Implementing Change: A View From the Trenches

With perhaps 100 patients scheduled for chemotherapy each day and about the same number of consultations, the nurses, physicians, and staff in any medium-sized oncology clinic are fully booked. Changing their routines may be the last thing anyone wants to think about.

But change is often on the horizon. New guidelines or standards, new Medicare programs, or novel drugs with new side effects create pressure for change in both practice and hospital settings. The impetus can come from an audit that finds deficiencies or a new idea on how to make things run more smoothly and improve patient outcomes.

Change and change implementation, while always important in nursing practice, have assumed greater visibility with the growing movement toward evidence-based nursing practice (EBNP).

"EBNP has caught on," said Dana Rutledge, RN, PhD, an associate professor at California State University, Fullerton and nursing research facilitator at St. Joseph's Hospital in Orange, Calif. "People have learned how to find the evidence. Now they have to learn how to use it to make changes. Change implementation may be the biggest challenge of the next decade."

Experts in change implementation often turn to theoretical frameworks to help guide the process. One of the most frequently cited is the diffusion of innovation model, proposed by Everett Rogers in his 1962 book, Diffusion of Innovations. Rogers describes five stages in the change process:

• Knowledge: learning about the existence and function of the innovation;

• Persuasion: becoming convinced of its value;

• Decision: committing to the adoption of the innovation;

• Implementation: putting it into practice; and

• Confirmation: accepting (or rejecting) the innovation.

Using tactics and communications channels specific to each stage can facilitate the change; for instance, a nurse manager might spend a lot of time collecting evidence and conveying it in meetings and presentations during the knowledge stage, having one-on-one discussions with opinion leaders during the persuasion phase, and so on.

"The beauty of this framework is just that-you have a framework so you can be strategic," said Maria Shirey, PhDc, MBA, RN, a consultant on change implementation and an adjunct professor at the College of Nursing and Health Professions at the University of Southern Indiana in Evansville.

Oncology nurses who have been involved in successful change implementation projects often use strategies that fit into this framework. Their experiences show how a theoretical model can translate into the day-to-day realities of change implementation.

Knowledge

At the outset of a change project, two kinds of information need to be collected and communicated: data on current practice and evidence showing why and how current practice should change.

When Cynthia Idell, RN, began thinking about how to improve pain assessment and reassessment at City of Hope National Medical Center, Duarte, California, she already had some data on current practice from a Joint Commissions on the Accreditation of Healthcare Organizations (JCAHO) audit and two internal surveys-enough to know that change was needed. So her first task was to search for information on how those practices should change. An advanced practice nurse in City of Hope's medical oncology unit, Idell turned to the nursing research department to help guide her through the research process and to a librarian who assisted her with literature searches on best practices.

The literature review suggested potential interventions to improve pain assessment. It also established a goal for the project: to align practices with the National Comprehensive Cancer Network's clinical practice guidelines for pain management, focusing particularly on the recommendation to reassess pain and document reassessment within 1 hour of an intervention for pain.

With her evidence base established, Idell met with key hospital executives, presented her data, and got their approval to move ahead.

In some cases, the main challenge at this stage is collecting firm data on current practice. This was step number one for Cathy Fortenbaugh, RN, when her clinic, Oncology Hematology Associates, in Philadelphia, became one of 15 pilot sites in the AIM Higher program. AIM Higher, supported by Amgen, Inc, has a built-in, broad goal: to improve the assessment and management of five chemotherapy-related symptoms. Fortenbaugh's challenge was to document the prevalence of the symptoms and analyze her clinic's current assessment and management methods.

To do this, she followed patients, doctors, and nurses through their routines and sat at the front desk to learn how assessment fit into the flow of the practice. Her groundwork revealed high rates of certain symptoms and bottlenecks in the assessment process, evidence that helped convince colleagues of the need for change.

Communications at this stage are often broadly targeted. Fortenbaugh kept the entire practice informed about what she was doing, using e-mails and presentations at staff meetings. She already had the blessing of upper management, who had instituted the project, but she knew she also had to begin looking for champions from other areas of the practice who would be important in the next stage.

Persuasion

This is the stage where attitudes begin to take shape. "People are starting to listen, thinking about the pros and cons," said Shirey.

Champions-people who may control resources and influence decision-making-and opinion leaders-those who nurses in the trenches respect-can make a big difference at this stage. At the City of Hope, Idell recruited opinion leaders from various sectors of the hospital, who would serve on a pain management task force. She persuaded them to participate, first through one-on-one conversations and then by formal invitation letters to a meeting, where she used a PowerPoint presentation and handouts to persuade them of the need for change.

Linking the innovation to improved outcomes is important at the persuasion stage. For instance, would improved assessment and treatment of symptoms lead to fewer transfusions, fewer hospital admissions, and fewer unplanned visits to the clinic? Improved outcomes can be important not only for patients but also for the organization, Shirey noted. At City of Hope, for instance, the change in pain-assessment practices would not only improve patient care but also prepare the organization for the next JCAHO survey.

Persuasion targeted at various groups can be important. The centerpiece of AIM Higher's assessment of symptoms is a handheld computer, an "e-tablet," that patients use in the waiting room at every visit to rate their symptoms. The attitudes of front office staff, who would be tasked with handing out the e-tablets and helping patients use them, were critical for success. Physicians also had to be convinced to review the e-tablet answers and make use of the information when appropriate.

Alice Quargnenti, RN, who led the AIM Higher program at the West Clinic in Memphis, used both formal staff meetings and one-on-one discussions to introduce the e-tablet to various groups. She and a physician champion conducted "creative inservices," tailoring each one to the audience.

"Our belief was that this technology would permeate every part of the clinic, so we wanted every staff member-including front desk, scheduling, billing, transcription, phlebotomy, radiology, phone operators, research department, volunteers, pharmacy, nurses and physicians-to know and understand the basics," she said. "That way they could answer patient's questions or concerns, and feel a part of the change happening in the clinic."

Decision

As the project moves into this stage, inclusion of people from various levels and disciplines becomes ever more critical. A decision-making body, such as Idell's task force, often comes into play now, if not before. That body should not only represent various disciplines, say experts, but it should also have members from various levels of the organization.

"You can't tell people it's going to happen no matter what," said Gregory Crow, RN,EdD, a consultant based in San Francisco and former member of the Oncology Nursing Society Board. "The hierarchical approach is chancy. The only way I can see to [effect change] is to invite staff in."

When Crow was director of nursing at an acute care hospital in Oakland, he initiated a project to reduce the number of forms in the charts in order to eliminate duplication and make information easier to find. The task force he formed to carry out the change included medical records staff, coders, nurses, and physicians. "The philosophy was that if change is going to impact your role and performance, you have a chance to have input," he said.

Team members must be carefully selected. To plan the pain assessment project at City of Hope, Idell made sure that her task force members were either formal or informal leaders, were considered to be early adopters and/or strong proponents of organizational change, and could fulfill certain roles on the task force.

Using guidelines developed by Dana Rutledge, she looked for people who could play diverse roles on the task force, including that of information broker, interested clinician, systems-savvy nurse, change agent or facilitator, retriever (one who uses libraries to gather information), critiquer (one who can evaluate research studies), early new practice user, late new practice user, and nurse educators.

The original team included advanced practice nurses and nurse leaders and managers, staff RNs, a librarian, physicians, pharmacists, a rehabilitation director, a quality- and risk-management specialist, and a professional program development director.

"Early on in this process, the most valuable team member was the librarian," said Idell. "Later on, systems-savvy members paved the way for overcoming logistical barriers, such as IRB [institutional review board] approval and staff resistance."

"Understanding the motivation and needs of the people directly impacted by the potential change allowed us a broader picture of what happens in the clinic, why it happens, and what will happen if this delicate balance is altered," said Rutledge. "Armed with this type of knowledge, we were able to address various concerns expressed by staff members prior to implementation. This assured a smoother implementation."

Implementation

As the go-live date approaches, resistance from people on the front lines can come to the fore. "No one likes to change," noted Fortenbaugh, "humans are inherently comfortable in what they do."

"This stage is hard," agreed Shirey. "That's why it's so good if the impetus has come from the trenches, rather than top down-staff will have already bought in." But even with enthusiastic buy-in from staff, the implementation stage calls for a lot of personal attention to detail, say those who have been through it.

"It took 6 to 8 months of working with people on the front lines," said Greta Dudley, RN, another AIM Higher manager, describing the introduction of the e-tablet at Central Georgia Cancer Care in Macon. "If there was a snafu, it was easy to stop using the e-tablet," she said. "I needed to keep supporting the new system with lots of training, teaching people how to troubleshoot."

At City of Hope, the pain assessment and reassessment project was implemented initially through a trial of an intervention-a grand rounds on pain assessment and reassessment plus one-on-one feedback sessions. Idell and her colleagues encouraged nurses to take part in the trial by creating posters and speaking at staff meetings, but also through one-on-one relationships.

Individualized approaches can play an important role during implementation. At the hospital in Oakland, Crow and his colleagues kept in touch with the various groups affected by the records change, using channels tailored to each one. "For instance, the physician groups wanted to be kept informed in person, so we routinely went to general medical staff meetings every other month," he said. "And on the pilot units, we presented at each medical staff meeting."

"It's a social process," said Shirey. "You need to have continued personal involvement...asking how is it working, what needs to be done from a system perspective, what support is needed."

Understanding the roles and motivations of everyone impacted by the change can pay off during this stage, said the West Clinic's Quargnenti. "Because of the attention to small details about how the proposed change might affect the various departments in the clinic and because the whole clinic was informed about the change, we received not just reports about what was going wrong or the problems encountered, but staff were offering solutions to the issues."

Confirmation

As the new way of doing things becomes established, it's important to document and showcase its benefits. "You ask if it worked," Shirey said. "Was it the right decision? If there are problems, how can they be fixed?"

One tool at this stage is outcome evaluation-data on whether the innovation is working. At City of Hope, for instance, Idell was able to show that the pain assessment and reassessment intervention had increased nurses' scores on the Nurses Knowledge and Attitudes Survey Regarding Pain, used as pre-test and post-test. Audits also showed significant improvement in performance. At the next visit of the JCAHO auditors, pain reassessment and documentation practices had greatly increased.

At the AIM Higher project in Philadelphia, six different chart reviews were used to measure the effectiveness of the new symptom assessment and management system based on the e-tablet. The data are not yet available, but the anecdotal evidence is promising, said Fortenbaugh. "From the information I gathered from my practice, I could see the decrease in the prevalence of chemotherapy-related symptoms."

Getting the endorsement of people who were involved in and impacted by the change project can help at the confirmation stage. After Crow and colleagues had changed the documentation system, the coders and physicians told them the benefits were real and that they could find what they needed much more quickly under the new system.

Spreading the word is especially important at this stage. Presentations, newsletters, and emails can showcase milestones at every stage, but here it is critical, said Shirey. "One big pitfall in implementing change is neglecting to permeate the institution, where you can broaden your support base," she said. "If you didn't spread the word at all stages, you better do it here."

At City of Hope, the pain assessment and reassessment task force presented information on the project at grand rounds and a symposium. Key points of effective pain management were summarized on a fact sheet to share at staff meetings, and performance improvement reports were sent to managers.

Acceptance of the innovation and integration into daily routines is the goal at this stage. "Here is where you freeze the innovation," said Shirey. "And this is where you can celebrate, too."