My current place of employment is a 7-bed ER in a 45-bed community hospital in the small city of Ashland, Oregon. Nurses and physicians work in a close-knit team here, and in general, we communicate very well with each other. We had a change in our nursing department manager about a year ago, and this has had a definite impact on our organizational culture. This is particularly notable in the change to nurse-initiated order sets.

Our previous manager, in collaboration with the physicians and staff, began to implement nurse-initiated, complaint-based protocol order sets that ER RNs would be expected to use in triage as appropriate. Using Dr. Kotter’s organizational change model, along with the benefit of hindsight, I can see how my previous manager was starting to successfully implement this. We would discuss the delayed triage to provider time and our needs to improve this. We discussed our concerns and anxieties, and like step 4 of Kotter’s model notes, our manager was attentive and promptly addressed our concerns by communicating the change vision. He would also lead by example. I recall an instance when he stepped in to work a night shift with me. He had triaged a pregnant patient with vaginal bleeding and the physician was going to be delayed in seeing her. He said to me, “Well, I should follow my own directives and use the complaint-based protocol, and get stuff going for her!” He was leading by example. This was a very effective part of the organizational model in action, as I remembered that and draw from it in my own practice, reinforcing the change that was put in place. He would also recognize and commend us for making the change happen. This was done by reviewing particular cases during our staff meeting, pointing out how care was faster, more efficient, and ultimately safer for our patients.  Dr. Kotter’s model acknowledges this as step 5, empowering employees for broad-based action.

That manager left last year and we now have a new manager. She is also the manager for the birth center, and the manager of the house supervisors. She doesn’t have the luxury of sufficient time to spend on our department. Dr. Kotter’s steps 7 and 8 refer to consolidating gains and producing more changes, as well as anchoring new approaches in the culture. We have had increasing staff turnover since the management change, and key staff are being replaced by staff with less training and experience, particularly in nurse-initiated ordering. We have not discussed the progress generated by this triage protocol, outcomes are not analyzed (at least with the staff nurses), and change agents are not recognized. Anecdotally, the new manager has failed to work effectively with the physicians regarding proposed changes to complaint-based protocol. An example is triage nurses’ ordering EKGs for patients presenting with chest pain. According to hospital policy and our triage protocol, EKGs are supposed to be immediately ordered, performed, and the tracing given to the provider within 10 minutes of presentation at triage for patients with chest pain or suspicious epigastric/jaw/neck/shoulder pain. One physician does not like this practice, and complained to the nurse manager that too many EKGs were being ordered prior to his evaluation. The nurse manager communicated this to the ERMD director, and the director told her that the protocol needed to stay in place. In spite of this, the nurse manager sent out an e-mail to ER staff, stating that we needed to be more judicious about ordering EKGs from triage and that we should discuss it with the physician first. The ERMD director then communicated directly with several nurses, stating that the lone physician’s request was inappropriate, as was the nurse manager’s new directive to staff. This has obviously created confusion among staff, and uncertainty as well as delay of care can have major safety implications for patients (time is muscle!) Relying on Kotter’s framework regarding contributing factors to failure of change management, this is a prime example. Step 2 notes a failure to define a clear rationale for change. In this case, the lone dissenting physician was relying on limited data that was not supported by his colleagues, and the nurse manager did not adequately explain the reason for the change or the evidence behind it. Step 7 also blames haphazard communication, which is also evidenced here, especially as the ERMD director’s directions were somewhat ignored.

This change in management strategies to a less-effective, haphazard model has had an impact on nurse-initiated orders and we have seen our door to discharge time suffer as well. I would be interested to see if this has impacted patient safety in my department.

Reference:

[Steven Thomsen]. (2013, February 17). KOTTER’S 8 STEP ORGANIZATIONAL CHANGE MODEL FC. [Video File]. Retrieved May 11, 2017, from https://www.youtube.com/watch?v=LxtF4OXzhyI#action=share