Change Theory in Nursing

The general definition of change is to alter or make something completely different from the way it has traditionally been done. Change can come in the form of being planned or unplanned. With planned changes, there brings a shift in the original plan and with unplanned change, the outcomes of the particular changes cannot be known until the dust has settled. In the field of nursing, any impact that is made on the field as to the typical fashion in which things are done is said to be performed by a change agent. In order to bring about said change, the change agent utilizes what is known as a change theory. Change theory most commonly occurs applies to business, but the principles are the same. As the nursing field is significantly altered by the impact of the change, it becomes all the more important for the change agent to select the best change theory for the appropriate situation. 

There are several change theories. In most nursing situations, the change theory by Kurt Lewin is frequently used. The field of nursing considered the Lewin Change Theory, a time tested method in approaching both organizational development and social psychology in the workplace. Lewin's presentation of change is that it is planned change and consists of three different components or stages: the unfreezing stage, the change stage and the refreeze stage. The first stage, unfreezing, is noted as involving the discovery of a particular pattern that is in need of changing. Essentially, the unfreezing stage is what prompts individuals in the environment to recognize that a change needs occurring. This recognition is done through a process of activities and dialogue among employees at the clinic, hospital or medical facility. It becomes important to ensure that there is open dialogue and that people verbalize the inner dialogue they are having in order for there to be an effective and smooth transition of the change. That is not to say that occurrences of interruption and turbulence will not happen but minimization of occurrences of that nature can potentially be prevented with a thorough discussion on what is being changed. This stage sets the scene for getting individuals prepared for a new change. The second stage of the change theory presented by Lewin is the overall process of that change in terms of seeking out the desired improvements and convincing individuals that the new technique or way of doing will undoubtedly be a better approach that what has been done prior and the potential tangible results that will be executed as a result of this change. This is the stage where the change actually occurs. In the final stage, refreezing, the new protocol is established as the standard. Hence, it reinforces the new operational methodology or approach in order to prevent a return to the old ways in which things were done in the medical setting (Bushe, 2001; Kaminski, 2013).

Implementing Chlorhexidine Gluconate Cloths

Sanitation of both environments and patients has always been an important component of hospitals. Nurses especially see many different types of patients and in a myriad of diverse settings within the medical arena that it becomes all the more fundamental for them to both receive the necessary training to prevent risk of infections and/or spreading of bacteria and viruses. Calkin (2012) stated that "it is best practice for [the medical arena] to have 24/7 cleaning services [and that] nurses should [be made] aware of the type of cleaning support they are receiving” (para. 8) in addition to their own ensuring that areas and patients are clean. The medical field is continually seeking out ways in which it can clean and wash areas and patients. One particular way that hospitals and medical facilities can prevent infection is through the implementation of chlorhexidine gluconate cloths. 

The most common area of infections of any form is the surgical site and post surgical operation. Thus, the latest weapon to emerge is the chlorhexidine gluconate cloth, which is a form of biguanide. In low and high concentrations, this particular biguanide disrupts bacterial membranes and microbial proteins and has been shown to be quite effective in ridding areas of issues. In addition to the cloths, there are other products on the market such as a catheter dressing, dental solution, gauze dressing, hand rub, scrub solution and topical solution (Stokowski, 2010) that can be applied to areas where patients have been and on patients themselves to prevent any kind of potential infection.

The Change Theory and Chlorhexidine Gluconate Cloths

Perhaps the central element that could be a barrier to implementation of Chlorhexidine Gluconate Cloths is the opinions of nurses. In an ever evolving healthcare landscape, any particular change may be too much for nurses, thus, a transformational practice becomes necessary. While the medical field continues to undergo notable changes in the ways in which they practice, often new changes such as this form of implementation can be daunting, yet a viable opportunity for change. There is reason to believe that the majority of the nurses will be on board with the implementation of the Chlorhexidine Gluconate Cloths as they want to prevent both patients and themselves from getting infected with any type of bacteria. Probably the most significant benefactor or change agent would be the medical staff of the medical setting that decides that said implementation needs to happen. This individual or these individuals would discuss the changes that will take place by unfreezing the traditional and conventional thoughts on preventative measures in the medical setting. The medical staff making this particular implementation would need to inform the nurses of what they are seeking and proposing to change. They would also have to have approval from the stakeholders in the medical facility that the cloths are needed in order for funds to be allotted for the process.

The medical staff will have to have frequent discussions with the nurses about the new change they are proposing. It will become all the more important to the nursing staff to understand why a new change is needed in the particular medical setting. Management will have to ensure that the ethical aspects are covered explicitly so that the nurses can ascertain the importance of the implementation. Promoting quality and efficient ethical practice is the most important facet in a hospital setting. The clinical staff must appreciate the patient to the best of their abilities and without the proper knowledge of the implementation of the cloths, there could be potential ethical dilemmas (Stokowski, 2010) due to the fact that this is a new format of cleaning patients and patients may not be comfortable with it. It will then be on the nurse leaders to make sure that discussions and dialogue are not only had with the nurses themselves, but with patients also. 

What Could Potentially Occur in the Change & Refreezing Stages?

When the implementation of the Chlorhexidine Gluconate cloths happens, there is reason to believe that it will not be a shock to all involved, as the individuals (employees, patients and nurses) would be fully aware of the repercussions of utilizing these types of sanitation cloths to prevent infection. The timeline of the change process would take place with a period of 5-6 months following discussion on why the cloths need to be implemented. As with anything new however, an adjustment period is needed. In the application of the cloths, there could be potential for nurses to forget to use them and use other methods of cleaning patients such as disinfectant chemicals, and scented chemicals; in other words anything other than the Chlorhexidine Gluconate cloths. That is not to say that nurses would be intentionally using these other ways of cleaning, but as the saying goes, habits have to be broken. In implementing this change, frequent monitoring of the ways in which nurses apply the cloths to patients would be needed. This will hopefully minimize the different problems that may occur as a result of the change process.

The routine of cleaning patients would be done daily through the use of a bath utilizing these types of clothes. Holder (2009) documented a fitting routine that was used/will be used in this implementation:

1. Patient admitted to the medical setting.

2. Perform an assessment of the patient (any wounds or prominences associated with infection).

3. If the patient is extremely dirty, then an initial bath or wipe down will need to be performed with soap and water only.

4. Review with patient the importance of using the cloths to prevent infection.

5. Proceed with bath and/or cleaning.

6. Obtain the cloths from a warming apparatus. 

7. Use approximately 6 cloths daily per patient. 

8. Apply topical treatment if needed.

9. Document what took place during treatment.

The change agent would need to be extremely important in assuring that these baths are going as they should. While it is assumed that the nurses will adjust over a certain timeframe, it becomes even more important at the early stages of change for the change agent to be the driving forces behind synergy within the workplace in making sure that protocol is followed. Any nurse that does not adhere to the new changes will be talked to, in order to find out why they are not adhering to the new change. Kaminski (2013) stated that “for change to happen, the status quo must be upset – either by adding conditions favorable to change or by reducing resisting forces” (para. 15). Therefore, if a nurse is not following the new changes made to the ways of cleaning, then decisions will have to be made to unearth whether the unfreezing process was effective or if the nurse simply is ignoring the policies of the medical setting. 

Following the change process, refreezing must take place in accordance with the Lewin change theory. The nurses in this implementation will more than likely accept the new adjustment of the Chlorhexidine Gluconate cloths as nurses are committed to ensuring that cleanliness is done first and foremost because their lives and the lives of the patients is in danger if cleanliness is not considered. Lewin noted that successful change is achieved through a cooperative dynamic among the group or groups where the change has been implemented. It can be said then that as a result of the nurses cooperating with the implementation of the cloths, that the change was a success and the refreezing process was effective. 

Implementation of Chlorhexidine Gluconate Cloths Table

(Table omitted for preview. Available via download)

References

Bushe, G. R. (2001). Five theories of change embedded in appreciative inquiry. In D. Cooperrider, D. Sorenson, D. Whitney, & T. Yeager (Eds.), Appreciative Inquiry: An Emerging Direction for Organization Development (pp. 117-127). Champaign, IL: Stipes. 

Calkin, S. (2012, September 4). Nurses left to fill gaps in cleaning. Nursing Times.net. Retrieved from http://www.nursingtimes.net/nursing-practice/clinical-zones/infection-control/nurses-left-to-fill-gaps-in-cleaning/5048827.article

Holder, C. (2009, November). Daily bathing with chlorhexidine in the ICU to prevent central line–associated bloodstream infections. Journal of Clinical Outcomes Management, 16(11), 509-513.

Kaminski, J. (2013, June 5). Theory applied to informatics – Lewin’s Change Theory.Canadian Journal of Nursing Informatics, 8(1-2), Retrieved from http://cjni.net/journal/?p=1210

Stokowski, L. A. (2010, August 4). Chlorhexidine in healthcare: Your questions answered. Medscape Today. Retrieved from http://www.medscape.com/viewarticle/726075