Running head: NURSING CHANGE
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Nursing Change
April Clahane
Jacksonville University
NURSING CHANGE
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Nursing Change
Identified Change
Patient classification systems (PCS) tools are designed to dictate safe and appropriate
staffing levels. PCS were developed in the 1970’s partly in response to the Health Maintenance
Organizational act of 1973 aimed at controlling health care costs (Hoven, 2004). Hospital
organizations began the institution of PCS tools to accurately measure staffing needs and to flex
staff according to patient care needs and continuous fluctuations in patient census. The
challenge was to find a tool which accurately reflected patient acuity based on a defined
patient population and apply that tool to determine a safe nurse to patient ratio.
CHOC Children’s Hospital in Orange California utilizes a PCS. CHOC Children’s has
utilized this tool since the late 1980’s and further refined the acuity scores based on new
evidence of flaws in the former tool (Harper & McCully, 2007). Five care indicators were
developed to differentiate specific patient characteristics and tailored to each nursing specialty
unit. They are: medications, treatments, procedures, teaching, and psychosocial support. The
nursing staff uses definitions for each care indicator to assign an acuity score to each patient.
Nurse to patient ratio is then determined. Patient acuity was done on a paper scoring tool and
collated into data reports by nursing supervisors. CHOC Children’s utilizes an electronic medical
record (EMR) and a hybrid medical record. Six months ago the PCS was interfaced into the
EMR. Since the conversion to an electronic tool, the nursing staff as well as nursing supervisors
noted a disparity on the calculated patient acuity scores. The disparity reflected an inflated
acuity score. Staff education will be needed to demonstrate the correct method of scoring.
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Driving Forces
Initiating change in a healthcare environment comes under fire when the proposed change
does not promote staff satisfaction (Lehman, 2008). The driving forces surrounding the need to
re-educate the nursing staff on accurate scoring of the PCS tool are: controlling costs,
accurately measuring patient acuity as it is directly linked to patient outcomes, adequate nurse
staffing to provide high quality patient care, and a balanced nurse workload among available
nurses to improve patient safety (Harper & McCully, 2007).
Restraining Forces
In as much as there are driving forces when a need for change is identified there are
also restraining forces against the change to maintain the status quo (Sullivan & Decker, 2009).
The restraining forces encountered with staff re-education on the PCS tool are: Burnout and
frustration over high patient acuity, perceived lack of control in regards to staffing, inadequate
nurse input upon initial implementation of the PCS tool, lack of respect and autonomy in the
workplace, fear of the impact of the change on workload, and lack of adaptability and flexibility
built into the PCS tool.
Change Theory and Strategy
Eric Havelock developed a change theory based on Kurt Lewin’s theory of change:
unfreezing, moving, and refreezing. Havelock recognized the need to address restraining
forces, active involvement by the change agent, and careful attention to planning change.
Havelock’s theory of change incorporates six stages for change to occur. The first stage is
relationship development with a system in need of change. It represents contemplation away
from the status quo. The second stage is a diagnosis by the change agent to find the needed
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areas of change. The third stage is acquiring knowledge which is the process of information
gathering and solution preparation. The fourth stage is selecting a pathway best suited for
dissemination of information. The fifth stage is establishing acceptance to change and
overcome the restraining forces. The sixth stage is maintenance and separation (Tyson, 2010).
Havelock’s Theory is closely aligned with the change process at CHOC Children’s. A shared
governance approach is used as are established teams for monthly meetings to address such
issues. Havelock’s theory incorporates the change agent as an integral part of the change
process as does CHOC Children’s.
The empirical-rational strategy will be applied to this change process as its core premise
is that people are typically rational beings (Sullivan & Decker, 2009). The nursing staff and
nursing supervisors by virtue of their discovery of the disparity of PCS scores reinforce they
possess rational thought and have delivery of quality patient care in their best interests.
Action Plan
Relationship Development: Assessment of the PCS tool identified a disparity in patient
acuity scores when converting to an electronic tool from a paper tool. A comparison of data
from the first six months of 2010 on the paper form to the first six months of 2011 on the
electronic form showed a significant variance. The data was presented at a monthly meeting to
an established group of nursing subject matter experts (SME’s) from each inpatient care area.
Diagnosis: Further investigation by the SME’s showed inaccuracy in the nurse’s
interpretation of the care indicators when the paper tool was used. Acuity creep was
suspected and is a phenomenon regarding rising acuities, implying that patient care needs are
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not rising but the nursing staff have become skilled at manipulating the PCS tool to validate the
need for more staffing (Brennan & Daly, 2009).
Acquiring Knowledge and Resources: Re-education of the nursing staff regarding the
definitions of the care indicators is needed. The SME’s reviewed the care indicator guidelines
for each specialty area to identify specific areas for re-education. Nurse champions from each
unit will be trained as well as the charge nurses.
Solution Pathway: It was decided that several avenues of education would be utilized.
The SME’s would gather two nurses from each shift and train them as champions. The care
indicators and PCS guidelines would be laminated and placed in each bedside hybrid chart. The
charge nurses offered to remind staff at change of shift to review the guidelines. A mass email
to the nursing staff will be sent detailing the coming education. The EMR will have the care
indicators embedded into the PCS tool for instant reference. The nursing staff will be taught
how to access the care indicators in the EMR via a ‘hot sheet’ which is common practice at
CHOC Children’s. The ‘hot sheet’ is published to the intranet documentation resource section.
Little resistance to the change is expected as the change is just a modification to their current
practice which supports the empirical-rational strategy.
Gaining Acceptance: Direct communication via the nurse champions to the nurses they
work with will be an invaluable tool for persuasion backed up with specific evidence of PCS tool
misinterpretations.
Maintenance and Separation: The EMR will be monitored monthly for acuity scores and
comparison to the previous year’s paper scores. Results of the comparisons will be sent to the
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SME’s group at their monthly meeting. At six months a determination will be made to
terminate the comparisons or if further evaluation is needed.
References
Brennan, C. W., & Daly, B. J. (2009). Patient acuity: a concept analysis. Journal of Advanced
Nursing, 65(5), 1114-1126. doi: 10.1111/j.1365-2648.2008.04920.x
Harper, K., & McCully, C. (2007). Acuity systems dialogue and patient classification system
essentials. Nursing Administration Quarterly, 31, 284-299. doi:
10.1097/01.NAQ.0000290426.41690.cb
Hoven, A. D. (2004). Report of the council on medicine. Retrieved from http://www.amaassn.org/ama1/pub/upload/mm/372/cmsreport4-a04.pdf
Lehman, K. L. (2008, July/August). Change management: magic or mayhem? Journal for Nurses
in Staff Development, 24(4), 176-184.
Sullivan, E. J., & Decker, P. J. (2009). Effective leadership and management in nursing (7th ed.).
Upper Saddle River, NJ: Pearson Prentice Hall.
Tyson, B. (2010). Havelock’s theory of change. Retrieved from
http://www.brighthub.com/office/project-management/articles/86803.aspx