1. The Nurse as Change Agent and Advocate
Chapter 8

2. Origins of Change Began in the 1990s
Continuing increase in health care costs
Employees expected to become multiskilled
Presents challenges for both providers and consumers

3. Types of Change Developmental change- Transitional change-
changes or improvements in currently used processes and operations
Transitional change-
Moves into a different pattern of operation and structure
Transformational change-
creates a whole new set of attitudes and appproaches

4. Change Driving forces for change Planned –deliberate and conscious
See page 300 for examples of driving and restraining forces
External forces
Insurance companies
Government
New technology
See page 300 for examples of
Internal forces
Strategy for success
New philosophy
Planned –deliberate and conscious
Unplanned- reactive change

5. Theories of Change Bridges’ transformational change
Focuses on transitions of attitudes and beliefs
Old must be given up
Lewin’s force field theory of change
Moving from one state to a new desired state
Unfreezing, movement, and refreezing
Coghlan and McAuliffe
5 tasks of change- determining the need, defining the desired state, assessing, implementing and managing it, and consolidating it

6. Question
Change in our health care delivery system is an ongoing process. The view that stability in any organization or system is achieved through a balance or equilibrium of forces acting on the situation is a component of which theory of change?
A. Coghlan and McAuliffe
B. Bridges
C. Lewin
D. Bennis and Chin

7. C. Lewin
Rationale: another theory of change is the force-field analysis described by Lewin. Force-field analysis begins with the view that stability in any organization or system is achieved through a balance or equilibrium of forces acting on the situation (Lewin, 1951).
Answer

8. Strategies for Creating Change
Environmental and adaptive strategy
Power-coercive strategy
Leader orders change
Empirical-rational strategy-
Change will be accepted if seen as desirable
Normative-reeducative strategy (most common)
Change will take place only after attitudes, values, skills etc. change

9. Leading and Managing Change
Role of the change agent
The person who seeks to lead or create change
Demonstrate your commitment to change
Believe in the necessity for planned change
Managers of change
Quality patient care continues
Staff feel supported in doing their jobs
Adverse effects of the change are mitigated

10. Facilitating the Change Process
Assessing the situation
Identifying driving and restraining forces
Understanding losses associated with change
Recognizing resistance to change
Lack of trust can be key
Fear and loss of control
Change fatigue- feel overwhelmed by the expectations and lose enthusiasm
Self-assessment

11. Facilitating the Change Process (cont’d)
Planning for change
Developing trust
Listening is very important
Planning a response to concerns
Fostering involvement
Timing the change

12. Facilitating the Change Process
Implementing the change
Using a pilot project
Providing resources and supports for change
Managing the time frame
Interpersonal processes for change
Negotiation- find areas both sides can give
Co-optation- enlist key people from opposition
Coercion- threat of adverse effects
Sustaining the change- “refreezing”
Monitoring and evaluating the change process- story board

13. Question Is the following statement true or false?
One reason that change fails is recognizing the losses inherent in change.

14. Answer
False.
Rationale: as mentioned earlier, Bridges (2003) suggests that there are many losses in any change and failure to acknowledge that loss is present is one reason for the failure of change.

15. Effectively Participating in Change
Understanding the change
Why it should occur
Who it will benefit
What is required for success
What is your place in the change?
Viewed as positive or negative
Participation is essential

16. Change Through Advocacy
Definitions
Pleading or arguing in favor of something
Mediation- helping 2 parties work out an agreement
Broker or responsible model- negotiation, compromise and persuasion
Adversarial model or legalistic- focus on rights of the client without concern for others
Empowerment of individual- advocate for self
Background
Ombudsman program (1978 Nursing Homes)
American Nurses Association- ethical standard

17. Change Through Advocacy (cont’d)
Prerequisite to effective advocacy
Identify and define your own beliefs and values
Avoid paternalism- making decisions for the person
Clinical competence
Believe that you have the right to speak up

18. Change Through Advocacy (cont’d)
Assessing the need for advocacy
Those who lack knowledge
Those with little power
Those who need to make decisions
Those who receive inadequate care
Those who are unable to communicate for themselves

19. Question What is a prerequisite to being an effective advocate?
A. Believe you know what is best for your client.
B. Define your own beliefs and values.
C. Identify what family members believe and value.
D. Be supportive of other health care personnel.

20. Answer B. Define your own beliefs and values.
Rationale: before being a client advocate, you must identify and define your own beliefs and values.

21. Advocacy Goals

22. Advocacy Outcomes

23. Advocacy Actions Preventing the need for advocacy
Providing information and education
Assisting and supporting client’s decision making

24. Communicating with Health Care Professionals
Demonstrate knowledge and tact
Include information about the client’s concerns, questions, and expectations
Call the appropriate physician
Encourage direct communication between the client and the appropriate health care providers

25. Working for Changes in the Health Care System
Advocate through understanding
Organizational structure
Volunteer for ethics committee
Make sure resources are available
Clients need to select options that fit their values and choices
Community services

26. Being Involved in Public Policy Formulation
Expertise to be an advocate for the health care needs
Support legislation that benefits health care consumers or makes needed services available
ANA encourages nurses to step forward as the experts they are to speak to the media

27. Question
One of the ways to be actively involved in the formulation of public policy is:
A. Networking with other professionals at a social level
B. Volunteering for planning committees in professional organizations
C. Knowing who your congressional representatives are
D. Being actively involved in nursing organizations that work for programs and services for clients

28. Answer
D. Being actively involved in nursing organizations that work for programs and services for clients
Rationale: the best ways to be actively involved in formulation of public policy is through nursing organizations that work for programs and services for clients, and network through professional organizations, alumni groups, friends, and coworkers.

29. Advocating for Other Staff Members
Managers must address:
Staff needs
Staff requests
Staff problems
Staff rights
Requires careful judgment relative to the staff member’s situation and the needs of the
agency

30. Constraints and Supports
Conflict with other staff
Lack of supports
“Bucking the system”
Supports
Legal mandate for client rights
Personal reward for quality care