The approaches used to introduce new behaviors should consider this negative reaction. In presenting new ideas, be assertive, not aggressive. Be positive in your belief in the value of the new learning and continue to model the new behavior, but begin slowly. To build up your support system, find the learners who are ready for changes. Find the covert leaders and win them over. “Restraint in the beginning will frequently pay off as dividends later on.”6 Knowledge is easiest to change; attitudes and behaviors are hardest, so start with the ideas and the concept. Share literature and course materials. Share your enthusiasm over coffee, but also share the feelings you had about changing your own behavior and how you came to grips with it. Blau suggests that acceptance by a group depends on both “attractiveness and appr~achability.”~ A person must present himself not only as attractive,

ie, with good qualities that earn respect, but also as approachable, ie, his “humanness,” through well-chosen, self-depreciating modesty. Humor is effective in communicating this humanness and self-depreciating modesty without destroying attractiveness. To be too humble could raise questions about one’s abilities. Responding to jibes with humor and relating one’s process of change in a humorous fashion using self-depreciating humor can be a face-saving device and relieve tensions. Yet, it can maintain the social relationship and ease the way to a more serious discussion and acceptance of the change. In presenting the new ideas, stay only enough ahead so people can understand you rather than so far ahead they can only reject you. On a continuum of changing values from the conservative to the liberal, starting in the middle can be a challenge while starting abruptly at the most radical point can be a threat. These approaches to encouraging change should be reflected in the conference report, which has become a common requirement of participants. The written or oral report should be given as soon as possible and include a brief summary of the CE offering’s content, application of the content to nursing practice, and any additional benefits gained by participation.” Focusing on the highlights and using

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audiovisual aids will help stimulate interest. The inservice educator serves a valuable role as consultant in preparing the report and in translating the idea into action. If a new behavior is to be applied to the setting, the inservice educator should be instrumental in developing the educational activities for assisting staff to learn it. The learning strategy should emphasize the application of knowledge to performance rather than simply a transmission of knowledge. The standards for performance, the policies governing performance, and the opportunity to acquire the skill should be provided. Then, the ability to perform must be validated by an objective measurement tool. Self-learning packages and audiovisual materials are effective methods of instruction. If knowledge is to have an effect on patient care, it must be applied. The third level of change, that of influencing the system, is a complex process. There are a number of variables to be considered in organizational change, and “an assessment of the quality and quantity of the resistance is crucial if the change agent is to make an informed choice of intervention ~ t r a t e g y . ” ~ The first of these variables is the nature of the change. As the scope or depth increases, the resistance increases. A procedure change is met with less resistance than changing the core objectives of the entire agency. Secondly, the value orientation of the decision maker and his style will affect change. Is the leader concerned with security and maintaining status quo? Is he ambitious and concerned about power, position, and prestige? Or, is he committed to his organization’s goals and to his professional ideals? His resistance or openness to change will be influenced accordingly.

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Organizational distance is also a variable. The greater the distance a proposal must travel from the initiator to the decision maker, the greater the likelihood of resistance, of a winnowing process along the way, and of distortion and pigeonholing. Face-to-face confrontation is the most effective. Another factor to consider is the amount of investment in the status quo--“sunk costs.” The more investment in time, energy, money, or personal commitment already made by an organization or its members to a goal, current practices, and specific equipment, the greater will be the resistance. What are the implications for the change agent, the participant who is attempting to incorporate behavior change and make an impact on this system? Analyzing the system provides the information to nssess what resources to mobilize, to know what he or she is fighting, and to develop strategies accordingly. He or she also can determine whether the goal is feasible and the resources sufficient. Analyzing can help determine where to focus interventions. If the administrator is resistant, start with the staff. If the administrator’s concern is economy, show him how the change will save money. For change to occur, there must eventually be the cooperation and willingness of all involved in an atmosphere of free and open communication about standards and values. Without change in performance of the staff and the full support from administration, there is a stalemate. When a stalemate occurs within the system, another recourse is through outside pressures. Demands from the client for accountability and quality and innovative health care are one such pressure. Patient teaching, preoperative orien-

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tation, and other health education classes are avenues for the nurse to consider. In one hospital, changes in delivery practices and the maternal and child care were brought about through prenatal classes in which patients were taught new approaches and what quality to expect. When these patients demanded from their physicians and the hospital the kind of care they wanted and were prepared for, the changes occurred. Incorporating behavioral changes into the practice setting is not easy but is possible if one has the knowledge and tools with which to proceed. Change creates conflict within the organization as well as within the individual. However, we would not want to avoid either the change or the conflict because the successful resolution of conflict and change is a growth process. Without change, systems, both individual and organized, stagnate and decay. Change is a way of life today. Learning to cope with change is a necessity. So, be a Jonathan Livingston Seagull in your approach and avoid the kiki bird mentality.1° Who is the kiki bird? The kiki bird, now extinct, was well-known for its ability to fly backwards. Such expertise, while often rewarded in academe, was of dubious value in the world of nature. This backward mobility enabled him to become an expert on where he had been. It also enabled him to avoid dealing with where he was going. Perhaps the kiki bird’s demise can be attributed to future shock. Unable to fly like the soaring and forward-looking Jonathan Livingston Seagull, the kiki bird miscalculated and met butt-on the wall of the future, believing it to be a sim-

ple repetition of the past. Unable to deal with change and the radical change of change, he was destroyed by it. 0 Note8 1. Alvin Toffler, Future Shock (New York: Random House, Inc, 1970). 2. Barbara Hom, “Identification of variables needed to evaluate the relationship of continuing education upon the quality of patient care,” pre sented at the 1976 National Conference on Continuing Education in Nursing, Austin, Tex, October 1976. 3. Card b e t s , Dorothy Blume, Evaluating the Effectiveness of Selected Continuing Education Offerings, final report of project conducted by the University of Texas System School of Nursing, 1974-1975. 4. Marlene Kramer, Reality Shock: Why Nurses Leave Nursing (St Louis: C V Mosby Co, 1974). 5. Ibid, 162. 6. Ibid, 230. 7. Peter M Blau, “A theory of social integration,” American Journal of Sociology 65 (1960) 545-556. 8. Signe Cooper, “Getting the most out of a conference,” Journal of Continuing Education in Nursing 7 (1976) 11-17. 9. Rino J Patti, ”Organizational resistance and change: The view from below,” Social Service Review 48 (September 1974) 367-383. 10. David I Welch, Fred Richards, Anne Cohen Richards, EducaHonal Accountability: A Humanistic Perspective (Fort Collins, Colo: Shields Publishing Co, Inc, 1973) 48.

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How to initiate change in practice.

Vera M Robinson, RN How to initiate change in practice When you participate in a workshop or seminar, how do you incorporate your new knowledge into...
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