There are two aspects to this planned change. The first one is to introduce different uniforms for different staff designations and the second change is to ensure the only people who are referred to as “nurse” are those who are registered or enrolled nurses. It is anticipated that the introduction of a uniform change will be easier than changing the way people refer to each other because a uniform change can be done at a managerial and policy level, whereas ensuring people refer to each other correctly relies on the individuals themselves.
According to Simms, Anderson, and Ervin (1994), a change that involves changing specific behaviors is easier to implement than one involving underlying beliefs and values. Many of the care associates at this elder care facility may like being called nurse, with all of the implications associated with being a nurse as opposed to being a care associate. Certainly none of them seem to correct anyone who does call them nurse, so the change agent could probably expect more resistance to this change than to the uniform change.
The change agent in this facility would probably be the nurse manager, who appears to have a positive pro-active effect on this workplace. She would have to act as a role model and view the change positively. She would accept that there will be initial resistance from some members of the staff and this is a natural response (Clarke, 1994). As part of the unfreezing phase of this change the change agent would explain to the staff that there was a problem and because of this problem there was a need for change.
According to Stephen (1999), staff wearing the same clothes is particularly unsettling to the elderly, and she goes on to say that it is important for nurses to identify their designation as registered nurses. If all staff look the same people may be inadvertently mislead into thinking they were receiving care from a registered nurse when they were actually being cared for by care associates. This deception is further reinforced when all staff are referred to as nurse. It is important for nurses to participate fully in defining themselves in their nursing role and ensure that in a setting where everybody may be regarded as “family”, they stand out.
According to Richardson (1999), nurses are proud to wear their uniform because it identifies them as belonging to the profession of nursing, and indicates responsibility, accountability and education. This is also reflected by the general public, who equate the nurses’ uniform with competence, stability, reliability and professionalism (Richardson, 1999). So it could be concluded that the nurses in the eldercare facility are not declining to wear a uniform that identifies them as nurses, rather they are not being offered one. This could give the change agent a clue as to where she can expect resistance.
As part of the unfreezing phase of this suggested change the change agent may have to coerce the staff to begin the change process. Part of the organisational culture of this facility is the staff regarding an obvious designation of staffing positions as being a ‘hierarchy’, which they appear to view negatively. Staff appeared to be quite satisfied with the status quo and would probably be resistant to the suggestion that a uniform change is necessary. Another factor the change agent may have to consider when proposing a uniform change is the cost of a new uniform and who is going to carry that cost. So the change agent could expect resistance from two avenues – the staff who do not appear to desire a new uniform and the management of the facility who may be reluctant to pay for new different uniforms.
The other issue the change agent will bring to the attention of her staff is that under the Nurses Act, 1977, it is illegal for people to call themselves “nurse” when they are not on the Nursing Council of New Zealand’s register of nurses (Burgess, 1996). Burgess, (1996) goes on to state that the right to call oneself a nurse is a privilege and carries certain obligations. These obligations are not necessarily legislated rather they are considered a social contract between nurses and society. Society has high expectations of nurses and it is important that these expectations are upheld. The care-givers are probably unaware they are violating a law when they refer to themselves and each other as nurse, so informing them of this would be the beginning of the unfreezing process. Part of the unfreezing process may involve creating dissention and making people uncomfortable about working outside the law is one way of beginning the unfreezing process.
In this environment the change agent could begin communicating her desire to make the changes in the weekly newsletter that is circulated to all the staff. She could then follow up by discussing the changes in more formal staff meetings, which would give her the opportunity to clarify the proposal and provide more information to staff. This would have given the staff members enough time to have thought about the changes and how they will be affected by them and they would be given an opportunity ask questions and to voice their opinions at the staff meeting. This would then provide the change agent with a gauge of how the changes may be received and where she may expect resistance.
This is the ‘movement’ phase of Lewin’s change theory, and it is at this phase where individuals may experience the emotional phases associated with change. This is also the phase where the manager and the staff will acknowledge their attitudes and values associated with the proposed change. These can often be seen as barriers to change which the change agent and the individuals will work to overcome.
In the movement phase the change agent will give staff time to voice their opinions regarding the change. Change often upsets individual’s sense of equilibrium, which is maintained by the concurrent occurrence of driving and restraining forces. Driving forces motivate a person to move forward and may include recognition, the achievement of personal goals and financial remuneration.
Restraining forces are forces that hold back change and may include the fear of change, little opportunity for input from those affected by the change, potential problems not being identified and an inadequate trial period (Hein & Nicholson, 1994). For change to occur and be successful the driving forces must be stronger or able to overcome the restraining forces. The movement phase also allows for any problems to be sorted out, for goals and objectives to be set and for any alternative solutions to be explored.
Culture change that involves changing underlying values and beliefs is difficult to change (Simms, et. al. 1994), so the change agent may have to use a reward system to motivate individuals to accept the challenge of change as part of the ‘refreezing’ phase. This can be important because staff often feel there is a loss of rewards when they make changes. In this instance some staff members may feel belittled or sense a loss of prestige when they are no longer called “nurse” and when they wear uniforms that clearly identify their designation.
To ensure the success of this change the change agent will depend on her ability to effectively communicate and motivate the staff to accept the change. According to Simms et. al. (1994), behaviors that are continually reinforced will eventually change values. The change agent can determine the success of the change by comparing the new behaviours with the standards of earlier times. The change agent could also use the ‘refreezing’ phase as an opportunity to motivate staff and encourage them to further their education, either by holding more ‘in-house’ educational opportunities or encouraging their formal training.
According to Schweiger (1980), it is the responsibility of the nurse manager (change agent) to encourage and enable staff “to develop and grow educationally and as people” (p. 99). By keeping the lines of communication open and being aware of the mood of the staff, the change agent will soon know when the changes have become a daily habit, and thus successfully refrozen into the organizational culture.
The scope of the change is not big but it will impact on the staff. Nurses will be identified as such and other caregivers will not be identified as nurses. This change will empower patient’s as they will know who is providing their care. Making this change will also encourage all the staff to accept more responsibility for providing a high standard of care within their scope of practice. By including staff in the change process, the change agent invite’s them to become more attached to the organisation, which in turn leads to greater commitment, motivation and willingness to accept change (Hein & Nicholson, 1994). It will also allay any potential confusion from patients and their families about exactly who is performing cares for them or their loved ones. From a managerial perspective this gives the organisation a very professional public face. Anyone entering their premises will be able to easily identify the designations of staff by looking at their uniforms.
Change is an essential factor in growth and development and while many people are initially resistant to change, others often feel empowered by it. Change involves three phases beginning with an idea and a change agent with vision and the ability to motivate and empower individuals will accomplish the change and ensure it is permanent. Excellent communication skills enable barriers and resistance to be overcome and allows those affected by change to have their say.
All healthcare professionals work in an environment of constant change and must adapt to it. The right to be called “nurse” is one that is earned and carries legal, ethical and social obligations. While the practicalities of this change are not large, they will have a big impact on those affected by them. Nurses will be identified as nurses, and other staff who are not nurses, will not refer or be referred to as a nurse. Change is vital for development and empowerment, and whilst change is not always welcomed, without it there would be stagnation.