Theories underpinning the change process
An adaptation of Spradley's 8-step model and Lewin's 3-step model of Unfreezing
provided us with useful frameworks for our change management [9
Unfreezing is about encouraging people think about the current situation and helping them recognise the need for change [5
]. Change to be initiated requires a sense of direction and considerable power of leadership [8
]. The authors were also guided by the work of Swansburg and Swansburg, [15
] who argued that "transformational leaders are seen in health care organizations as a commitment to excellence."
The first move therefore was to create awareness by communicating the proposed change to all those who were going to be affected by the new practice: the nurses, patients and the ward manager so that they all had a shared vision of an improved handover system. A goal-seeking behavior with a clear logical sequence of action, were demonstrated throughout the process as advocated by Lancaster and Lancaster [8
]. Research based articles were also used to demonstrate how this system was successfully implemented in different areas of the health care system.
The proposed change was announced in advance by using different communication channels, e.g. personal contact with individual nurses, staff information/notice board by the authors. This initiated informal discussion among nurses of the ward by creating a cognitive dissonance which led to a quest for more information about the new handover. This consultation phase allowed the nurses to discuss various clinical scenarios and analyse the constraints and benefits of the new proposal in the local context. They were also involved in group work to identify and make proposals on how to deal with some of the problems that we may encounter in our local context e.g. handover coinciding with ward rounds or emergency situations and patients too distressed to talk. Case studies and research articles on this topic were used for discussion and to further reinforce the beliefs of staff of the ward that the current practice had shortcomings and could be improved. The status quo was therefore unsettled and this enabled us to rule out the first resistance through a normative re-educative strategy. A group of senior nurses who had experience in this particular area agreed take turn to act as mentors in order to facilitate this process and offer support to their junior colleagues in the first week until they become confident to carry out the process without supervision.
Analysing the alternative options
The extensive literature search also provided us with options for alternatives to bedside handover. These were thoroughly debated before reaching a decision. The options considered were the following:
1) Tape recorded handover
2) Computer generated handover using information technology
3) Bedside handover, based on individualized care plan
The 'SMART' criteria were used to evaluate the feasibility of the alternatives to bedside of handover. The tape recorded handover would require a tape recorder being taken around to each of the patients and the interaction recorded. An informal discussion with the patients revealed that this method was distractive and the majority of them did not feel comfortable about their conversation being recorded. With regards to the computer generated handover using information technology, the patients felt this system will not enable them to engage fully in the process. It was also felt that since the first two options required extra financial, technical resources for implementation, these would not be feasible in the first instance whereas the bedside handover gained unanimous support from both patients and staff. This was also more realistic in term of its applicability in our practice area. It was specific, measurable in terms of its performance and achievable within existing resources and a defined time frame. Its foundation rested on evidence base practice, which showed theoretical soundness.
Selecting the change
There was a shared vision about the worth of the proposed change by the team and consequently bedside handover was logically considered as the best option for change. The vision formulated was that in three months' time, bedside handover would become the normal shift handover process of the ward. The mission statement agreed was "all handovers would be carried out at the patients' bedside between the incoming and outgoing nursing staff with the patients' involvement."
A force field analysis, as shown in table was carried out to evaluate the driving and the restraining forces for the change as per Lewin's model [9
]. The driving forces resided in the support of the ward manager, peers, evidence based arguments and our determination to see the change happen. The restraining forces were mostly related to a lack of information and uncertainty surrounding the change process. Other significant issues that were identified to cause resistance to the change were lateness at work, non-overlapping of shifts and maintaining confidentiality of patient's information.
A force field analysis using Lewin's (1951) driving and restraining forces
Planning the change
Careful planning is essential if trauma is to be minimized [2
]. It was quite important for us to provide information so as to unlock the status quo. This was done by drafting a protocol, (table ) on a six points systematic step on how to proceed in practice with the change. This protocol was piloted over 2 morning and 2 evening handover sessions to ensure validity and reliability. There were no changes required to the protocol following the pilot study.
Results of protocol with 6 criteria based on observational data on 10 handovers
The time frame earmarked to implement the change was three months starting from the 8th of February 2003 up to 8th May 2003. One-month time was judged sufficient to unfreeze the situation and the remainder to implement and evaluate the change.
Selecting strategies for change
Choosing a strategy for the change process depended upon various factors and good interpersonal relationship was a critical factor. It has been proposed that strong leadership and excellent communication skills were essential if an atmosphere of trust was to be engendered [7
]. With this in mind, the change was announced in advance to encourage the nurses. It also offered the opportunity to share the reaction of colleagues where some valuable proposals were proposed, for example, how to cater for lateness at work, non-overlapping of shift as well as dealing with confidentiality of information.
Confidential issues related to matters that the patients brought up during the admission procedure and during their stay, certain issues that were brought up during ward rounds and from the patients own requests.
In cases of occasional lateness in resuming work, the handover would proceed with the other patients in first the instance and if the staff was still late, then some other colleague would step in her place. Reassurance was given with respect to 'no substantial overlapping' of shift in that it would not have major bearing on the handover process by explaining that shorter handover can reduce the likelihood of information overload and result in concise and pertinent information being exchanged as per care plans. There was a general agreement that fifteen minutes as officially allocated for handover would be sufficient for this purpose. Assurance was also given that confidentiality of patients' clinical information would be taken into consideration in drafting a protocol for bedside handover, as shown in table .
Empowering the staff
Several meetings were organized with different groups of nurses to explain and clarify any shortcomings and to reach a consensus. This approach was recommended by Driscol [4
], as it empowers the team to make the change for itself, without instruction or oversight and is believed to be a strategy for an effective and lasting transformation in a team spirit. The empirical rational strategy was used to convince others of the veracity of the change by making reference to evidence base documentation on the positive outcomes that bedside handover might bring, for example, increase patient satisfaction. Nurses within the ring of informal leaders were gradually encouraged to take some of the ownership of the change by entrusting role model responsibilities to them. This proved to be quite successful as a strategy to encourage participation to create attitudinal and behavioral change. Eventually, there was more acceptance and collaboration on the part of the team to implement the change. In keeping with Skinner's theory [13
], positive reinforcement, was used to praise and encourage staff. The ward manager helped in the reinforcement process by complimenting the whole team for their excellent effort to bring the change during the weekly meeting of staff. The strategy of facilitation also involved providing training in the new skill demanded by the change. Mocked handover exercises were demonstrated with the different steps of bedside handover to different groups of nurses. This was done by adopting a democratic leadership style engendering a participative approach, which in turn generated a degree of enthusiasm for the change.
Following a pilot handover session involving senior staff in a participant and an observer capacity over 2 morning and 2 evening handover sessions, which did not require any major changes, implementation of the bedside handover was started on 8th of March 2003. For the first week, six senior staff who had experience in this area volunteered and took turn to continue to be present in as many handovers as observers and participants, to monitor and reinforce the established protocol step by step.
They also provided clarification and support to staff in cases of difficulty, and helped evaluate the extent of change that had taken place in an effective manner. The nurses present during the handover had no difficulty in adapting to this new situation, using a care plan incorporating a more psychosocial and patient-centered approach to bedside handover with the patients' participation.