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Change needed in healthcare np scholarly articles

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Change is inevitable, yet slow to accomplish. While change theories can help provide best practices for change leadership and implementation, their use cannot guarantee success.

The process of change is vulnerable to many internal and external influences. Using change champions from all shifts, force field analyses, and regular supportive communication can help increase the chances of success [5]. Knowing how each departmental staff member will likely respond to change based on the diffusion of innovation phases can also indicate the types of conversations leaders should have with staff to shift departmental processes.

You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Turn recording back on. Help Accessibility Careers. StatPearls [Internet]. Search term. Change Management Jennifer M. Affiliations 1 McNeese State University. Confirmation staff recognize the value and benefits of the change and continue to use changed processes. Issues of Concern All change initiatives, no matter how big or small, unfold in three major stages: pre-change, change, and post-change.

He further qualified those change acceptance categories with the following descriptions: Innovator: passionate about change and technology; frequently suggest new ideas for departmental change.

Early majority: Prefer the status quo; willing to follow early adopters when notified of upcoming changes. Late majority: Skeptical of change but will eventually accept the change once the majority has accepted; susceptible to increased departmental social pressure. Laggard: High levels of skepticism; openly resist change [4]. Clinical Significance Change is inevitable, yet slow to accomplish. Review Questions Access free multiple choice questions on this topic. Comment on this article.

References 1. Leading change: a concept analysis. J Adv Nurs. Shirey MR. Lewin's Theory of Planned Change as a strategic resource. J Nurs Adm. Mitchell G. Selecting the best theory to implement planned change. Nurs Manag Harrow. Using Diffusion of Innovations Theory to implement the confusion assessment method for the intensive care unit.

J Nurs Care Qual. Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. Change Management. In: StatPearls [Internet]. In this Page. Bulk Download. Related information. PubMed Links to PubMed. Similar articles in PubMed. Ann Clin Lab Sci. The patient experience of patient-centered communication with nurses in the hospital setting: a qualitative systematic review protocol.

Newell S, Jordan Z. First, this paper fills the quantitative assessment gap related to the PC hospital model with a specific focus on efficiency and effectiveness. Such an organizational change towards the PC model can be a costly process, implying a rebalancing of responsibilities and power among hospital personnel, affecting inter-disciplinary and inter-professional relations e. Nevertheless, our results confirm the effect of these hospital innovations on efficiency [ 11 ] , adding some robust results, thus suggesting that a change to the PC model can be worthwhile.

This evidence can be used to inform and sustain hospital managers and policy makers in their hospital design efforts, and to communicate the innovation advantages within the hospital organizations, among the personnel and in the public debate.

With these data analysis, we believe that this health care innovation can be regarded as an actual improvement to meet the needs of the community, contrasting the possible perception that it may have been driven by managerial, international or political trends.

As suggested by McKee and Healy [ 36 ] , all that we can be certain of is that the hospital of the future will be different from the hospital of today and the PC model is an interesting innovation, which, however, requires a proper evaluation.

Second, this research exercise can be also considered as a guiding example for ex-post evaluation of broad interventions. This is a complicated task, although worthwhile as it provides fundamental suggestions to policy makers engaged in important future and complex innovations [ 46 ].

This study refers to the long-standing tradition of program evaluation, which may be used when the real-world provides data to support testing hypothesis with a counterfactual approach. The availability of administrative data, which is increasing in all developed countries and is characterised by little measurement error and high detail of information, makes the opportunity for sound quantitative assessments, offering evidence that turns useful in the planning of innovation initiatives and their policy implications for the overall society.

This paper provides a quantitative estimation of efficiency and effectiveness changes following the implementation of the PC hospital model in a major region of Italy. Taking advantage of a quasi-experimental setting and a detailed administrative dataset, we perform an ex-post evaluation of innovating the hospital organization by switching from a traditional functional model to a PC organizational one.

We provide robust evidence, at the average MDC, of a statistically significant and positive effect of the introduction of the PC model on both effectiveness and efficiency. In particular, the increase in efficiency emerges from the reduction of the average length of stay, while for efficacy, our results, show a reduction in re-hospitalization rates of hospitals that switched to a PC organization.

These results are in line with our theoretical framework which suggests an increase in efficiency and effectiveness of PC hospitals and provides a sound example of a quantitative evaluation of an organizational intervention adopting a counterfactual approach. MDC codes are internationally recognized thanks to their adoption in the United States medical care reimbursement system. They are formed mapping all the DRG codes into 25 mutually exclusive diagnosis areas.

We estimate log-linear models of the outcome means considering that the outcomes that we use are strictly non-negative e. This is clearly equivalent to including a standard interaction term between the treatment variable and a post-reform dummy. Also notice that there is no need to include a treatment dummy, as we have the full set of hospital fixed effects, or a post-reform dummy variable, as we have the full set of year fixed effects.

Individual HDC records are not publicly available under the Italian privacy law. The Health Care Department of the Lombardy Region must be contacted to discuss the provision of the data. The diagnosis-related group DRG code is a standard classification [ 48 ] adopted in the Lombardy Region of Italy since In fact, HDC data trace the department that is in charge of each patient and record the total number of departmental transfers of each HDC, but not whether a transfer is in fact a bed change within the same hospital or, more simply, a change of the administratively responsible department.

An important efficiency measure that we do not observe is the cost of single HDCs as we have no information on the composition and cost of the physical and human resources used. In fact, we are provided with the cost of reimbursement by the Lombardy Health Care System to hospitals for each HDC, but this variable is unsuitable for use as a cost measure as it is affected by DRG up-coding practices, discretionality of the regional policy makers in deciding the price of the duration and the DRG of each HDC, allowing for strategic behaviour of hospital managers.

For an extensive analysis of the reimbursement mechanism adopted in the Lombardy Health Care System, see [ 49 ]. The main reason for dropping the HDCs of patients with residence outside Lombardy is because they might be occasional users of the Lombardy Health Care System and we lack relevant information about them regarding their possible re-hospitalization and death.

For instance, as we know the date of death of Lombardy residents only, including non-Lombardy patients would bias the average mortality rate of patients downward by an unpredictable amount. We also dropped one-day-long and subacute HDCs due to comparability issues. A similar approach was used by [ 50 ]. Some robustness checks assessing the relevance of this selection rule are provided in Tables 7 and 8. We developed this test results in Table 4 for all the models that we estimated in Table 5 columns 1 to 4 , starting from the basic equation Eq.

First, we computed each outcome variable of interest after partialling out the contribution of all the independent variables except for P C h , t. Hence, we regressed each of them on a fourth-degree polynomial time trend, allowing all the coefficients to differ between the PC and the traditionally organized hospitals unrestricted model , and we regressed the same dependent variable on a fourth-degree polynomial time trend in which only the intercept is allowed to differ between the two groups considered.

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Baltimore: Johns Hopkins University Press; Google Scholar. Hospital innovations in the light of patient engagement. Patient engagement: a consumer-centered model to innovate healthcare. Warsaw: Gruyter Open: Patient-centered innovation in health care organizations: A conceptual framework and case study application. Health Care Manage Rev. Patient centered care and outcomes: A systematic review of the literature.

Med Care Res Rev. Berwick DM. What patient-centered should mean: Confessions of an extremist. Health Aff Millwood. Article Google Scholar. The patient centered organizational model in italian hospitals: Practical challenges for patient engagement. San Francisco, California: Jossey-Bass; Lega F, DePietro C. Converging patterns in hospital organization: beyond the professional bureaucracy. Health Policy. Vera A, Kuntz L. Processe-based organization disegn and hospital efficiency.

Restructuring patient flow logistics around patient care needs: implications and practicalities from three critical cases. Health Care Manag Sci. Cicchetti A. Fra Tradizione e Strategie per Il Futuro.

Milano: Vita e pensiero; Therapy by design: evaluating the uk hospital building program. Health Place. The efficiency of hospital-based clusters: Evaluating system performance using data envelopment analysis. Salge TO, Vera A. Hospital innovativeness and organizational performance: Evidence from english public acute care.

A multi-method approach for looking inside healthcare practices. Qual Res Organ Manag. Walston S, Kimberley J. Re-engineering hospitals: experience and analysis from the field. Hosp Health Serv Adm. Changes in U. J Policy Anal Manage. Towards an organisation-wide process-oriented organisation of care: A literature review. Implement Sci. Waring JJ, Bishop S. Lean healthcare: rhetoric, ritual and resistance. Soc Sci Med. Hurst K. Leeds: NHS Executive; Bainton D.

Building blocks. Health Serv J. Coulson-Thomas C. Re-engineering hospitals and health care processes. Br J Health Care Manag. Brodersen J, Thorwid J. Enabling sustainable change for healthcare in stockholm. Lega F. Lights and shades in the managerialization of the italian national health service. Health Serv Manage Res. Edwards N, McKee M. The future role of the hospital.

Reorganising hospitals to implement a patient-centered model of care. J Healt Org Man. An integrative model of patient-centeredness - a systematic review and concept analysis. Integrative practices in hospitals and their impact on patient flow. Int J Oper Prod Manag. Lean in healthcare: The unfilled promise? Exploring the practice of patient centered care: The role of ethnography and reflexivity. Consulting A. Patient Centred Care: Reinventing the Hospital.

New York: Andersen Consulting; Glanville R. Hospital Healthcare Europe, — Brussels: Campden Publisher: Dias C, Escoval A. Improvement of hospital performance through innovation: toward the value of hospital care.

Health Care Manag. McKee M, Healy J. Hospitals in a Changing Europe. Buckingham: Open University Press; Stratification for the propensity score compared with linear regression techniques to assess the effect of treatment or exposure.

Stat Med. Boyce NW. Canberra: Australian Government Publishing Service; Statistical issues in assessing hospital performance. Quant Health Sci Publ Presentations. Paper Comparing health outcomes among hospitals: the experience of the lombardy region. Austin C, Tu J. Comparing clinical data with administrative data for producing acute myocardial infarction report cards. J R Stat Soc A.

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Empir Econ. Mariani L, Cavenago D. Download references. The scientific output expressed does not imply a policy position of the European Commission. Neither the European Commission nor any person acting on behalf of the Commission is responsible for the use which might be made of this publication. The data are administrative records accessible upon authorization granted by the Health Care Department of the Lombardy Region.

Fermi, , Ispra VA , , Italy. You can also search for this author in PubMed Google Scholar. All the authors have made substantial contributions to conception, design and the drafting of the manuscript. All authors read and approved the final manuscript. Correspondence to Stefano Verzillo. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and Permissions. Fiorio, C. Evaluating organizational change in health care: the patient-centered hospital model.

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Skip to main content. Search all BMC articles Search. Download PDF. Research article Open Access Published: 08 February Evaluating organizational change in health care: the patient-centered hospital model Carlo V.

Abstract Background An increasing number of hospitals react to recent demographic, epidemiological and managerial challenges moving from a traditional organizational model to a Patient-Centered PC hospital model.

Methods We take advantage of a quasi-experimental setting and of a unique administrative data set on the population of hospital discharge charts HDCs over a period of 9 years of Lombardy, the richest and one of the most populated region of Italy. Results We contribute to the literature that addresses the evaluation of healthcare and hospital change by providing a quantitative estimation of efficiency and effectiveness changes following to the implementation of the PC hospital model.

Conclusions Although an organizational change towards the PC model can be a costly process, implying a rebalancing of responsibilities and power among hospital personnel e. Background In recent decades, national health care systems have been dealing with an increased demand for high-quality and patient-centered services, but limited resources have often challenged their sustainability [ 1 ].

The patient-centered hospital model Hospitals have often been conceived as functional organizational structures, in which patients requiring a similar area of expertise are grouped into independently controlled departments.

Table 1 Disentangling the differences between traditional and PC hospitals Full size table. Methods The empirical model A key ingredient in assessing the effects of a change from a functional to a PC model is to observe, in a group of comparable hospitals, a change in a group of hospitals treated units as opposed to others control units over time. Table 3 Summary statistics before and after the organizational change, in average MDCs Full size table.

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Change needed in healthcare np scholarly articles 454
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Epicor software melbourne For example, some of our colleagues at Partners HealthCare in Boston source testing innovative technologies such as tablet computers, web portals, and telephonic interactive systems for collecting outcomes data from patients after cardiac surgery or as they live with chronic conditions such as diabetes. Knowledge of conditions associated with successful organizational change has the potential to improve selection, planning, implementation and management of ubiquitous changes in health care organizations. The intensifying pressure from employers and insurers for artocles pricing is already beginning to force providers to explain—or eliminate—hard-to-justify price variations. Data show that RNs tried to expand their responsibilities following the implementation of AA. Reduction of medical errors Reducing errors is essential, but errors n just one of the outcomes that matter to patients. One example was expressed by an RN who was disappointed at the departure of a FP recognized as a particularly influential leader in developing processes to support her practice change within the AA model.
Change needed in healthcare np scholarly articles Embracing the goal of value at the senior management and click here levels is essential, because the value agenda requires a fundamental departure from the past. In areas where provider shortages limit access uealthcare care and where new practitioner types can lead to better and more efficient delivery of care, allowing the overlapping scope of practice, when appropriate, is essential. The preceding five components of the value agenda are powerfully enabled by a sixth: a supporting information technology platform. Even assuming a well-justified and well-planned change initiative, research underscores the importance of managers building internal support for change by means of employee participation in the change process [ 31 ]. Int J Fam Med.

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Despite the higher acuity of care required by patients under NP-directed care than those under physician-only care, the discharge outcomes were similar. In addition, a large cohort study [ 38 ] reported a significantly shorter length of stay in medical ICUs for patients whose management were led by NPs than those under physician-only management. Patients in the NP-directed group also had lower odds odds ratio 0. All included studies that compared NP-physician collaborative model of care with usual physician-only model of care found similar lengths of hospital stay [ 35 , 36 , 37 , 41 ] between the comparison groups.

However, in one study [ 36 ], after subgroup analysis, a significantly shorter length of stay was found in the physician-NP collaborative group for patients transferred from another service mean difference 6.

The management of such patients warrants greater communication with multidisciplinary teams, discharge planning, care coordination, and administrative work were required; in this niche, NPs are familiar with such tasks and can competently perform them [ 43 ]. Only one study [ 39 ] examined the impact of advanced nursing practice roles on waiting time in the critical care setting. Five [ 34 , 37 , 38 , 39 , 41 ] out of the 15 studies analyzed the impact of the advanced nursing practice roles on hospital and ICU mortality.

Two studies [ 38 , 39 ] comparing NP-directed care with physician-only care found comparable patient mortality. This finding was consistent with that in the other three studies conducted in ICUs [ 34 , 37 , 41 ] which compared the NP-physician collaborative care with physician-only care. Of the 15 studies, only one examined patient satisfaction in the critical care settings [ 31 ]. The study developed a new self-reported tool to measure patient satisfaction and found similar scores when comparing NP-directed care with physician-only care.

Nonetheless, the study [ 31 ] reported that NPs performed better than physicians in teaching, answering questions, listening, and pain management.

This finding was akin to the study [ 30 ] conducted in the ED which assessed the healthcare provider for completeness of care, politeness of service provider, explanation and advice given, waiting time, and comprehension of discharge instruction. Three of the 15 studies reviewed the impact of the advanced nursing practice roles on cost [ 34 , 36 , 41 ], all of which compared NP-physician collaborative care with physician-only care in the critical care setting.

One study [ 41 ] reported that despite a longer ICU stay for patients in the NP-physician group than for those in physician-only group, there was no significant difference in the observed charges between them.

This supports the contention that involving NPs in the management of the critically ill can lead to cost savings. The other two studies [ 34 , 36 ] had results that demonstrated cost savings in the NP-physician group compared to physician-only group.

With population aging and the consequent global epidemic of chronic diseases, healthcare demands will only rise. Accordingly, nurses in advanced practice can add value and increase access to healthcare by, potentially strengthening the healthcare workforce.

Nonetheless, the expansion of role and autonomy of nurses will lead to concerns of patient safety and clinical outcomes. Through the narrative synthesis of the available evidence from Australia, Canada, New Zealand, UK, and USA, nurses in advanced practice appear to generate clinical outcomes comparable to those of physicians in the emergency and critical settings.

Generally, in the ICU setting, the involvement of NPs in managing the critically ill allowed for greater continuity of care [ 37 ], as NPs did not have to be on frequent rotation coverage as junior physicians. Hence, NPs developed greater familiarity with the environment and patient demands than the physicians who were constantly on rotation.

When daily multidisciplinary rounds were initiated by NPs, the coordination of care was shown to improve [ 40 ]. Providing effective care coordination is a forte of nurses [ 10 ]. Care coordination requires interpersonal communication and collaboration. As nurses can establish more personal and tangible relationships with patients than do physicians [ 44 ], they perform better in care coordination. The value of NPs was exemplified when the patient care required cross-disciplinary communication, discharge planning, follow-up care, and administrative work.

Apart from delivering efficient care, nurses in advanced practice will get to develop expertise for managing specific groups of patients through assigned responsibilities [ 35 ]. One of the prioritized quality-of-care indicators in the emergency setting is the time from arrival to first assessment by physician [ 45 ].

This review has demonstrated that NPs were capable of rendering emergency care services as timely [ 28 , 32 ] as, if not faster [ 33 ] than, physicians. The addition of nurses in advanced practice in the emergency settings enabled physicians to pay greater attention to patients of higher complexity and acuity, thereby, improving access to prompt emergency care.

Time to treatment is also a priority in emergency care. The time to first administration of analgesia is an important quality-of-care indicator in EDs [ 45 ]. There are national targets in place to improve this aspect of care. In Australia, New Zealand, and the USA, the national target for time to analgesia is 30 min from time of arrival [ 46 , 47 ] and, in the UK, it is 20 min [ 48 ]. When compared with physicians, NPs were observed to have greater adherence to the recommended targets for administering analgesia in a timely fashion [ 29 ].

In their provision of a hybrid model of care amalgamating nursing and medical tasks, NPs are trained to perform patient assessment and, in some countries, have prescription rights.

These factors contributed to a shortened time to treatment in the emergency setting for patients [ 29 ]. The experience of the patient is highly valued in the healthcare system [ 49 ]. NPs were rated to perform better at patient education, answering queries, listening, and pain management than physicians [ 31 ]. These are the strengths of NPs, consistent with the NP goals and education, which are grounded in nursing [ 43 , 50 ].

Cost savings are an important outcome measure in evaluating the feasibility of any new service model [ 51 ]. Findings from this review suggest greater cost savings with the implementation of the advanced nursing practice role in emergency or critical care [ 34 , 36 , 41 ].

However, judicious interpretation of the evidence is recommended. A fair synthesis of the cost savings in the included studies could not be performed as they had been done in different countries. The varying financial and funding models make it difficult to synthesize the findings.

Furthermore, none of the studies in this review performed any cost-effectiveness analysis. The existing evidence has demonstrated the positive impact of advanced nursing practice roles in the emergency and critical setting, it is then of benefit to examine the necessary conditions for its implementation and receptivity.

According to Pettigrew et al. Three of which are especially apparent in the studies featured in this review. They are namely the presence of environmental pressure, supportive organizational culture, and managerial-clinical relations. Environmental pressure can be especially pivotal in creating favorable conditions for change. When considering environmental pressure, besides the entire healthcare system, the political context of the country has an integral role in defining the environment [ 53 ].

Political influence, a large environmental pressure, was evident in the studies conducted in the USA [ 35 , 36 , 37 , 38 , 39 , 40 , 41 ] and UK [ 34 ]. In the USA, the implementation of the Affordable Care Act in was a catalyst for the development of more efficient healthcare delivery models to cope with the projected influx of new patients.

In the UK study [ 34 ] featured in this review, political influence was also observed. The enactment of provisional immigration laws for physicians outside of the European Union and the European Working Time Directive has make it more difficult to support safe staff-to-patient ratios in the critical care setting.

The political context of the country created an environmental pressure which consequently compelled the institutions [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ] cited in this review to capitalize on nurses in advanced practice and experiment with new models of care delivery.

The environmental pressures trigger the development of a supportive organizational culture to effect change to ease the pressure [ 52 ]. A supportive organizational culture strives to promote staff engagement [ 53 ]. Staff engagement involves autonomy to be extended, and it was apparent in the included studies. In this review, the NPs were given greater autonomy to either practice independently [ 28 , 29 , 30 , 31 , 33 , 34 ] or collaborate [ 32 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ] with physicians at greater extents in the emergency and critical care settings.

Effective managerial-clinical relations is also a crucial factor in leveraging institutional change [ 53 ]. In the study conducted in Canada [ 31 ], the authors attributed the success observed in the NP role implementation in the post-operative cardiac surgery unit to the support from and collaboration between the administrators and clinical staff.

One approach to facilitate effective managerial-clinical relations is through adopting a distributed model of leadership [ 55 ], which encourages collaboration between the administrators and clinical staff. The distributed leadership approach is known to be most efficacious where job roles are mutually dependent [ 56 ]. The implementation of advanced practice nursing roles in the emergency and critical care settings involves mutually dependent job roles and so will benefit from the distributed leadership approach.

The distributed leadership approach utilizes a bottom-up process, where individuals working in the setting-of-interest participates in decision-making [ 55 ]. Using this approach creates the notion of co-construction, which avoids the overreliance on a dominant individual, increasing the likelihood for sustainable change [ 54 ].

State law governs advanced nursing practice and define supervisory requirements [ 60 ]. Professional indemnity is closely associated to legislative boundaries [ 63 ]. It, therefore, reiterates the importance of having coherent policies to define roles and professional independence of nurses in advanced practice. The meta-analysis of the outcomes was not done to present the combined effect of estimates on the impact of advanced nursing roles in the emergency and critical care settings.

Yet, to perform a meta-analysis would be inappropriate as the included studies were heterogeneous in designs, interventions, and outcome measures. The heterogeneity of studies was expected as the professional boundaries of nurses differ across countries.

However, a review of the impact of advance nursing practice across countries is still valuable. A limitation in all studies is the poor definition and description of the scope of advanced nursing practice.

In addition, preparatory training for nurses to assume advanced practice was rarely discussed. The level of theoretical knowledge and clinical competence of the nurses might differ across the studies; hence, the comparison might not have been fair.

Finally, despite the search across nine international databases, this review included papers in only English; relevant papers not published in English might have been omitted. Caring for the critically ill patient.

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An international survey on advanced practice nursing education, practice, and regulation. J Nurs Scholarsh. Schober M, Affara FA. International council of nurses: advanced nursing practice. Oxford: Blackwell Pub; Google Scholar. Savrin C. Growth and development of the nurse practitioner role around the globe. J Pediatr Health Care.

A summary of the World Health Report. Accessed 31 July Quality of primary care by advanced practice nurses: a systematic review. Int J Qual Health Care.

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Evaluating emergency nurse practitioner services: a randomized controlled trial. A systematic review of advance practice providers in acute care: options for a new model in a burn intensive care unit. Ann Plast Surg. A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: a systematic review.

Int J Nurs Stud. Ann Intern Med. Sackett DL. Evidence-based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone; The Joanna Briggs Institute. Adelaide: The Joanna Briggs Institute; Quality control in systematic reviews and meta-analyses. Eur J Vasc Endovasc Surg. Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia. J Clin Nurs. Evaluating emergency nurse practitioner service effectiveness on achieving timely analgesia: a pragmatic randomized controlled trial.

Acad Emerg Med. Evaluating the quality of care delivered by an emergency department fast track unit with both nurse practitioners and doctors. Australas Emerg Nurs J. Nurse practitioners in postoperative cardiac surgery: are they effective? Can J Cardiovasc Nurs. Impact of a nurse practitioner on patient care in a Canadian emergency department. Emergency nurse practitioners: do they provide an effective service in managing minor injuries, compared to emergency medicine registrars?

Advanced care nurse practitioners can safely provide sole resident cover for level three patients: impact on outcomes, cost and work patterns in a cardiac surgery programme. Eur J Cardiothorac Surg. Cardiac acute care nurse practitioner and day readmission. J Cardiovasc Nurs. Effect of a dedicated orthopaedic advanced practice provider in a level I trauma center: analysis of length of stay and cost. J Orthop Trauma. Comparison of 2 models for managing tracheotomized patients in a subacute medical intensive care unit.

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Time to analgesia and pain score documentation best practice standards for the emergency department: a literature review. Timely pain management in the emergency department. J Emerg Med. Keating L, Smith S. Acute pain in the emergency department: the challenges. Rev Pain. Sidani S, Irvine D. A conceptual framework for evaluating the nurse practitioner role in acute care settings. Jamison DT.

Priorities in health. Washington, DC: World Bank; Book Google Scholar. Shaping strategic change: making change in large organizations, the case of the National Health Service. London: Sage Publications; Western S. Leadership: a critical text. Barrow 1 ; Pavan Annamaraju 2 ; Tammy J. Change is inevitable in health care. A significant problem specific to health care is that almost two-thirds of all change projects fail for many reasons, such as poor planning, unmotivated staff, deficient communication, or excessively frequent changes [1].

All healthcare providers, at the bedside to the boardroom, have a role in ensuring effective change. Using best practices derived from change theories can help improve the odds of success and subsequent practice improvement. Suppose a health care provider works in a hospital department that has experienced a 3-month increase in unwitnessed patient falls during the hours surrounding shift change. Evidence-based changes in the current shift change process would likely decrease patient falls; however, departmental leadership has attempted unsuccessfully to fix this problem twice in the past 3 months.

Staff continues to revert to previous shift change protocols to save time, which leaves patients unmonitored for extended periods. The answer may lie within the work of several change leaders and theorists. Although theories may seem abstract and impractical for direct healthcare practice, they can be quite helpful for solving common healthcare problems.

Lewin was an early change scholar who proposed a three-step process for ensuring successful change [2]. All change initiatives, no matter how big or small, unfold in three major stages: pre-change, change, and post-change. Within those stages, healthcare providers working as change agents or change champions should select actions that match change theories.

One of the most critical aspects of pre-change planning is involving key stakeholders in problem identification, goal setting, and action planning [5]. Involving stakeholders in change planning increases staff buy-in. These stakeholders should include staff from all shifts, including nights and weekends, to create peer change champions for all shifts [5].

During pre-change planning, change agents should assess their departmental staff to determine which staff belong to each category. Rogers described the different categories of staff as innovators, early adopters, early majority, late majority, and laggards [4]. He further qualified those change acceptance categories with the following descriptions:. Most departmental staff will likely belong to the early or late majority. Change agents should focus their initial education efforts on Innovator and Early Adopter staff.

Early adopters are often the most pivotal change champions that persuade early and late majority staff to embrace change efforts [4]. A force field analysis involves a review of change facilitators and barriers at work in the department. Change leaders should work to reduce change barriers through open communication and education while also aiming to strengthen change facilitators through staff recognition and various incentives.

One of the biggest mistakes a change leader can make during the midst of change implementation is failing to validate that staff members are performing new processes as planned. Ongoing leader engagement throughout change execution will increase the chances of success [5].

Staff resistance remains common during this stage. Change leaders may find it helpful to conduct another Force Field Analysis during this changing phase to ensure no new barriers have emerged [3]. Further strengthening of change facilitators through staff engagement, recognition, and sharing of short-term wins will help maintain momentum. Staff may require additional on-the-spot training to overcome knowledge deficits as the change process continues. Finally, leaders must continue to monitor progress toward goals using information like patient satisfaction, staff satisfaction, fall rates, and chart audits [3].

Change agents can redefine their relationship with the staff to take on a less active role in the change maintenance process. However, once the change leader begins to release control over the change process, staff members may slowly revert to old, negative behaviors. Change managers should celebrate wins with staff while continuing to share evidence of success in staff meetings or with departmental communication boards [5].

Change is inevitable, yet slow to accomplish. While change theories can help provide best practices for change leadership and implementation, their use cannot guarantee success. The process of change is vulnerable to many internal and external influences. Using change champions from all shifts, force field analyses, and regular supportive communication can help increase the chances of success [5]. Knowing how each departmental staff member will likely respond to change based on the diffusion of innovation phases can also indicate the types of conversations leaders should have with staff to shift departmental processes.

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