Running head: CHANGE PROJECT
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Lauren Walker
Change Project
Georgetown University
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The Critical Care Unit (CCU) at Prince William Hospital (PWH) is a growing and
transitioning unit that seeks to improve outcomes and standards of care. Over the recent years,
the hospital has overcome many challenges and has had many system changes as it merged with
Novant Health System. This leading body has helped mold a positive mission and vision and
enabled the hospital to visualize the need for major changes and improvements. While Novant
has brought some positive change to the unit, he CCU has continued to face many specific
challenges and barriers such as central line infections, ventilator associated pneumonia, urine
catheter associated urinary tract infections, and frequent ICU transfers to a more acute ICU in the
area when patients become critically unstable. The unit leadership, along with staff nurses and
physicians have started to work together to initiate changes in practice to help improve patient
outcomes, however many projects are not completed due to a decrease in interest, major
resistance from staff, and frequent priority changes of the unit. As this unit has grown in their
standards of care, there are still major practice interventions, along with improvement in nurse
and physician skill and assessment to enhance the quality of care, standards of practice, and
patient outcomes.
The CCU manages many patients who are on mechanical ventilation, are recovering from
surgical procedures, or have a sleep or respiratory abnormality. Due to the rapid overturn of
nursing and physician staff, there are inconsistencies with assessment including a wide range of
skill and critical thinking levels of the health care team. When a patient’s condition rapidly
deteriorates due to post-operative narcotics, failure to wean from the ventilator, or complication
of their disease, the nursing team can be seen anxious and often flustered with the responsibility
of priority assessment and quick and effective patient management. With the implementation of
a patient measuring tool, patients can be provided with a standard of monitoring and provide
nurses, respiratory therapists and physicians guides for quicker changes in patient condition,
leading to a decline in emergent situations.
The use of end tidal carbon dioxide (EtCO2) monitoring would enable both nurses and
physicians to provide evidence based practice to guide their patient care and treatment decisions.
EtCO2 is a continuous non-invasive measurement of exhaled carbon dioxide. It is transmitted to
the central monitor through a nasal cannula sensor or ventilator attachment sensor and cord.
Through the analysis of the CO2 value and waveform, nurses can swiftly note changes in
ventilation that can be impacted by anesthesia and sedation, agitation, procedures, obstructive
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sleep apnea, weaning from mechanical ventilation, or any other abnormality. After trending CO2
values, nurses will be able to note changes in patient condition and enable physicians to
determine interventions to prevent an emergent situation and alter treatment according to
respiratory status. This practice change will influence care on the CCU, provide the team with
valuable information that impacts their interventions, and hopefully impact outcomes of patients.
Change would not be a concern within organizations if organizations would stabilize or
slow down. However, organizations today are continually challenged with the need to develop
into a strong, competitive, and unique system. As the economy continually changes, and
standards are developed, each organization needs to mold and change to meet the demands. One
such example is a hospital meeting the demands of the patients and standards set by accrediting
boards as well as system leaders. The change paradigm theory, established by John Kotter,
describes how change impacts the organizations and how to effectively transform through
specific strategies using a dynamic, nonlinear eight step approach (Campbell, 2008). Kotter
(1996) describes how the eight steps help to create change, which are associated with
fundamental errors that undermine transformation efforts. The steps include establishing a sense
of urgency, creating the guiding coalition, developing a vision and strategy, communicating the
change vision, empowering broad-based action, generating short-term wins, consolidating gains
and producing more change, anchoring new approaches in the culture.
In the change paradigm theory, Kotter describes the first four steps in the transformation
process as a phase focused on creating an environment of change (Campbell, 2008). Kotter
(1996) then describes that phases five to seven address new practices, engagement of members
and the final stage addressing a permanent change. During this process, it is necessary to follow
each step for successful implementation of change and avoid and concerns or problems through
this process regardless of time limitation or pressure to create the change. Recently a graduate
student in the CCU at PWH was faced with helping to institute end tidal carbon dioxide (EtCO2)
monitoring. Knowing that this was a major practice and monitoring change for the entire
medical team, the graduate student was guided by the change paradigm theory by Kotter for
successful implementation.
Before initiating any of the steps in the change paradigm theory, it is first necessary for
the leader to understand that the change process will consistently require them to address feelings
such as anger, pessimism, cynicism, panic, exhaustion, insecurity and anxiety from their
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employees (Campbell, 2008). However, through the steps of the change theory, the leader will be
fit with tools to overcome these feelings. The first step in the implementation, according to
Kotter, is to establish a sense of urgency. This feeling of urgency is critical to gain needed
support and cooperation from the medical team including physicians, nurses and respiratory
therapists. Urgency puts a group together and creates power and credibility to guide the effort
and convince key individuals to spend the time necessary to create and communicate a change
vision (Kotter, 1996). Before the institution of the change project, the graduate student evaluated
patient care performed by the medical team and within a few weeks noted that a few patients had
unexpected change in clinical condition which startled the team. While working to recover the
patients, the medical team became anxious, did not effectively communicate as a team, and were
frustrated when one of the patients had to be transferred out to another hospital for more
advanced care.
Due to this evaluation, the graduate student and the clinical nurse specialist wanted to
create a way for the team to have specific monitoring strategies which could help detect changes
in a patient’s clinical condition sooner which could impact decision making and patient
management. Knowing that there was already major resistance to change in the unit caused by
the many system and management changes, the graduate student first understood that change was
only going to happen if the staff wanted the change and could participate in the decision process.
Therefore, to develop a sense of urgency, the graduate student was able to participate in team
debriefing and determined that nurses felt pressured in emergent situations. Not only was the
medical team stressed out, the medical team was informed of the increased transport to another
hospital, the decline in patent satisfaction scores and negative change in census on the unit.
Through these discussions, over two weeks, the graduate student expressed that the team
could work together to help prevent emergent situations, can help to create their own policy and
bring a monitoring device that would help more effectively care for their patient. With the
inclusion of EtCO2 monitoring on selected patients, nurses realized that they can note clinical
changes and prevent putting their patient and self in a stressful or emergent situation. Nurses and
physicians recognized that the prevention of these situations could impact the outcomes of their
patients, and would enable them to have a positive patient care experience. While all emergent
situations are not avoidable, the team wanted to find a way to help decrease this number. To
encourage the group towards change, it was necessary for the staff to be motivated towards
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something that they feel in their hearts and not in their heads that impel them into action
(Campbell, 2008). After recognizing their feelings of anxiety, frustration and concern for
patient assessment and care, the team recognized a sense of urgency and was ready to discover
possible changes that can alleviate the concern.
Once the team recognized a need for change and was open to a new intervention, the
graduate was able to transition into the second step of the change paradigm theory, creating the
guiding coalition. Creating a coalition of those committed to change helps drive momentum,
establish buy-in and create a sense of necessity (Noble, Lemer & Stanton, 2011). Since change
is so difficult to accomplish, a powerful force is required to sustain the process and not one
individual is ever able to do it alone (Kotter, 1996). A strong guiding coalition is necessary and
building a team is essential at the beginning. Campbell (2008) describes how the change
paradigm theory later explains that only teams with the right composition, knowledge about the
change, and sufficient trust among members can be highly effective under new circumstances
and can process more information quickly.
When developing the EtCO2 monitoring team at PWH, it was necessary to include
members who would bring a sense of trust to the team and are welcomed according to their
position power, expertise, good reputation and credibility on the unit, and leadership. Therefore,
members of the team included an attending physician, the Director of Nursing Education, CCNS
graduate student, CNS, a respiratory therapist, one shift manager and one staff nurse. It was
important to include members of this group who had leadership qualities to help influence the
vision to the staff as well as management to help guide the group according to feasibility of
resource, staffing and scheduling. Also, including these specific members secured significant
buy-in, which will help the change effect (Noble, Lemer & Stanton, 2011). Since this project
also impacts multiple health care providers, it was necessary to include each specialty in the
group so that it pertained and had support from each participant.
In the change paradigm theory, Kotter (1996) stresses the qualities of trust and
communication within the group. It was necessary to develop the mutual understanding, respect
and care associated with trust to work together. This was done in the initial team organization
when each group was able to independently voice their needs, concerns, and desires. For
example, the attending physician verbalized that he was concerned that all patients were going to
be monitored with EtCO2 regardless of their diagnosis. He verbalized the need for the team to
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select patients who could benefit from EtCO2 monitoring which would help the medical team
better select and treat those patients. Therefore, through these discussions, the team could
understand where each member was coming from and unite as a group to work towards a vision.
Vision, as defined by Kotter (1996), is a picture of the future with some implicit or
explicit commentary on why people should strive to create that future. Campbell (2008)
describes how the change paradigm theory describes that a vision is necessary to clearly describe
the direction in which their organization is headed and clarify the general direction for change.
The guiding team must also understand the answers to all questions regarding vision, otherwise
they will never be able to develop an adequate vision for their organization and successful
change will be impossible (Campbell, 2008). Vision motivates people to take action in the right
direction and helps coordinate the actions of different people. Kotter (1996) further explains that
clarifying the direction of change is important because people at times will disagree with
direction, are confused, or may not even think that change is necessary. With a clear direction,
decisions become easier to make and the team is united towards the change. With a shared
vision, the team can work together with some degree of autonomy and not stumble over each
other (Kotter, 1996). Along with vision, it is imperative to establish a feeling that emphasizes
attention to all staff members in which it impacts (Kirby, 2005).
To develop and communicate a clear vision, the team worked together to first discuss the
characteristics of their vision and unit. A picture of what the future of the CCU would look like
was developed. The team was very consistent with this and the CCU was described as being
competitive, top ranking in the area for critical care, following standards of best practice, having
only invested and critically thinking nurses, physicians, and therapists, as well as being a role
model for other CCU’s to strive to be like. Once a future vision was developed, the graduate
student encouraged the team to then discuss the desired needs of the CCU. These interests
included having nurse driven policies and procedures, a more effective patient transport in and
out of the CCU, more licensed individual practitioners with more specialized care, and an
increased competency of their staff. After discussing the desired factors, feasibility of the vision
was important to recognize. The team said that realistic goals for the CCU at this time included
the development of nurse driven practices, increased competency training of all staff and
additional training to enhance skills and practice to make the unit more competitive and provide
positive and safe patient care.
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After continually discussing the vision of the unit, the team wanted to communicate a
vision that was realistic, and would positively impact the stakeholders and employees. Therefore
the team developed the vision for the development of EtCO2 to say:
The vision driving the Critical Care Unit to implement end tidal carbon dioxide
monitoring for selected patients is for the enhancement of safe patient care and
possible early detection of adverse events. These goals are based on collected unit
data including ICU transfers, patient satisfaction, staff satisfaction, and patient
outcomes. When completely implemented and transitioned into practice, by
approximately six months, we will have enhanced quality of care, help to improve
patient satisfaction, and taken a step towards a more competitive CCU in the Northern
Virginia and District of Colombia Metro Area.
With the development of a vision, it was next important to communicate the vision to the entire
team. Kirby (2005) explains that gaining understanding and commitment to a new direction is
never an easy task and can be challenging. While developing the vision took a few weeks,
communicating the vision to the entire team is crucial for effective change and may take time. It
was first important to make the communication simple. The vision was provided to the staff by
in many forms through the weekly memo, on an educational bulletin board in the staff lounge,
through shift safety huddles and through discussions on the unit. The staff was given room to
ask questions, express concerns and participate in the vision discussion. Kotter (1996) described
the importance of leading by example to communicate the new direction and vision. Therefore,
the graduate student, CNS and shift managers strived to maintain effective communication, work
with members to answer questions, and provide an open space for the entire team to work
together.
The fifth step in the change paradigm theory is empowering employees for broad-based
action, meaning employees understand the vision and want to make it a reality. The first action
in this step is to help remove barriers against the change process. Barriers included a knowledge
deficit of EtCO2 monitoring from the staff, bringing forth another “thing” for the nurses to do,
and time to train the staff. To address these barriers, the graduate student worked with the staff
and team to develop ways to officially introduce EtCO2 monitoring in the CCU.
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The graduate student and CNS first performed a full review of the literature and worked
with the physician to determine patients who could benefit from EtCO2 monitoring. The
physicians then worked with the other physicians to discuss which patients they would select and
how this would change and impact their management. The CNS ordered the proper equipment
and the graduate student then worked with the equipment supplier to gain information regarding
equipment training. With that information and evidence based practice literature, the graduate
student developed a self-learning packet for the nursing staff and a procedural policy for PWH
on EtCO2 monitoring. As well as a self-learning packet, the graduate student rallied up a team
of super user nurses. These staff nurses volunteered to be trained in EtCO2 monitoring and
waveform interpretation and then will be resources for the staff for training and support. Finally,
the respiratory therapist worked with the other respiratory therapists to provide education and
training on their roll in EtCO2 monitoring. This peer support is essential in the implementation
in change, therefore information is not provided in one form or by one specific person, it is an
entire team effort and the nurses feel empowered.
In this fifth step, it was challenging to empower people to change. The individuals who
were eager to participate in the training process or be part of the original team were easy to
obtain buy-in for this change. However, the staff members who did not participate, read through
the self-learning packet and had a negative attitude were a barrier to implementation. Kirby
(2005) notes that change does take time and often needs re-evaluation in the implementation
process to meet the demands of all members. The team should also communicate a sensible
vision to the staff members, and if all have a shared sense of purpose, it will be easer to initiate
actions to achieve that purpose (Kotter, 1996). At this time, it is important to confront negative
attitudes; nothing can disempower people more (Kotter, 1996). To help address negatives on the
unit, the graduate student, along with the unit manager, continued to support and encourage each
staff member.
After empowering the team, it is time to generate short-term wins in the change process.
While major change takes time, it is important to make sure that the change is on course.
According to Kotter (1996), a good short-term win has at least the following characteristics: it is
visible and large amounts of people can see for themselves whether the results are real or hype.
Next it is unambiguous and there is little argument over the call. Finally, it is clearly related to
the change effort. The short term performance improvements help the change transition by
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giving reinforcement, drives the change, helps to fine tune strategies and vision, undermines
cynics, keeps leaders on board and builds momentum (Kotter, 1996). While this change step at
PWH is currently in process with the EtCO2 monitoring practice change, short term wins are very
critical to the overall change of practice in the CCU. It is necessary for nurses, respiratory
therapists and physicians to use the EtCO2 monitoring device, have confidence and skill to
interpret the values and act on them for any sort of practice change. The use of the device and
interpretation of data will hopefully drive clinical decisions so that emergent situations due to
hypoventilation, hypeventilation and critical carbon dioxide levels occur less frequently. The
confidence of the team will increase and they will hopefully understand that what they are doing
is making a difference in the outcomes of their patients. Therefore, they will use this monitoring
device for selected patients in the future to help drive care at the bedside if they continue to see
positive clinical significance. This step may take months, however small victories along the way
will influence the overall unit change.
Noble, Lemer & Stanton (2011) describe that in the change paradigm theory it is
important to celebrate short term wins, but there is danger in triumphalism with the first win, and
declaring victory too soon can destroy the drive for change. To prevent this it is important to
continue to communicate change in performance and also continue to invest time in the next
group to embrace change. After using EtCO2 monitoring in the CCU for a few months, it is
important to recognize the time it takes for change to occur. During this time, change can stall
due to changing priorities in the unit, key stakeholders leaving, and exhaustion of the group and
staff from the process (Campbell, 2008). Resistance to change also exists and the team cannot
win everyone’s support for the change project. Therefore, according to Kotter (1996)
consequences to mistakes can be very serious. At this point, it would be important for the
graduate student to turn to experienced change agents for advice and guidance to prevent a lull in
the process or have a declining staff support. It is also ok to add in a variety of efforts to keep
the process going and look towards some adding some fresh members to the group. It is
important to not give up because when persevered, more changes can be made than originally
envisioned (Kotter, 1996). Kotter (1996) also stresses that that good leadership helps everyone
to understand the big picture and help guide members in each of their projects. Therefore, the
graduate student will remain in positive spirits to encourage, communicate, welcome new help,
and engage the staff in the change project.
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Change is necessary in all environments and even more important to compete each step in
the process. It is necessary for the group and all leaders to recognize that change comes last, not
first and that the alterations in practice of EtCO2 measurements will come at the end of the
change process. It may take weeks, to months and even longer for the nurses, physicians and
respiratory therapist to fully utilize EtCO2 monitoring to its fullest extent, but through this
process, there should be a connect and improvement in their knowledge and skill level to impact
patient care. Kotter (1996) further explains that in the final step, new interventions usually
impact a group only after it is clear that their new work is superior to older methods. Therefore,
the nurses need to see how this monitoring has made a difference compared to past interventions.
Not only is it important for the staff to see that new interventions are superior, but necessary to
have support from the leadership, clear instruction through the entire process and necessary for
the leadership to understand that if the promotion process are not changed to be compatible for
new practices, the old culture will reassert itself (Kotter, 1996). Therefore, the graduate student
and leaders of the practice change need to continue to fully support, educate and communicate
the impact the team can make with the monitoring, make the monitoring easy to incorporate in
their already busy schedule and help to guide the assessment and monitoring process of the team.
Change is difficult and Kotter’s change paradigm theory has many steps to help structure the
process over time for the entire team (Kotter, 1996).
Like change in any organization, there are many challenges to the implementation of
EtCO2 monitoring in the CCU at PWH. The first barrier to the graduate student was the
resistance to the information and implementation process from an outsider and student. The
education and recruitment of champions was limited due to the position of the student to the
staff. The graduate student at times was ignored, brushed off and pushed aside when trying to
initiate excitement for the project and providing education and nursing change practices to the
nursing staff. This barrier was overcome by the student by remaining positive, recognizing best
times to work with the team and recruiting unit champions that can help effectively deliver
information, training and encouragement from a staff position. Being an outsider is difficult and
it is crucial to take the time to get to know and understand the staff prior to initiating any change.
It is also important for the staff in return to understand what the intentions are of the student and
the impact the student can help provide to the staff.
Time is also a major challenge in the implementation of EtCO2 measurement or any other
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practice change on any unit. Like many hospital systems, there is priority in education and
training and at times, there are other matters that take priority to implement in the unit such as
order sets and system changes. Time is also limited according to the student clinical rotation
hours and the entire change process steps are not fully complete as the student leaving the
clinical rotation. It is therefore important to excite and recruit key stakeholders who will strive
to complete each change step and follow through with the staff and unit to fully create the
change and evaluate the final process over the next few months. Change is also very hard to do
and it is almost always resisted from the entire health care team. With the implementation of
EtCO2 monitoring, it would involve an entire team approach from nurses, respiratory therapists
as well as managing physicians. A change like this to be important for the unit would require a
consensus to want to implement it, understand a reason for change and have it important for
follow through. To overcome this, it is important for everyone of many disciplines to be
involved in the change process which include training other staff, developing the policy and
procedure together and work together to interpret results.
When creating change as a novice CCNS, there are many strengths and weaknesses that
need to be recognized and acknowledged for successful implementation. With any changes there
is often conflicting thoughts, ideas and of course resistance. Confrontation is an issue that is
difficult for the new graduate CCNS to address. When faced with conflict or opposing thoughts,
rather to stir up any uncomfortable feelings or ideas, the new graduate CCNS at times will avoid
addressing the situation. This could lead to unsuccessful implementation of the change and poor
leadership. To improve uncomfortable confrontation, it is important for the new graduate CCNS
to work with the member to determine the concern, issue or feelings. Therefore, all thoughts are
considered, heard and appropriately addressed. While confrontation is a concern of the new
graduate CCNS, the idea of being completely new is also a weakness to developing change. Not
only being new to the unit is unique, but also being completely new to the CNS role is a
weakness for the new graduate CCNS. It is important to strive to successfully develop a unit
culture assessment to understand how the unit works, runs and determine leaders. This will
enable an easier transition into the unit as well as potentially develop positive change. While
being a new CCNS, it is important for the new graduate to have confidence because they are
coming with a lot of excellent experience, have a wealth of knowledge and can focus on the
multitude of resources when faced with a barrier.
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A personal weakness of the new graduate change agent is the need to do everything
independently as well as take on any project when asked to. It is important to understand
personal limitations to successfully complete projects and learn that change is not successful
with one person, it is the entire working of the team which can lead to success. A final weakness
of the change agent is the need for instant gratification. Change takes weeks, to months to even
years and the CCNS needs to recognize that successful evaluation of change may not be evident
quickly, but to continue to persevere and evaluation will eventually come.
While change does take time, the new graduate CCNS has a lot of patience. Patience is
essential in the change process, and will help when working with multiple key stakeholders,
implementation and possible long time for evaluation. Organization is also a strength of the
change agent CCNS. Many key stakeholders will be involved and working as a team to develop
a change project and it is important for everyone to understand what has been done as well as the
next steps that need to be taken. Being organized will help identify the above steps, help provide
effective communication as well as help lead the team through the process. The new graduate
CCNS is also very open and easy to get along with. It is important for the team to feel as if they
can communicate and work well with a leader. When resistance is evident, the new CCNS wants
the staff to understand that there is always a space for them to come to if they need to express
dissatisfaction, ideas for improvement or any other concerns that they have. This way, the staff
will have the support, encourage and know that they have the ability to influence change on their
unit.
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References
Campbell, R. Change Management in Health Care. The Health Care Manager. 27(1). 23-39.
Kotter, J. (1996). Leading Change. Boston: Harvard Business School Press.
Kirby, J. (2005). Toward a Theory of High Performance. Harvard Business Review. July-Aug
(30-39).
Noble, D., Lemer, C., Stanton, E. (2011) What has change management in industry got to do
with improving patient safety? Postgrad Med Journal. (87) 345-348.