Lippitt Theory of Change Paper

Implementing Planned Change on Surgical Unit

Krishna Amin

Rush University College of Nursing

Implementing Planned Change on Surgical Unit

            While in an acute hospital setting, patients are an increased fall risk due to their general disposition and current state of health. According to The Joint Commission (2015), the United States has hundreds of thousands of patients falls a year, with over 50% of falls resulting in injury. Falls can increase a patient’s length of stay, require alteration in current treatment course and additional care for the fall injury (The Joint Commission, 2015). Interventions and safety measures can be completed to decrease the risk of a patient falling.

Problem Definition and System-Level Change

Patient falls is a current problem at Rush University Medical Center (RUMC) on 12 East Tower, a spine/CVT/neuro surgical unit. Unit data demonstrates a problem regarding the high number of patient falls in the presence of patient care techs (PCT) and nursing assistants (NA), in addition to an increase in patient falls during early hours of the morning (between 2am-5am), during this ongoing fiscal year (FY16-17).

Unit Data

Data collected between July 2016 to December 2016 show there has been a 34% increase in falls on 12 East when compared to July-December 2015. It is additionally noted that 63% of patients who fell were identified as “Moderate” fall risks and 56% of falls happened with toileting between the hours of 02:00AM and 05:00AM. Anecdotal evidence obtained from management on 12 East indicates a factor contributing to the increased number of falls was inappropriate use, or lack of use of safety equipment like gait belts and stand assist devices (Stedy, Sara Stedy).

Literature Support

The patient population is to be taken into consideration when evaluating the importance of patient falls. The unit population is comprised of predominantly surgical patients, and those with advancing age. Literary evidence supports that older adults, and surgical patients are at a higher risk for falls. A study completed by Lakatos et al. (2011) analyzed 252 adult inpatients who fell between April 2009 and June 2009. They found that 74% of the studied population were over the age of 75, additionally, 54% of the total fall population were surgical patients (Lakatos et al., 2011).  RUMC 12 East identified there was an increase rate of falls in the presence of patient care techs (PCT) or nursing assistants (NA).  Literature provides supportive evidence of staffing association with increased rates of falls.  It was found that an additional patient care hour with a registered nurse, decreased fall rates by 3 percent in non-ICUs (Lake et al., 2010). In contrast, it was found that an additional patient care hour with a PCT or NA in a non-ICU actually showed a 2-4% increase in fall rates.

Proposed Change

An appropriate response to the increased number of falls on RUMC 12 East, would be to implement additional measures to reduce circumstances leading to falls. The proposed change includes providing education to night staff (1900-0700AM) on the use of gait belts and standing assist devices. The education would be provided to all levels of nursing staff and in addition to PCTs and NAs. It would include indications and contraindications to using the equipment, specific to surgical patients. This would allow staff to be comfortable using the devices to aid in patient transport and ambulation. In an effort to address the increased number of falls occurring during toileting, an increased amount of purposeful and timely rounding specific to toileting will occur. This will decrease the amount of call lights activated to toilet and reduce the amount of time it takes for a nurse to physically respond to a toileting request. This purposeful rounding will also decrease the risk of patients attempting to ambulate themselves to use the bathroom. Daniels (2016) assessed the implementation of purposeful rounding and its effects on patient satisfaction, patient safety and nursing compliance.  The use of intentional rounding with purposeful questioning pertaining to toileting increased responsiveness of staff to toileting needs by 15%, in addition to an increase in actual toileting by 41% (Daniels, 2016). This had a positive effect on reducing falls by patient falls decreasing by 50% during the intervention period. A negative effect of intentional rounding with purposeful questioning regarding toileting, was that patient restfulness and sleeping periods were interrupted hourly and patient satisfaction in this regard decreased by 18% (Daniels, 2016). The Institute for Healthcare Improvement (IHI) endorsed hourly rounding as the best way to reduce call lights and fall injuries, and increase both quality of care and patient satisfaction. Evidence supports purposeful rounding can aid in decreasing number of falls (Daniels, 2016).  

Change Theory

In order to apply effective change there are many steps that need to take place prior. Therefore, careful consideration and planning should take place in the appropriate context. The theoretical framework that can help guide the proposed change is Lippitt’s Change Theory. Lippitt’s Change Theory is comprised of the following seven phases:

1. Diagnosing the problem.
2. Assessing motivation and capacity for change.
3. Assessing change agent’s motivation and available resources.
4. Selecting progressive change objectives.
5. Choosing appropriate role of the change agent.
6. Maintain change.
7. Terminate the helping relationship (Mitchell, 2013, p. 33).

Lippitt’s Change Theory is an effective tool in implementing change, it requires democratic leadership and supportive culture to be operative (Mitchell, 2013, p. 33). The seven phases of the change theory are rooted in the four stages of the nursing process; assessment, planning, implementation, and evaluation (Mitchell, 2013, p. 33).

The first phase of Lippitt’s change theory involves setting up the framework for the desired change. It requires a detailed plan of the change and also an assessment of all those implementing and affected by the desired change (Mitchel, 2013, p. 35).  Once a detailed plan has been established it should be dispersed to all involved individuals. Additionally, the plan should include a detailed time schedule of implementation. Establishing a timeline would allow for deadlines to be met and increase the likelihood of success (Mitchell, 2013, p. 35)

Phase two of Lippitt’s change theory involves assessing the involved party’s capacity for change and their motivation. In order to complete that assessment, it requires effective communication to take place between those implementing, evaluating and experiencing the change. The barriers that might deter motivation of the involved party should be assessed as well, barriers can halt change and slow growth. It is important to know that resistance to change is always expected, this is primarily due to the general discourse of stress that change brings about in human nature (Mitchell, 2013, p.35)

Phase three addresses the change agent’s motivation for implementation. The change agent can be management or a third party. Essentially, it needs to be determined if the change agent is able to implement the determined plan (Mitchell, 2013 pg. 36). Additionally, the involved party’s perceptions of the change agent should be assessed. This is important because will not impose another barrier to motivation for change.

Phase four is the planning stage, the previous steps should have defined the problem and established the process. At this phase, adjustments identified in previous phases are made and the plan is finalized (Mitchell, 2013, pg. 36). The change agent assigned responsibilities to individuals and assessments are made to ensure individuals are capable of assuming said responsibilities.

Phase five builds on the responsibilities defined in the previous phase, but it is focused on the change agent. The role of the change agent is defined and all individuals are informed so to maintain transparency. The next phase, six, involves implementation of the nursing process. The change agents push change, and encourage motivation in the individuals to ensure that change is maintained. The implementation should encourage the change becoming part of the system (Mitchell, 2013,p. 36)

The final phase terminates the helping relationship, at this phase the change should be incorporated into the system, change is being maintained and is effective (Mitchell, 2013, pg. 37). The change agent can withdraw from their role progressively in order to allow for stakeholders to maintain change independently. At this final phase, the change should be made permanent and established policies should be followed.

Rationale

Lippitt’s Change Theory has potential to be extremely effective on RUMC 12 East, primarily due to the comprehensive nature and need to detail to implement and maintain change. The phases outline specific roles and checkpoints that need to be completed prior to proceeding to the next phase.  Lippitt’s theory focuses on a change agent that ensures that goals and objectives are met adequately, therefore it is appropriate to state that Lippitt’s Change Theory is goal directed.  This would allow for permanent change to take place in terms of reducing falls on 12 East and an increase in purposeful rounding. Lippitt’s theory assesses and addresses potential problems that arise during the phases, this is in contrast to other theoretical frameworks that address problems retroactively (Mitchell, 2013 p.36).  Additionally, this framework is appropriate because it takes into account personal factors that influence change. This allows for flow between phases due to personal, social and environmental factors that can influence change, this will also allow for movement back phases to correct and adapt to any issues the change agent identifies.

The proposed change intervention is a categorical first order change. A first order change involves a step-by-step process with intentional planning and processing (Garon, 2014). The proposed change will not influence the entire organization, but will impact the unit as a whole. It is hoped after the proposed change is completed and evaluated, that neighboring units will adopt the change. The proposed change is an adaptation to current practice in order to increase patient safety, decrease patient falls and promote purposeful rounding in addition to intentional rounding by nursing staff.

Unit culture on RUMC 12 East and the organization of RUMC itself contains elements that can help establish change but also includes barriers to change. Rush University Medical Center has a shared governance model for their Professional Nursing Staff (PNS), this allows nurses to have a voice, influence and impact quality of care in their environment (Rush University, 2016). The advantages the PNS shared governance model has specific to the proposed change, is that it allows nurses to be vocal about what will influence their professional practice, in addition to collaborating with the change agent to ensure that said change will have a positive effect on patient care and safety.  The shared governance model promotes professional nursing staff to be involved on their respective units and have an influence on their care and environment, this invests the staff in common goals and objectives and allows to increased buy in from staff to adopt change (Rush, 2016). 

Barriers to change can be identified though through evaluation and assessment by the change agent, this can be done during phase two of Lippitt’s Change Theory. Completing an assessment for barriers to said change will afford the change agent an opportunity to collaborate and discuss issues with nursing staff.  The change agent is responsible for addressing the barriers that are pin-pointed and doing so will open up communication and collaboration with nursing staff, further investing them into the proposed change.

Managing Change

A literature review has demonstrated that Lippitt’s Change Theory has proven to be effective in acute care settings, in addition to specific surgical environments. Ward (2015) completed a study in an acute care hospital setting, to assess fall risk identification and the utilization of a fall prevention program to decrease the number of falls on a general medicine unit. They utilized Lippitt’s theoretical framework to implement a multidisciplinary fall prevention program. Ward (2015) found that utilizing fall prevention tools specific to age of the patient were effective at accurately identifying fall risk and decrease the number of falls a patient’s experienced with or without injury.  Patients who completed the age specific fall prevention tool experienced a 13% decrease in falls over a 12-month period, 68% of patients who fell, had the incident occur in an acute care setting (Ward, 2015). Lippitt’s framework demonstrated an increased aptitude to implement a planned and purposeful change to increase patient safety.

Another study completed by Dykes, Carroll and Hurley (2011) assessed the implementation of a standardized fall prevention tool across four surgical units in four hospitals. Lippitt’s theoretical framework was utilized to implement and preserve the change. The study was a randomized control trial with 5160 patients between 23 and 77 years of age.  The fall prevention tool was implemented over a 6-month period, the units found that the use of Lippitt’s theoretical framework aided in identifying and combating barriers to preventing falls. They found through communication and collaboration with the nurses that fall risk assessments were not completed at the same time each shift and were sometimes missed based on time of admission (Dykes et al., 2011). Therefore, patients were not being correctly identified as fall risks. The new fall assessment tool was implemented per the phases of Lippitt’s theoretical framework. Dykes et al. (2011) found that there was a significant decrease in the number of falls per 1000 patient care days with the use of the new fall prevention tool. 

Legal and Ethical Implications

Legal

            Patient falls has sizable legal implications on an institution and healthcare provider. When a patient falls, the safety of the patient has been compromised. The consequences of a fall can be immense and can result in serious injury, harm or death of a patient. Additionally, the institution can be held liable and have a legal suit filed against them. Finally, the question remains, who pays when a patient falls? Certain insurance companies do not reimburse hospitals if medical mistakes could have been prevented (Bulletin of World Health Organization, 2009). Medicare is a current example of aforementioned statement; a preventable mistake would be an injury due to a fall.  Falls are a costly result of a fault in patient safety, but is also a commonly argued dilemma in ensuring patient safety without restricting a patient. The Joint Commission (2015) estimates a cost of $14,000 per patient for injuries related to a fall. They also found that common sentinel events related to fall were inadequate assessments, communication failures, failure to adhere to protocols, and deficiencies in physical environment (Joint Commission, 2015).

Ethical

An ethical principle that is involved in the planned change to increase patient safety and decrease falls is autonomy. Autonomy is the patients right to make decision, to choose and to have self- determination (Cooper, 2014, p. 103). A patient has the right not to call for help when standing up or ambulating, they have the right to decide if they need assistance or not. This is regardless of the healthcare provider’s opinion of need of assistance or monitoring. While the choices a patient’s makes, under the ethical principle of autonomy, may increase the chance of injury due to falls, they must still be respected. This presents an ethical dilemma; a nurse must strive to maintain a patient’s autonomy whilst ensuring patient safety. This can be completed by fully informing and educating the patient. A nurse can explain to the patient the importance of utilizing the call light, inform the patient of the risks and consequences pertaining to falls, in additions to alterations in care after a fall (American Nurses Association, 2016).  A dynamic nurse-patient relationship with a foundation of trust, respect and accountability aid in maintaining patient autonomy.

Conclusion

            Lippitt’s Change Theory is goal oriented, planned and purposeful in its phases. This allows for effective change to be implemented in group settings. The problem lies in an increased number of falls at Rush University Medical Center on 12 East Tower, which is a surgical unit. The increased number of falls has been identified in the presence of Patient Care Technicians and Nursing Assistants, in addition to an increased number of falls between the hours of 2AM and 5AM. The proposed change would include educating night staff members on the use of gait belts and assistive standing devices. Additionally, purposeful rounding will be implemented to address the additional problem of falls occurring on toileting. Purposeful rounding will be added to intentional rounding by asking toileting specific questions to alleviate potential patient urgency.  Lippitt’s framework includes detailed phases and a change agent to aid in implementing change. The change agent is a vital part of the unit, and assesses all potential barriers and areas of need. Lippitt’s Change Theory allows for the inclusion of personal, social and environmental factors in phases, in addition to progressive movement between phases. Lippitt’s theoretical framework will be contributory in progressive change to increase patient safety and decreasing falls.

References

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Cooper, R.W. (2014). Legal and ethical issues. In D. Huber (Ed.), Leadership and nursing care management (5^th ed. pp. 94-102). St Louis: Elsevier.

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Garon, M. (2014). Change and innovation. D. Huber (Ed.), Leadership and nursing care management (5^th ed. pp. 37-43). St Louis: Elsevier.     

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Lakatos, B. E., Capasso, V., Mitchell, M. T., Kilroy, S. M., Lussier Cushing, M., Sumner, L., ... Stern, T. A. (2009). Falls in the general hospital: association with delirium, advanced age, and specific surgical procedures. Psychosomatics, 50(3), 218-226.

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Rush University (2016). Shared Governance. Retrieved from https://www.rush.edu/health-care-professionals/nursing-rush/about-rush-nursing/nursing-practice-rush-university-medical

The Joint Commission. (2015). Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert, (55).

Ward, K. (2015). Interdisciplinary assessment and intervention tools for fall prevention in decreasing fall rates. ProQuest Acute Care Journals. doi:1591642

When the patient falls out of bed, who pays? (2009). Bulletin of the World Health Organization, 87(3), 169–170. http://doi.org/10.2471/BLT.09.030309