Exploration of Dutch Intensive Care Nurses' Experience of Planned or Emergent Change Implementation of an Innovation
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Session presented on Friday, July 25, 2014: Purpose: Workplace empowerment is considered an important magnet hospital characteristic, which is also related to patient outcomes and job satisfaction (Upenieks 2003 , Laschinger & Havens 1997). Armstrong (2006) described workplace empowerment as workplace structural factors related to nurses' ability to function with autonomy and make decisions about their practice, i.e. how to implement their practice. In implementation science, Burnes (1996), Bamford and Forrester (2003) divide implementation approaches for innovations into two types. They distinguish planned change implementation and emergent change implementation. The crucial difference between these types is staff members' participation in the implementation process and in the construction of the final innovation. In planned change implementation approach, there is no such participation, it is 'a pre-planned and centrally-directed process'(Burnes 1996). In emergent change implementation approach, the goal to aim for is put forward by management to the staff members. The staff members are invited to participate in finding ways to achieve the goal. Magnet hospital research seems to indicate that an emergent change implementation would provide more workplace empowerment than planned change implementation and therefore be more attractive for nurses as a working method. The aim of this study was to describe the intensive care nurses' experience of the introduction of an innovation using either implementation approach and to identify what aspects were positively or negatively valued. Methods: An innovation was implemented in two groups (teams) of nurses using planned change implementation in one team and emergent change implementation in the other team. The two teams were part of one intensive care unit with two spatially separated wings. The patients were admitted to either wing at random. The innovation was an intensive insulin therapy (IIT) for the treatment of high blood glucose values in intensive care unit (ICU) patients. This IIT described how ICU-nurses' treatment can bring about the desired effect for the patient. The IIT was self directing, which entailed that the ICU-nurses made their own decisions to initiate, change and stop the intravenous insulin administration and check the blood glucose values with the help of a treatment protocol. This self directing was a new feature in this ICU. In one team (planned change team) a planned change implementation approach was used, in the other (emergent change team) an emergent change implementation approach. The members of the emergent change team were invited to propose changes to the protocol while the members of the planned change team were not given the opportunity to change the protocol. The effectiveness of the IIT in both teams on patient blood glucose control and nurse compliance are described elsewhere and show a slightly better patient blood glucose control and better nurse compliance in the ECteam. (Luiking et al 2013) The resulting differences of both implementation approaches in the nurses' professional clinical autonomy and personal values and norms are also described elsewhere, and show an increase in the nurses' professional clinical autonomy in the emergent change team and a decrease in the planned change team. The personal values and norms in the teams showed changes in line with the implementation approach applied in the team (Article submitted). Thereafter 8 nurses from either group were interviewed. A qualitative content analysis was done of these semi-structured interviews. The found positive and negative appreciation subcategories were further quantitative analysed using quantitizing. Quantitizing involves the transformation of qualitative date esp. qualitative themes to numerical form. This quantitizing was done using frequency manifest effect sizes. Frequency manifest effect sizes represent the prevalence rates of themes or observations in a qualitative study. They can be used to compare prevalence rates of themes or observations in (sub)groups of participants. Results: The 5 inductive categories emerging from the interviews were: perception of the innovation, of the implementation, of the implementation and innovation as a responsibility for the nurses, of the influence on the profession and of the influence on the team. The experiences of the innovation and implementation was in line with the character of the implementation approach. A striking example of this is the way the nurses worded the nurses' role in this innovation. In the emergent change team the nurses' role was described as achieving better patient results. It was described that the protocol had to be followed: 'The innovation is nice, because you know exactly what is to come and you know what you have to focus upon'. But it was also described that getting better patient results was more important than exactly adhering to the written down protocol: 'you have to adapt the treatment but not according to the exact protocol', because: ' I know that if I adhere to the protocol in that way, the patient will develop hypoglycaemias or hyperglycaemias' [complications]. In the planned change team the adherence to the exact wording of the protocol was emphasized: 'Look on the list [protocol], this is the glucose value, so that's what you have to do.' Both groups had similar views upon what they considered important in their work, e.g. the feeling of being supported by management was important to the nurses. The quantitizing showed a higher ratio of positive than negative appreciation statements in the emergent change group for the subcategories perception of the innovation (Chi square=5.156, p= 0.023), of the implementation (Chi square=26.381, p<0.0001)and of the implementation and innovation as a responsibility of the nurses (Chi square=52.846, p< 0.0001). Conclusion: In the planned change group innovations and their implementation were seen as the responsibility of the management. In the emergent change group it was seen as a shared responsibility. In the emergent change group it was in line with how Burnes (1996) described the goal for using emergent change: 'developing a workforce that will take responsibility for identifying the need for change and implementing it'. Thus emergent change implementation provided increased workplace empowerment to the nurses. The quantitizing of the statements in the interviews indicated that the emergent change implementation was more attractive for the nurses. This seems to corroborate the magnet hospital research which indicated that an emergent change implementation would provide more workplace empowerment than planned change implementation and therefore would be more attractive for the nurses as a working method. Although support by management in the two implementation approaches was very different. It was considered important irrespective of the specific type of support provided.