Introduction
Healthcare organizations are complex systems that are continually developing and changing to ensure high-quality care, an advanced level of patient safety, and ongoing improvements in patient outcomes (Mennella & Woten, 2015; Weaver & Manzano, 2016). One of the major concerns that are relevant to patient safety in various settings is that of patient falls, which can result in injuries, including serious ones. The issue tends to affect older adults as well as patients that experience muscle weaknesses or disturbances in balance and gait (Trepanier & Hilsenbeck, 2014), which makes falls a significant concern for oncology patients. Indeed, oncology patients demonstrate rather high numbers of falls when compared to those without the illness. These falls are typically associated with older age, cognitive impairment, oncology- and comorbidities-specific medications, fatigue, unstable gait, and metastases in the nervous system (Weaver & Manzano, 2016, p. 371). Given the fact that cancer is also a rather widespread illness and a major cause of death in the US, it can be suggested that the concern of oncology patients patient falls in hospital settings is a significant issue. However, this issue can also be regarded as preventable.
Indeed, while unable to eliminate the issue, modern healthcare practitioners have managed to produce advice on best practices in the field. In particular, risk factors for falls have been identified, and strategies for their control have been developed. Patient falls can be prevented through modifications of the environment (for example, the use of non-slippery tiles), application of special equipment (including bed rails or bed alarms), supervision, and patient education (Hempel et al., 2013; Trepanier & Hilsenbeck, 2014; Weaver & Manzano, 2016). Environment modification has been shown to decrease the rate of falls by 18%, but a comprehensive intervention is capable of halving the rate of falls and reducing the number of related injuries to 23% (Trepanier & Hilsenbeck, 2014, p. 137). As a result, comprehensive individual fall risk factors management is suggested as a solution for oncology patients (Weaver & Manzano, 2016, p. 372). Moreover, staff-related interventions like education and the development of quality management committees can be regarded as relevant approaches (Hempel et al., 2013, p. 486). Finally, as shown by Hempel et al. (2013), a significant intervention is the establishment of post-fall assessment procedures, which can provide valuable information for the improvement of the situation.
Description of Lewin’s Change Model
Lewin’s Change Model (LCM) was proposed in the middle of the previous century by psychologist Kurt Lewin (Mennella & Woten, 2015). One of the major advantages of the model is its focus on the complex issue of barriers that can prevent the change from occurring or persisting. Here, LCM also comes in contact with another model that Lewin used: force field analysis, which is aimed at determining the “forces” of a system (Batras, Duff, & Smith, 2014, p. 233). These forces are classified as driving and restraining ones depending on the effect that they have on a potential change (Shirey, 2013, p.69).
LCM contains three stages, and the first one is usually regarded as the most difficult one; it is termed “unfreezing” because it is supposed to “unfreeze” the existing status quo by mobilizing people and resources (Mennella & Woten, 2015, p. 1). The motivation to change is central to the process and is developed through the creation of a “sense of urgency” (Shirey, 2013, p. 70). To this end, the change agent is supposed to gather sufficient evidence to identify and prove the need for change and propose a solution. An analysis of various facilitators, barriers, and risks for change is also required. For instance, in the case of patient falls, budgeting constraints can limit the opportunity for equipment introduction, but nurses’ commitment to patient safety can facilitate training interventions.
During the first stage, the evidence should be used to foster the development of driving forces, which can facilitate change, and decrease the influence of restraining forces, which resist or prevent the change. Apart from that, certain activities which set change in motion should be introduced during this stage to “disturb” the existing state of events (Manchester et al., 2014, p. 85). For instance, if a system does not employ certain fall reduction interventions that are mentioned above, this stage can involve their establishment. In particular, the introduction of a patient safety committee that would supervise the documentation of existing falls and carry out an assessment of the environment and related policies and procedures seems to be particularly appropriate for this evidence-dependent stage. Indeed, it is apparent that LCM heavily relies on evidence, which means that it is also an explicitly customizable approach.
The second stage is typically defined as “change,” but it may be more accurate to term it as “movement” or “transitioning” (Mennella & Woten, 2015, p. 1). In LCM, the change begins during the first stage and is not regarded as completed before the end of the third stage, which makes the latter terms more appropriate. This stage involves direct and detailed planning and implementation of strategies that would enact change (Shirey, 2013, p. 70). LCM also requires paying particular attention to the employees during this stage; to ensure the success of the movement, appropriate training and support are required (Mennella & Woten, 2015, p. 2). Moreover, this stage involves the evaluation and modification of the change while it is in progress. Here, the attention to the staff can also be helpful: the employees can provide valuable feedback, and for a successful change, it needs to be solicited (Shirey, 2013). The trial-and-error approach can be acceptable for this stage (Manchester et al., 2014, p. 85), especially since it is correlated with uncertainty (Shirey, 2013, p. 70). In oncology patient falls reduction, this stage is likely to involve a complex, comprehensive intervention (Weaver & Manzano, 2016), which takes into account the specific needs of a system that have been determined during the first stage.
The final stage of LCM is termed “refreezing,” and it is aimed at transforming the results of the change in a new status-quo situation (Manchester et al., 2014). Officially, it can be done by cementing certain aspects of the change in updated policies, which can refer, for instance, to new standards of personal fall risk management. Apart from that, it is necessary to make the improved process habitual for the employees and transform it into a part of their practice and organizational culture (Batras et al., 2014). During this process, the management of the forces becomes particularly significant once again, and the change agent is supposed to stabilize the change by supporting the driving factors and weakening the restraining ones (Shirey, 2013). Mennella and Woten (2015) point out that the sustainability of change is impossible without successful completion of this stage, which makes it particularly important.
The role of Doctor of Nursing Practice in the model
LCM is meant to inform the activities of change agents (Mennella & Woten, 2015), and a Doctor of Nursing Practice (DNP) is suited for this role. Indeed, as demonstrated by Sherrod and Goda, (2016) and Walker and Polancich (2015), DNP-prepared advanced practice nurses have the necessary competencies and skills for the fulfillment of the role of a change agent. In particular, the authors show that DNPs are capable of acting in complex environments and promoting the continuous improvement in patient safety measures in a variety of fields, including oncology (Walker & Polancich, 2015, pp. 264, 266). The essentials, which are defined for DNP by the American Association of Colleges of Nursing (AACN), establish that DNP is supposed to be capable of fulfilling the role of a change agent, in particular, by employing their analytical and interpersonal skills. Essential number two explicitly states that DNP is expected to engage in change and lead it (Walker & Polancich, 2015, pp. 265).
Concerning analytical abilities, DNPs are specifically trained to address practice-related issues (Alexander, 2016), which is a central competency to force field analysis and LCM. It is also noteworthy that DNP-prepared nurses have advanced research skills and an improved understanding of research application and evidence-based practice (Alexander, 2016; Sherrod & Goda, 2016), which helps DNP to manage LCM-led change in a knowledge-dependent field like oncology. Apart from that, the position of a leader, which DNP typically take, offers large opportunities for effecting change through people. In particular, DNPs can provide orientation, inspiration, mentoring, and other forms of support (Sherrod & Goda, 2016, p. 13; Walker & Polancich, 2015, p. 270), which help the nurses to process change.
The sixth essential of DNP education presupposes the use of communication skills for collaborative work and the management of nursing teams (Walker & Polancich, 2015). Communication skills are required by LCM, especially during the movement stage when they are used to meaningfully exchange information, communicate goals and aims, and solicit feedback (Manchester et al., 2014). Therefore, it is apparent that this essential competency of a DNP-prepared nurse is also relevant for LCM.
When working with the selected problem, an LCM-guided DNP would be expected to examine the existing issues in the area of patient falls for a particular system during the first stage of change. Here, post-fall assessment procedures could be particularly useful (Hempel et al., 2013). In case they are not used by a system, they can also be introduced during this stage as a part of the activities that are aimed at “disturbing” the status quo and creating a sense of urgency. Other sources of information, including nurses’ feedback, can also be employed by a change agent with advanced research skills. The same research would also be expected to yield data for force field analysis, which should be useful for the unfreezing process.
carry out detailed planning of a comprehensive intervention and begin to implement it during the first and second stages. For oncology patients, the problems are likely to include, for example, deficient or inefficient personal risk management practices, which can be improved through the introduction of better practices that have been evidenced to work in the settings (Weaver & Manzano, 2016). The second stage would also involve actively training and supporting personnel while also soliciting feedback from them and using it to modify the process if required. Here, DNP’s communication skills would be particularly important. Similarly, during the third stage, the same communication skills would be required to proceed to manage various forces, including those in the organizational culture, and employ them to cement the change. Thus, DNP-prepared nurses are capable of leading and significantly contributing to the sustainability of an LCM change due to the core competencies of their training, which correspond to the essentials established by the AACN.
Expected outcomes
As demonstrated above, the use of LCM for quality improvement offers the opportunity to understand the process of system change from the perspective of individual and organizational responses to it (Manchester et al., 2014, p. 84). LCM employs the concepts of driving and restricting forces, suggesting the means of analyzing them and affecting their dynamics. It also provides a framework for the management of change resistance and sustainability development. It may be oriented predominantly towards top-down approaches (Shirey, 2013, p. 70), but it also clearly emphasizes the need to engage employees (Batras et al., 2014). There are certain limitations to the model, including its relatively simplistic approach and linear nature (Shirey, 2013, p. 70). Both these claims have ground, even though it should be pointed out that reiteration of processes (hence, a nonlinear approach) is regarded as a requirement for the second stage of the model and can be implied by the first one. When applied to patient falls reduction in oncology settings, LCM would also be expected to structure the change, assist in the determination of resources and elimination of barriers, and help to cement the change, ensuring its sustainability. It may have the undesired outcome of non-continuous change given the aim of establishing a status quo at the end of the process. However, LCM offers the opportunity for the modification of change while it is in the process, and it may be particularly useful if the existing status quo is difficult to dismantle. To sum up, the expected outcomes of the application of LCM to the concern of oncology patient falls in hospital settings involve the improvement of patient safety through the successful introduction of systems change.
Conclusion
The current report offers LCM as a suitable framework for sustainable DNP-managed change, which is aimed at the reduction of oncology patient falls in hospital settings. The analysis demonstrates that major advantages of LCM include the fact that it is evidence-based and customizable: LCM involves an extensive and continuous assessment of system needs and presupposes the proposal and implementation of relevant solutions. Moreover, LCM is capable of dismantling the existing status quo and establishing a new one, which may be particularly important for obsolete practices. Finally, LCM emphasizes the importance of communication with the employees who can fulfill the roles of driving forces and information sources while also being capable of hindering the change as a resistant force. It is apparent that DNP skills, including those related to research, analysis, leadership, and communication, are appropriate for LCM and can be used successfully to employ the model. As a result, the expected results of the application of the proposed model to DNP-led change, which targets the chosen issue, include the dismantling of obsolete or inefficient practices and the successful, sustainable introduction of customized new ones with positive patient outcomes.
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