by Meaghan MacDonald, RN, BScN
Registered Nurse, Queen Elizabeth Hospital, Prince Edward Island
MSN Student, Memorial University of Newfoundland and Labrador
Registered nurses entering the critical care area after graduation from a baccalaureate program, have many learning needs as they seek to integrate into the nursing workforce. These beginning nurses must continue to refine their basic entry-level competencies while attempting to learn new complex nursing skills and techniques. Critical care presents many challenges even for the seasoned nurse thus orientation to this setting requires a tailored approach for new graduate nurses. A review of the literature demonstrated that the use of computers for orientation and education can be beneficial and cost effective often offering the same value as classroom learning. This proposed nursing informatics project will seek to (a) enhance graduate nurses’ orientation to the critical care setting, (b) support new graduate nurses while supplementing their education and (c) increase professional communication through the use of information technology. These goals will be accomplished by developing a wiki website tailored to the needs of graduate nurses entering the critical care setting. The seven stages of Lippitt’s theory of planned change are explored as they apply to the implementation of the project. The anticipated barriers and facilitating factors associated with implementing a new form of information technology into the workplace of nurses will also be explored.
Graduate Nurses, Computers, Change Management, Wiki, Critical Care, Orientation, Lippitt’s theory of planned change
Registered nurses entering the workforce today are required to possess a wide array of skills in order to function as beginning professionals. The learning curve is certainly not complete when they receive their baccalaureate degree. In fact, the learning is just commencing for these graduate nurses as they embark on a career path fraught with issues, including nursing shortages, health care reform, advancements in technology and an aging population with increased health care needs. The purpose of this paper is to present a hypothetical nursing informatics project to implement in my workplace to enhance the current orientation of graduate nurses in the critical care setting. I currently work in the critical care setting and act as a preceptor for new employees including new graduate nurses entering this specialised area. I believe that new graduate nurses entering this setting require a large amount of support and guidance to function effectively and safely. Not only do they need to further develop their basic entry-level competencies, but they are also expected to learn many complex nursing skills while functioning under high stress and pressure conditions. I believe the development of a wiki website that is specific to the requirements of working in the areas of intensive care, coronary care and progressive care, may help these beginning nurses to transition more smoothly into the workforce.
Using Lippitt’s theory of planned change (Lippitt, Watson & Westley, 1958), I explain the proposed project and discuss the anticipated barriers and facilitating factors associated with implementing a new form of information technology into the workplace of nurses. The seven stages of Lippitt’s theory of planned change are explored as they apply to the implementation of the project. The work of Lippitt was greatly influenced by Kurt Lewin and therefore, the key aspects from Lewin’s theorizations are touched upon within this paper. For the purpose of this paper, the term “graduate nurse” will refer to nurses who have recently graduated from a baccalaureate degree program and are entering the critical care setting as their first position.
According to Travale (2007) the area of critical care is most affected by the nursing shortage. By necessity, less experienced nurses are entering this area with little experience in the basics of medical-surgical nursing. They require a creative means of education and teaching tailored to this unique situation. Travale (2007) states: “An inexperienced nurse’s knowledge is theory based because he or she lacks the wisdom that defines an experienced nurse. Targeted education needs to be progressive to engage this computer-savvy generation in learning” (p. 132).
Chestnutt and Everhart (2007) also discussed the nursing shortage and the inability to fill positions with experienced nurses. They described these new graduates as “advanced beginners” in critical care who are often oriented toward completing tasks and find it difficult to adapt to rapidly changing clinical situations (Chestnutt & Everhart, 2007). It is therefore essential that graduate nurses entering the critical care area receive appropriate orientation that meets their needs, provides support and fosters an effort for retention of trained professionals. It is not only new graduates that are affected by the shortage in nursing either. Billings et al. (2006) suggested that the shortage of nurses also spills over into academia and impacts nursing faculty and educators. These authors claimed that a useful way to simplify orientation and capitalize on educator resources, is to offer online courses.
Travale (2007) advocates that the use of computer assisted instruction (CAI) can be used to bridge the gap for novice nurses between basic curriculum knowledge gained in the university setting and orientation practices, by acting as an adjunct to their knowledge development. The term CAI is used to include a wide array of technologically based tools such as multimedia programs, internet based learning, and chat rooms to name a few (Letterie 2003, as cited in Travale, 2007).
Nerlich (1995) also discussed the use of computers for learning under the title of computer assisted learning (CAL). CAL is defined as, “Any learning that is mediated by a computer and which requires no direct interaction between the user and a human instructor in order to run” (Nerlich, 1995, p. 23). It can be used as a sole learning tool or in conjunction with verbal and printed learning tools. According to Nerlich (1995), in comparison to alternative education methods, CAL has offered the same degree of knowledge retention and provides easily accessible information that can be obtained 24 hours a day through the use of a computer. Nerlich (1995) suggested that educators can save the expense of commercial CAL packages by authoring their own CAL tools. This is an ideal suggestion and the new era of technological advancements that we are currently experiencing, has brought about the use of social interaction tools including blogs and wikis.
Wikis are defined as: “Collaborative websites, created and maintained by groups of people with specific interests” (Varga-Atkins, Dangerfield & Brigden, 2010, p. 825). The word wiki comes from the Hawaiian word meaning ‘quick’ and it is estimated that there are several million of these sites although it is not possible to know exactly how many there are due to the lack of an appropriate search engine for this type of site (Sandars, 2006). There is evidence from published research that demonstrates the usefulness of the wiki for educational purposes in undergraduate nursing education. According to Morley (2012), 45 percent of nursing students who participated in a wiki that was part of a complementary learning technique, felt that the wiki was a useful way to communicate with other students. Thirty-three percent of nursing students felt that the wiki fostered information sharing among group members. According to Varga-Atkins et al. (2010) the phenomenon of using wikis for educational purposes was found to enhance medical students’ learning in two ways. In the first instance, they were able to use the wiki as a means for information sharing related to professionalism. Second, medical students were able to develop their professional identity through interactions they had with other students. This demonstrated that although many students in today’s era of technology participate in online social media, participating in a wiki dedicated to a professional endeavor held a different meaning to students than participating in social networking sites like Twitter© or Facebook©.
As presented in the literature, the use of a wiki can serve a variety of purposes. In the proposed nursing informatics project, I seek to develop a wiki that supplements educational materials that have already been put in place in the critical care setting. Presently, graduate nurses are placed with a preceptor for a minimum of six weeks, attend a three-day cardiac education course, a two- day general nursing orientation, and are given a USB flash drive with pertinent articles and information to review. They must pass a three hour exam based on the information given to them along with an electrocardiogram analysis exam in order to be covered to work in the telemetry section of progressive care. There are a series of modules for the intensive care unit that are completed at the learner’s convenience and once this is accomplished, the graduate nurse is able to attend ‘code blue’ calls within the hospital as a junior staff member when patients require cardiopulmonary resuscitation. They also require certifications in basic life support and advanced cardiac life support prior to attending ‘code blue’ calls. Throughout the orientation process, there is ongoing direction from preceptors and patient assignments are coordinated with the skill level of the graduate nurse in mind.
Recently, within my workplace, there has been a large turnover of experienced staff and an influx of new nurses with a background in medical surgical nursing, and also graduate nurses who are ‘fresh’ from nursing school education at baccalaureate level. The staff consists of an all RN complement with support staff of ward clerks for clerical duties. The development of a wiki website may provide nurses working within these critical care areas with education material, links to pertinent websites and online audiovisual aids and provide a means of interacting with other staff members. The use of a wiki can be protected with password protection or also can be made available to the public (Billings & Kowalski, 2009). For the purposes of this project, only nursing staff working in the areas of intensive care, coronary care and progressive care units would be able to access the information.
Wiki content can be created, customized, and altered by the participating users (Sandars, 2007). The importance of referencing and providing trustworthy information from respected sites and material would be stressed on the main page of the site. Confidentiality would also have to be addressed with employees. The site would be monitored by myself, the creator and the content would be directed by the nurse educator for the unit in conjunction with the staffs’ identified learning needs. This is what makes the wiki valuable, as it provides a means of communication and creation of learning opportunities for everyone involved (Sandars, 2007). Another very good advantage of a wiki for health care education is that it offers a means of communication between employees working in the same area who may otherwise never come into contact. For example, the shift schedule is divided into two day shifts, followed by two night shifts, then four-five shifts off. Certain nurses end up working together on an ongoing basis and may not see or interact with other nurses due to scheduling. The wiki would create interaction between the various shifts and foster communication between employees. In contrast to using e-mail to remain in contact with other employees regarding pertinent information for education and updating on policies and protocols, a wiki provides a means of easily storing messages and links to documents by date (Sandars, 2007). The wiki can be set-up free of charge using common software packages such as PBWiki (as cited in Sandars, 2007).
According to Billings and Kowalski (2009) nurse educators can use wikis to facilitate teaching and learning in a wide array of clinical practice settings. For example, a wiki can be utilized to develop an orientation manual with nursing departments contributing pertinent information specific to the area of practice. The authors also described how a wiki can be used for continuing education in the form of a syllabus, research and protocol documents, learning activities and evaluation materials. It is easy to envision that the possibilities are vast and diverse so it is imperative that the wiki be developed with the needs of the staff involved. Sandars (2006) stressed this fact and encouraged users to be clear on why they want to use a blog or wiki to direct learning. The convenience of a wiki according to Sandars (2006) is that it offers a low degree of technology that can be linked to other sources such as websites, text and audio. This is very appropriate for the purposes of this project as the technology should be simple and easy to use while providing optimal learning resources for critical care nursing.
The change management theory that will guide the implementation of the proposed informatics project is Lippitt’s theory of planned change (Lippitt et al., 1958). According to Geraci (1997), Lippitt’s model builds on the work of Kurt Lewin by concentrating on problem solving and interpersonal domains of the change process. Lippitt et al. (1958) claimed that Lewin was a pioneer in change theory with his development of the three phases of the change process. These stages are described as unfreezing, moving and freezing (Lehman, 2008). The criticisms of Lewin’s theory have been that it is incomplete and it relies heavily on upper management carrying out a change and further, that is does not involve key stake holders in the process of change (Tiffany et al. as cited in Lehman (2008).
Geraci (1997) defined the seven phases of Lippitt’s theory as:
(a) diagnosing the problem;
(b) assessing the motivation and capacity for change;
(c) assessing the change agent’s motivations and resources;
(d) selecting progressive change objectives;
(e) choosing the appropriate role for the change agent;
(f) maintaining the change once it has started; and
(g) ending the helping relationship.
In Lippitt et al.’s (1958) book The dynamics of planned change, the stages are referred to as:
(a) development of a need for change,
(b) establishment of a change relationship,
(c) working toward change,
(d) the clarification or diagnosis of client systems problem,
(e) the examination of alternative routes and goals/establishing goals and intentions of action,
(f) transformation of intentions into actual change efforts, and
(g) the generalization and stabilization of change and achieving a terminal relationship.
There is some discrepancy between how Geraci (1997) and Lippitt et al. (1958) chose to refer to the nonclementure of the seven phases of change. Based on my assessment, the phases appear to be the same and entail similar objectives but are described using different terminology. Gercaci (1997) offered that the seven step process of Lippitt’s theory aligns well with what nurses know as the nursing process for problem solving and that the theory can be applied to just about any setting in nursing practice. This was the main motivation for choosing the theory to guide the current project. To explain the process of change for the purposes of this paper, Lippitt’s original work and terminology will be used.
This stage of the change process can occur in a few different ways. According to Lippitt et al. (1958) this stage will align with what Lewin described as ‘unfreezing’. More specifically Lippitt et al. describes three ways in which this first phase might occur. In the first instance, a change agent may notice that an intervention or change would benefit the system or person and offers assistance or opens a dialogue to make others aware of the situation. Second, a third party that is related to the change agent and the potential group affected by the change brings the two parties together. Third, a person or group in need of assistance seeks help from an outside source. In the case of the present project proposal, the first scenario would most closely coincide with the situation since I am the change agent hypothesizing about the change I would like to put in place. According to Lippitt et al. (1958) a change agent is simply defined as an individual from any type of system who seeks to help a situation by offering their skill set. As the change agent I will have to be aware of the forces that influence the process of change. Lippitt et al. (1958) refers to the forces that resist change or favor change respectively as, resistance forces and change forces.
Lippitt et al. (1958) stated, “Maintaining a favorable balance of forces is a continuous job for the change agent and client system, beginning with the initial decision to undertake a change project or helping relationship and continuing until the project has been completed” (p. 73).
The goals of the project would be to (a) enhance graduate nurses’ orientation to critical care setting, (b) support new graduate nurses while supplementing their education, and (c) increase professional communication through information technology. This initial stage would involve approaching the department nurse educator and nurse manager to discuss how this proposal could be integrated into the current orientation of new graduate nurses to critical care. Their support and awareness of the benefits that this project could offer to new graduates and staff would be the primary focus of the unfreezing phase as they manage this process for the most part. After the support of the key stakeholders is obtained (nurse educator and nurse manager), I would then move on to the second stage of the change process.
This second phase involves the change agent (myself) gaining the trust of the group at my work setting in order to proceed with the project. According to Lippitt et al. (1958) an important aspect of this stage is how the group perceives the change agent and the potential change.
“What the client system really wants is two change agents in one. It wants an agent who will identify himself with the client system’s problems and sympathize with the system’s needs and values, but who will at the same time be neutral enough to take a genuinely objective and different view of the system’s predicament” (p. 134).
I believe that this stage needs to be approached in a sensitive and appropriate manner. Due to the fact that I am a nurse and able to identify with the work setting and also that this change is meant to enhance learning and support workers, I anticipate being able to gain access and trust from the group quite readily. The recipients of this project – new graduate nurses, will hopefully be open to acquiring the best possible orientation and take advantage of the resources being provided. The one barrier that I foresee here is potential information overload as they are given a wealth of information related to their new nursing positions. This will have to be considered in respect of the optimal timing to introduce the wiki to their practice and education in the critical care setting.
According to Lippitt et al (1958), working toward change encompasses stages three, four and five, which coincides with Lewin’s second stage labelled ‘moving’. For the purpose of this third stage, information must be collected regarding the situation in the workplace and why the project would benefit staff. It has already been identified that there is plethora of very junior staff in the unit and that support and ongoing education is a priority. Being a staff member and acting as a preceptor for some of these employees puts me in an ideal position to interact with and obtain information about what their needs are. A meeting to discuss what staff would like to have offered within the wiki would be beneficial so that they feel they are participants in the process. If a meeting were to take place I believe a brief presentation on what a wiki is and how it works would be beneficial for staff. This would give me the opportunity to provide rationale and state the benefits of its use. The meetings would be targeted towards new graduates but all staff would be welcome.
Within this phase the group will begin to formulate ideas about the change. Lippitt et al. (1958) cautioned that problems related to motivation may arise when the group starts to formulate actual intentions and specified actions. These problems with motivation occur in many cases due to anxiety about the change or fear of failure. The authors offered that a trial procedure involving the change may help to alleviate these anxieties and foster the adoption of the idea. In the case of the informatics project of developing a wiki to enhance orientation, it is my hope that once staff members become aware of how this new way of learning can enrich their practice and increase their knowledge base that they will be more willing to accept it. Also, recent graduates may have experience with the technology already and be able to offer information on past experiences, and assist in helping with the implementation of the project.
During this phase, the change agent works to ensure that the staff feel supported and encouraged to work towards actual efforts based on their intentions. For this project it would be the actual creation of the wiki, followed by an active demonstration of an activity that could be performed on the site. An example activity could be to provide a link to a website where answers to clinical practice questions are found. It would be very brief but informative in order to display simplicity and applicability to the work setting. I envision providing links to pertinent clinical skills or techniques as well as links to articles for current practice that will provide best practice guidelines and evidence for clinical interventions. Links to visual aids and websites are possible when using a wiki (Sandars, 2006). Videos of procedures would also be helpful for new graduates who do not get to experience assisting with a procedure during their orientation. For instance, it is possible to view procedures such as innovative surgeries or insertion of a central lines and temporary pacing wires on websites such as Youtube©. This can give the learner a visual aid so that when they are faced with this in practice they at least have the knowledge and visual recall of what takes place during a procedure though they may not have the hands on experience.
During the implementation of the informatics project the focus will be to target new graduate nurses entering critical care to enhance their orientation. If the project is well received it is my hope that the inclusion of this piece of information technology into the orientation could also be useful for other employees entering the critical care setting with no prior critical care experience. It may also benefit existing staff as a resource to review material and use audio visual aids to review a procedure that they have not encountered in quite some time.
According to Lippitt et al. (1958), “One critical factor in the stabilization of change is the spread or non-spread of change to neighboring systems or to subparts of the client system” (p. 140).
If the use of a wiki in my workplace spreads from the target group of new graduate nurses to other staff members, this would signify to me that stabilization of the intervention is occurring.
According to Lippitt et al. (1958) the termination of the change agent’s involvement in the change process can end as early as the third phase of the change process. Therefore the issues that may arise during this phase are dependent on when the relationship ends. Many of the issues that are able to occur within phase two (establishment of a change relationship) may occur, taking into account that the goal of a project is for the group to become completely independent of the change agent or to continue to be in consultation with the change agent.
For the purposes of this project, and taking into account that I am a staff member as well as the creator of the site, I will have to have an ongoing involvement and relationship with the group/staff as well as nurse educator and nurse manager. However, the goal behind a wiki is that it becomes a way to contribute to discussion and share knowledge. According to Sandars (2007) a wiki allows content to be directly altered or edited by users of a site. As time goes on, and staff members become more comfortable using the wiki, I envision nurses contributing their knowledge and participating more readily in discussion about ways to enhance education and practice in critical care nursing.
According to Bozak (2003) in order to decrease resistance and favour adaption to change, a well formulated strategy is essential. In the proposed project, I discussed an endeavor to encourage staff involvement in the process and offer opportunities to enhance learning during the challenging time of orientation for new graduate nurses in critical care. Lippitt’s model offers a comprehensive seven stage process that closely aligns with the nursing process and is appropriate for a variety of settings. Being astute to the needs of staff as well as the barriers and facilitators to change that may be encountered is paramount for moving this initiative forward. Adapting to these factors during the change process will be an ongoing endeavor that requires a constant interaction with key stakeholders in the work setting. As a staff member, I am already in a position to be able to interact with staff regarding the project. I foresee that this project may be a valuable learning opportunity for new graduate nurses that could enhance their orientation experience and promote a smoother transition in a challenging practice area.
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Meaghan MacDonald is a registered nurse working in the critical area at the Queen Elizabeth Hospital in Charlottetown, PEI. She pursues part-time distance education at the Masters level through Memorial University of NewFoundland. Her long-term goals are to complete her master degree and eventually become a Geriatric Nurse Practitioner.