How do nurses get better practice to the bedside? What are the tactics used to engage one’s management or administrative partners in order to enact change or be active in the implementation of new and valid evidence-based practice? These are the dilemmas and challenges faced by many nurses who are trying to: “Do the right thing for the right reason.”
Many new ideas in practice get hindered, held up, or hijacked because of the agenda of an individual with authority, an institution with other competing priorities, or the age old tradition of siloed control. In an effort to better support the consistent evolution and growth of health care in today’s new era, nurses, as frontline staffs, need to empower themselves and become armed with the right tools and tactics to properly manage integrating change into their environment even in the face of such “active resisters and organizational constipators” (Saint et al., 2009,).
Getting in Step
So, how does one do it? The solution is to use a step-wise plan:
- Investigate all existing, current evidence and critique its value.
- Gather supportive stakeholders onto your team.
- Develop an all-inclusive plan.
- Use salesmanship to vet the idea to administration - marry the dollar to the potential benefits and outcomes.
- Implement small tests of change and make necessary improvements.
- Launch a formalized, system-wide change as the result of the previous rapid-process pilot evaluations and improvements.
Take the example of trying to implement an early progressive mobility program in an intensive care unit or, better yet, within an entire hospital setting. How would you do it? What do you need to navigate? What can you expect? The answers to these questions (and many more) could be enough to potentially “constipate” your plan or slow you down to a stop if you are not well-prepared to deal with them even before you begin to discuss the potential for practice change.
The first step in trying to implement a beneficial practice change in your patient care area is to collect current evidence on the topic. Before you approach anyone in management with an idea for change, do some of the leg work:
- What is written on the topic in the literature at-large?
- Which recognized authority or body of practice supports the change and at what level (local, regional, national [federal], or global)?
- Is there any potential bias (corporate or organizational) implied in any of your findings or supportive information surrounding the change idea?—you want to be careful to find supporting literature that is not prejudiced.
- Is there any independent, randomized control trial research associated with any of your idea?
In our EPMP example, there is an abundance of literature support for such practice from every level or domain of critical thought: professional experience, wisdom, and intuition; quality improvement; EBP; and research (Clark, Lowman, Griffin, Matthews, & Reiff, 2013; Dammeyer, Dickinson, Packard, Baldwin, & Ricklemann, 2013; Drolet et al., 2013; & Saint et al., 2009).
Putting a Team Together
Next, try to develop the significance or importance of the potential change issue to use as a tactic to gain favor among the ranks. Create the need for it; put it in terms that you can use to gain favor from management or administration even before you approach them. This means you should focus on selling your concept to others outside of administration, and strive to develop your own working team of supporters. It does not necessarily imply approaching formalized organizational administration yet and pitching your idea (until you are confident that you have all the angles covered). Perhaps you need a team composed of multidisciplinary players collaborating to help you solidify the concept (a co-worker, a physician, a colleague from another vital discipline). Your informal work group certainly could include formalized leadership or management team players, but you want to make sure they are not going to slow down the evolution of the process; rather, aid in moving it forward and strengthening it. Remember, timing is everything.
This type of supportive measure (establishing a diverse group of supporters and influencers) not only helps your idea into becoming a reality, but it lets the resisters and constipators know that you have an effective, “critical mass” of colleagues who favor your position to improve patient care or outcomes. Any impending pervasive attitude from other co-nurses intending to slow down your good idea or propose a potential change may dissipate if you have a strong teamwork in nursing gathered at your table (Saint et al., 2009).
The best idea can go a long way and become more easily achieved if you have a workforce project team composed of strong and lively, influential stakeholders. In particular, having a physician champion to support your proposal can help to influence change in a more efficacious manner (Valente & Pumpuang, 2007).
Physician supporters can prove to be great opinion leaders and motivators for influencing organizational transformation regarding change or innovation in health care practice (Valente & Pumpuang, 2007). In our EPMP scenario, obtaining physician buy-in as well as physical therapy support early on (before approaching administration) could greatly advance the creative process, assist in streamlining the plan, and ensure guaranteed acceptance and adoption of the idea at the system level.
A proper change plan needs to be developed by the nurse as though it is going to “solve everyone’s problems,” for lack of better words. You always want to aim as high as you can: make the plan as all-inclusive as possible. As Les Brown has been credited for saying: “Shoot for the Moon, because even if you miss, you’ll land among the stars” (Eliason, 2009). Therefore, if you try to address the specifics of your plan, making it as thorough as possible, you are likely to get even a little of it accepted and implemented rather than having all of it tossed out by any resister or constipator. This will tend to keep you in the spotlight more, even though you may not necessarily be the star.
The CSR Model
Next, you need to work on a great sales pitch: How can you paint a picture about your idea to anyone and cause them to want to implement it or guarantee their support to you by the time you are done talking? This is not only an art, but it is a convenience wrapped in what I have been known to refer to as “CSR” (consistency, standardization, and reproducibility) for the purposes of personal, professional and patient benefit. What this implies is that your idea needs to not only be thorough and show improvement to practice or outcomes, but it also needs to be easy to implement and it should try to improve practice by reducing readmission and hospital costs to carry out other related practices.
Utilizing a CSR model will ensure that the idea will be able to be implemented not only in your work area but anywhere else in the organization, an easier approach when administration is looking at you through fiscal eyeglasses. For example, when discussing the EPMP idea, how would it sell if the nurse pitching the concept was able to entice early physician support by asking for standardized activity order sets for all admitted inpatients within a hospital:
“Out of bed (OOB) to chair/Activity as tolerated (AAT)?” —unless __________ (check box here and fill in reason).
That way, a nurse would not have to remember to seek out an activity order if one was forgotten on a patient, and all disciplines (so long as it was permitted and practical), such as nursing and physical therapy could immediately get patients OOB and perform AAT. Would patients become mobile sooner? Would they go home earlier (have a reduced length of stay), would they be more or less likely to be at baseline (pre-admission) functional mobility or better? Would more patients receive evaluation and treatment procedures sooner than the day of discharge? How about readmission rates within 30 days: If I can move better before discharge due to this auto-order concept, will I be more likely to become readmitted? Similarly, what if particular groups of patients received automatic physical medicine evaluations as part of the new change process?
We already see standardized order sets including physical medicine and rehab for cardiac surgery patients and orthopedic patients. Why just them? Why wait for the federal government to dictate how to improve care, we should be active and not reactive. What about all stroke patients, or even all ICU patients? Remember, in many states, one of the top reasons for patient readmissions is a mobility issue. Similarly, the sooner a patient can move or walk (think ICU now), the sooner they get extubated, OOB, have central lines removed, and are less likely to experience delirium (Barr et al., 2013). How many hospital-acquired conditions have we just avoided by implementing one consistent process with two standardized steps? Try it.
Now you are evolving into a true nursing leader from the frontline by learning to influence care through the art of marketing better practice to the right stakeholders. Fill your toolbox. Make the idea reasonable, desirable, easier, timely, and cost effective (preferably as budget neutral as possible and cost saving in the long run). Everyone wins when you take this approach: “Always hold a meeting before the meeting.” The meaning of this is that when you are prepared for everything ahead of time, nothing (or no one) can slow you down (or at least so the concept would appear).
Drive the Bus
Before a large, organizational change occurs, the nurse and their support team should implement a few small pilot tests in one or two work areas. Following such small tests of change (about a couple weeks to no more than a month), your team should assess the outcomes and work to re-evaluate the entire process to see if improvements can be made (Levin, Keefer, Marren, Vetter, Lauder, & Sobolewski, 2010). That way, when it comes time for an approved, formalized roll-out, the new practice concept or idea has been pretested and potentially already improved before “the final curtain call.”
Certainly, there is always a risk of having to improve the idea further following a live implementation on a larger scale, but it should not be problematic for your team if you have done all this work thus far. In examining the EPMP scenario one final time, a group of influencers armed with the right plan could potentially improve a whole organization. Patient outcomes, satisfaction and throughput could advance and recover greatly, as well as cost savings for the organization while freeing up provider and caregiver time: so long as there is no staunch resistance (for whatever reason) toward implementing right action of standardizing an approach to early mobility for all hospitalized patients.
Nurses are the closest stakeholders to the patient: our focal point of care. Today, we also have peripheral points of care: the patient’s family and significant others. Our caregiving becomes one large, involved process for good. When frontline staff discovers opportunities to improve care, professional practice, and outcomes, they need to take advantage of the opportunity and step into that spotlight. You do not have to be the star — you can be the engineer, the bus driver, the band leader, the change agent.
Nurses need to empower themselves to influence better care through change in any possible way. Following the steps and methods outlined here can offer some relief to what might seem like a (once) impossibility. Become the leaders that you are all taught to become and meant to be. Make that difference. Advocate for better practice: drive the bus, and then teach others how to do the same. Be active and collaborative in your working relationships. Show your organizational administrative partners that you know how to get things done (if they will only let you). We can all certainly make a difference if we do it together.
Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gelinas, C., Dasta, J. F.,…Jaeschke, R. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1), 263-306. doi:10.1097/CCM.0b013e3182783b72
Clark, D. E., Lowman, J. D., Griffin, R. L., Matthews, H. M., & Reiff, D. R. (2013). Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: A retrospective cohort study. Physical Therapy, 93(2), 186-196. Retrieved from CINAHL database.
Dammeyer, J., Dickinson, S., Packard, D., Baldwin, N., & Ricklemann, C. (2013). Building a protocol to guide mobility in the ICU. Critical Care Nursing Quarterly, 36(1), 37-49. Retrieved from CINAHL database.
Drolet, A., DeJuilio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, E.,…Williams, S. (2013). Move to improve: The feasibility of using an early mobility protocol to increase ambulation in the intensive care and intermediate care settings. Physical Therapy, 93(2), 197-207. Retrieved from CINAHL database.
Eliason, T. (2009, August 1). Shoot for the moon: Because even if you miss, you’ll land among the stars (Interview with Les Brown). Success Magazine. Retrieved from http://www.success.com/articles/750-shoot-for-the-moon
Garfinkel, S. (2012, July 5). Making health care lean. Hospitals and Helathy Networks Daily. Retrieved from http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay. dhtml?id=4920002085
Levin, R. F., Keefer, J. M., Marren, J., Vetter, M. J., Lauder, B., & Sobolewski, S. (2010). Evidence-based practice improvement: Merging 2 paradigms. Journal of Nursing Care Quality, 25(2), 117-126. doi: 10.1097/NCQ.0b013e3181b5f19f
Saint, S., Kowalski, C. P., Banaszak-Holl, J., Forman, J., Damschroder, L., & Krein, S. L. (2009). How active resisters and organizational constipators affect health care-acquired infection prevention efforts. The Joint Commission Journal on Quality and Patient Safety, 35(5), 239-246. Retrieved form CINAHL database.
Valente, T. W., & Pumpuang, P. (2007). Identifying opinion leaders to promote behavior change. Health Education & Behavior, 34(6), 881–896. Retrieved from http://heb.sagepub.com
Williams, A. M., Toye, C., Deas, K., Fairclough, D., Curro, K., & Oldham, L. (2012). Evaluating the feasibility and effect of using a hospital-wide coordinated approach to introducing evidence-based changes for pain management. Pain Management Nursing, 13(4), 202-214. Retrieved from CINAHL database.