Using the 4 Ps to underpin your essay and using legal, ethical and professional issues discuss the nurse’s professional role in advocating for others and how personal knowledge, skills, values and beliefs contribute to your professional identity and development.

The aim of this assignment is to research legal, ethical and professional issues in order to discuss the nurse’s professional role in advocating for others, and also to look at how personal knowledge, skills, values and beliefs contribute to a nurse’s professional development and identity. Firstly, it will consider advocacy and how legal, ethical and professional issues shape the nurse’s role.

Advocacy has been argued to be a fundamental aspect of nursing, it is reinforced by the current codes of conduct, as well as codes of ethics and competency standards that govern nursing practice. Advocacy has been defined as the ‘means by which individuals can be empowered to express their opinion’ (Gallagher et al. 2012, p. 71). There are three main models of advocacy that were discussed by Fry and Johnstone (2008), these are the ‘rights patient protection’ model, the ‘value-based’ decision model and the ‘respect-for-persons’ model. Each of these models interprets advocacy in a different way, but one key similarity is that each model looks at the best interest for the patients in their individual ways. The ‘rights patient protection’ model is where the nurse defends the patient’s rights, the ‘values-based’ decision model looks at the nurse helping the patient to discuss their needs, interests and choices without the nurse imposing their own personal opinions on the patient, and finally the ‘respect-for-persons’ model, here the nurse looks at the patient as a fellow human being who is entitled to respect.

Being an advocate on behalf of a patient can mean many things, it could be helping a patient make an informed decision regarding their health, translating medical jargon and assisting them to understand complex systems and conditions or it could be helping them come to ethical decisions. It is important to remember that ethical principles are standards of conduct that constitute an ethical system (Johnstone, 2009) and that a nurse must understand the cultural differences may exist for the people in the care of the nurse. Different beliefs and values mean that advocacy will be different for each individual, two people will not require the same level of care and support. Advocacy is highlighted throughout the Nursing and Midwifery Code (NMC, 2018), in all four sections. Under ‘Preserving Safety’ it is stated that a nurse should be “raising concerns immediately whenever you come across situations that put patients or public safety at risk”. This helps to shape a nurse’s role as an advocate as it highlights the importance of raising concerns in the best interest of the patient, this could potentially refer to Safeguarding or a range of other policies when necessary, always ensuring that the patient’s safety and needs are put at the forefront. Furthermore, within the NMC there is a section for ‘Prioritising People’. Prioritising people shapes the nurse’s role in being an advocate as it is all about putting the patient first, ensuring that their care needs are met and that their safety is of the upmost importance. It also mentions that nurses are to challenge any discriminatory attitudes and behaviours that are aimed towards the people receiving care, this helps shape the nurse’s role in advocacy as it is another guideline of what a nurse should speak up against.

The nurses’ role of being an advocate has changed over the previous years, this is due to a number of reasons, including legal issues. Both criminal law and civil law affect the nursing profession in their individual ways, on the one hand criminal law focuses on conduct that would cause harm or damage social order, this refers to criminal acts. Criminal law is very rarely used against nurses in a professional manner, as it refers to committing crimes such as theft from a patient, assault or murder. On the other hand, there is civil law, which deals with actions in “tort” which means civil wrongs. Dealings of civil law are much more common than criminal law dealings in nursing practice, disputes of civil law can occur between two individuals, an individual and an organisation or two organisations, the most common form of “tort” in a healthcare setting is negligence, which may arise due to failure to gain consent or a breach of confidentiality. It is due to the cases that exist from both types of law that have altered and caused the need for new policies and legislation. Some legislation that has been developed due to legal issues and cases include the Human Rights Act (1998), Mental Capacity Act (2005), Equality Act (2010) and many more. These legislations have resulted in a change in the way nurses practice and how they advocate for their patients, the legislation sets out standards that should be upheld and met, and provide a type of guideline that can be used to show what is expected of a nurse.

Professional identity could be defined as including both personal and professional development and involving the internalisation of the core values recognised as essential to the nursing profession. Many factors contribute towards a nurse’s professional identity and development, these include, but are not limited to knowledge, skills and values. Throughout their career, a nurse is expected to continue expanding their knowledge and professional development, this is done through the requirement of lifelong learning for nursing. Lifelong learning is used in order to promote and deliver the best possible care that is based on the most updated and best available evidence. Continuing Professional Development (CPD) is a requirement of the Nursing and Midwifery Council (2018), in order for a nurse to revalidate and remain on the register they are expected to complete a minimum of thirty-five hours every three years in order to increase the nurses level of knowledge and skills, this is a critical tool in order to deliver improved patient outcomes and a high quality of care. Furthermore, Eason (2010) stated that lifelong learning supports critical thinking which in turn is able to enhance a nurse’s satisfaction with their professional role and encourage the nurse to research and apply the newest evidence into their practice, this highlights the importance for a nurse to continue to develop their knowledge and learning new and more up to date information.

The NMC (2018) also expects nurses to keep their skills up to date throughout their working career by participating in relevant learning activities, this is to ensure that the nurse is fully competent and to ensure that they are using the most recent practices, ensuring patient safety and high standards of practice. The NMC Code of Conduct (2018) asserts that a nurse is to provide care to the best of their ability, using the basis of the best available evidence and also expects nurses to reflect and act on any feedback given in order to improve practice, this is highlighted under ‘Practice Effectively’ in the code (2018), and it emphasises the importance for continued learning throughout a nurses’ career, this is because in order to provide the best care, a nurse must be up to date with the most recent evidence. In addition, reflective practice is used in order to help to learn and develop practice in order to optimise learning and improve a nurses’ abilities, it enables the nurse to consider what they did, why they did it and allows them to consider what knowledge they can take from the experience.

A nurse should embrace fundamental values in every aspect of their practice,

professional values

are likely to be influenced by a nurses’ personal values, Badcott (2011) suggested that personal values and beliefs should have a minimal effect on professional values for practice, he further states that when certain values are required for a profession they must become integral for both personal and professional aspects of the nurses’ life. Professional values are seen to be rooted into personal values and are seen as a necessary aspect to nursing that reinforce a nurses professional and personal identity, as well as a nurse’s performance. The use of values in nursing practice is considered to increase the quality of patient care and are a source that aid in promoting nurses’ ethical competencies in a clinical setting and dealing with ethical concerns.

To conclude, this assignment has researched the legal, ethical and professional issues in order to discuss the nurse’s professional role in advocating for others, and has also looked at how personal knowledge, skills, values and beliefs contribute to a nurse’s professional development and identity. It is clear from research that legal, ethical and professional issues have all influenced the nurses’ professional role in advocating for others, there have been a range of legal issues that have resulted in new legislation which have in turn altered the nurses’ role as an advocate for patients. Furthermore, from the discussion it is evident that there are many contributing factors to a nurses’ professional identity and development, one of the most significant ones from the discussion would be a nurses’ personal and professional values, both personal and professional values are considered as essential for a nurses’ identity and professional development as they are viewed to increase the quality of care that a patient receives and are a way of promoting nurses’ ethical competencies. Also, it is apparent from the discussion that knowledge and skills are of the upmost importance for professional identity and development, this is to ensure that a nurse remains able to give the most up to date care, based on the best and most recent evidence available, ensuring that they remain fully competent throughout their career and always provide the best quality of care.

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Reference List

• Badcott, D. (2011). Professional values: introduction to the theme.
  
  Medicine, Health Care and Philosophy
  
  , 14(2), 185-186. Available from: https://link.springer.com/article/10.1007/s11019-010-9282-z [accessed 10 December 2018]
• Baillie, L. and Black, S. (2015). Professional Values in Nursing. Boca Raton: CRC Press, Taylor & Francis Group, 88-89.
• Eason, T. (2010). Lifelong Learning: Fostering a Culture of Curiosity.
  
  Creative Nursing
  
  , 16(4), 155-159. Available from: https://search.proquest.com/openview/68b934aca12d1c613836414b4e9db781/1?pq-origsite=gscholar&cbl=30045 [accessed 05 December 2018]
• Fry, T. and Johnstone, M. (2008).
  
  Ethics in Nursing Practice: A Guide to Ethical Decision Making
  
  . 3rd edition. Oxford, UK: Blackwell. [accessed 08 December 2018]
• Gallagher, A. and Hodge, S. (2012). Ethics, Law and Professional Issues. A Practical-Based Approach for Health Professionals. Basingstoke, UK: Palgrave Macmillan. [accessed 07 December 2018]
• Johnstone, M. (2009).
  
  Bioethics: A Nursing Perspective
  
  . 5th ed. Chatswood, Australia: Elsevier. [accessed 05 December 2018]
• Nursing and Midwifery Council (2018) The Code for nurses and midwives. London: Nursing and Midwifery Council. Available from https://www.nmc.org.uk/standards/code/read-the-code-online/#fifth [accessed 06 December 2018]

Bibliography

• Badcott, D. (2011). Professional values: introduction to the theme.
  
  Medicine, Health Care and Philosophy
  
  , 14(2), Available from: https://link.springer.com/article/10.1007/s11019-010-9282-z [accessed 10 December 2018]
• Baillie, L. and Black, S. (2015). Professional Values in Nursing. Boca Raton: CRC Press, Taylor & Francis Group.
• Eason, T. (2010). Lifelong Learning: Fostering a Culture of Curiosity.
  
  Creative Nursing
  
  , 16(4). Available from: https://search.proquest.com/openview/68b934aca12d1c613836414b4e9db781/1?pq-origsite=gscholar&cbl=30045 [accessed 05 December 2018]
• Fry, T. and Johnstone, M. (2008).
  
  Ethics in Nursing Practice: A Guide to Ethical Decision Making
  
  . 3rd edition. Oxford, UK: Blackwell. [accessed 08 December 2018]
• Gallagher, A. and Hodge, S. (2012). Ethics, Law and Professional Issues. A Practical-Based Approach for Health Professionals. Basingstoke, UK: Palgrave Macmillan. [accessed 07 December 2018]
• Johnstone, M. (2009).
  
  Bioethics: A Nursing Perspective
  
  . 5th ed. Chatswood, Australia: Elsevier. [accessed 05 December 2018]
• Nursing and Midwifery Council (2018) The Code for nurses and midwives. London: Nursing and Midwifery Council. Available from https://www.nmc.org.uk/standards/code/read-the-code-online/#fifth [accessed 06 December 2018]
• 
  Human Rights Act 1998
  
  (c.42). London. Available from: https://www.legislation.gov.uk/ukpga/1998/42/contents [accessed 15 December 2018]
• 
  Mental Capacity Act 2005
  
  (c.9). London. Available from: https://www.legislation.gov.uk/ukpga/2005/9/contents [accessed 15 December 2018]
• 
  Equality Act 2010
  
  (c.15). London. Available at: https://www.legislation.gov.uk/ukpga/2010/15/contents [accessed 15 December 2018]

Prolonged labor and obstructed labor are major causes of maternal and newborn morbidity and mortality in india. One of the tools used to monitor labor and prevent prolonged and obstructed labor is the partograph, a single sheet printed paper on which labor observations are recorded.

(Fistula care., 2011).

The timing of interventions is the one of the crucial factors in active management of labor, whether these be amniotomy, augmentation, ceasarean section or transfer to a central unit. The maintenance of a partogram for the management of the labor helps to indicate, with its alert line and action lines, the optimum timing of these interventions and to clearly differentiate normal from abnormal progress in labor. The partogram could be used at all areas of obstetric care by basic care providers who are specially trained to assess dilatation of the cervix and when it used properly, helps to detect cases of abnormal labor without delay, thus allowing timely intervention. Partogram is a composite graphic record of cervical dilatation and descent of head against duration of labor in hours. It also provides information about fetal and maternal condition that are all recorded on a single sheet of paper.

The modern partogram contains many relevant parameters related to labor, mother and the fetus. These parameters are cervical effacement and dilatation, descent of part which is present, fetal heart rate, duration and frequency of uterine contractions, color and quantity of amniotic fluid which is passed per vaginum, maternal parameters such as vital signs and drugs used during labour. This pictorial documentation of labor facilitates early recognition of poor progress. Plotting of cervical dilatation also enables prediction of the time of onset the recording of all relevant data on a single page, it facilitates the easy handing over of mothers, helps in early recognition of complications and highlights inefficient clinical practice.

(James et al., 2001).

The partogram is an observation chart that may be used to facilitate assessment of the progress of labor, including maternal and fetal well being. Historically progress is measured by linear progression along a prescribed time scale, whereby a curve of cervical dilatation is measured in centimeters plotted against time in hours (Friedman 1955), and descent of the head abdominally. Many modifications to the partogram have occurred, resulting in the introduction of alert line and action lines. Basically, the action line was 2 hrs to the right of the alert line, and augmentation instituted at this time. Once labor is confirmed as in the active phase, cervical dilatation is expected to progress at <2cm in 4 hrs (NICE 2008). Alberts (2007) also supports this as a realistic expectation, she goes on to say that for some women, progress might be as little as 0.3cm per hour and the progress of labor should not be assessment of the descent of the presenting part abdominally.

(Macdonald et al., 2011).

An accurate record during labor provides the basis from which clinical improvements, progress or complications of the mother or fetus can be judged. For this reason the notes should be kept in chronological order. The maternity record is shared between the midwife and the obstetrician. The obstetrician makes notes of his or her findings, timing of visits and may prescriptions made. The same standards apply to all practitioners. The midwife usually enters the summary of labor and initial details about the baby. In recent years the partogram or partograph has been widely accepted as an effective means of recording the progress of labor. It is chart on which the salient features of the labor are entered in a pictorial form and therefore provides the opportunity for early identification of deviations from normal labour.

(Fraser et al., 2007).

The best clinical tool that diagnoses the poor progress of labor is the partogram (even in higher centers) and will always help in early detection of the abnormal labor. It is very handy, easy to use and easily reproducible too. The use of a partograph in labor was associated with reduction in prolonged labor and decreased caesarean section rate. Another advantage of the use of a partograph was improvements in fetal and maternal morbidity in a significant manner.

(Kamini., 2011).

The cervicograph is the pictorial representation of the cervical dilatation charted against the hours of labour. Studies have shown (Friedman and Sachtleben 1965 & pearson 1981)that the cervical dilatation time of normal labor has a significant sigmoid curve which can be divided into two distinct parts such as the latent phase and the active phase

. (Bennett et al., 2001).

In some cases the partogram may allow space for a certain amount of comment but usually the midwife will keep a separate written account in which she records her observations of the women’s psychological condition and any other details not included on the graph. If any changes in the birth plan become necessary ,the midwife will note down how these were discussed with the women and her partner and with what outcome.In this way the women will feel involved in any decisions made, which encourages feelings of being in control and enhance the birth experiences

. (Ali et al., 2010).

The midwife can verify the progress of labor effectively through the use of graphic charts (partograms) on which one plot cervical dilation and station (descent), this type of graphic charting assists in early identification of deviations from expected labor patterns.

(Lowdermilk, et al 1997 ).

NEED FOR THE STUDY

The latest available data on MMR india is 212 per 100,000 live births and IMR is 44 per 1000 live births. Out of 180 countries now india ia ranked 126 when countries are arranged in an ascending order for MMR and 45 out of 195 countries in IMR.

(Petterson, 2004).

The obstructed labor stands one of the five major causes of maternal morbidity and mortality in developing countries like india. About 4% and 70% of all maternal deaths is due to obstructed labour or rupture of the uterus, accounting to a maternal mortality rate as high as 410/100,000 live births.

(S. Quenby et al., 2003).

Introduction of partograph in the management of labor(WHO 1994) has reduced the incidence of prolonged labor and caesarean section. There is improvement in maternal morbidity, fetal morbidity and mortality.

(Dutta., 2013).

The development of the partograph (or partogram) provides a graphical overview of the labor to allow early identification and easy diagnosis of the pathological labor for health care providers. Emanuel Friedman was the first obstetrician who provide an accurate tool for the study of individual labours. In the 1970’s partographs starts getting popularity and today majority of delivery and labour units use them. A large number of literature shows that their correct use reduced the rates of prolonged labors and many complications which arises during labour. There is also a suggestion that the use of the partograph results in fewer surgical interventions such as Caesarean sections.

Nowadays the electronic partographs are becoming popular and it can be made into medical records systems. The use of partographs is very common in hospitals. A study has been conducted on health care workers and midwives who works in delivery units of Nigeria found that only 10% of caregivers used the partograph while conducting labour, and only few used it properly. The study found that the correct use of partograph may be restricted by training, time, and caregiver skill level. In many of the cases, literacy and numeracy are major problems to use it. Finally, the study concludes that the health workers requires training about partograph for the early identification of deviation from normal labour.

(Neison et al.,2005)

The partograph provides information about deviations from the normal progress of labor and about various abnormalities of maternal or fetal condition during labor. It may alters providers when a woman needs an intervention and which facilitates throughout evaluation of the effects of those interventions.

(Fistula care., 2011).

The partograph helps to reduce the time midwives spent on writing notes, while helps them to keep detailed and accurate records. It also allow them to provide an emotional support to the women in labour. Hence, the investigator who has done the research feels that it is very imperative to train the nurses working in maternity unit and to improve the knowledge and skill in the use of partograph. This would help the nurses to provide a comprehensive intrapartum care to the mothers in labour with early identification and prevention of complication arising during labour, So said that the partograph plays an important role in reducing the maternal mortality and morbidity due to labour.

(Arez


et al., 2009).

In maternal health care, it is imperative that a skilled attendant be present at each delivery. According to WHO, a skilled attendant at birth is one of the most effective interventions to reduce maternal mortality. Among various interventions which have proven valuable in maternal health care is the partograph, which should be used in health facilities everywhere for monitoring labor and preventing complications.

(Dangal., 2006).

In a WHO multicenter trial conducted in southeast Asia which includes 35 484 women. The study shows that the introduction of the partograph during labor management significantly reduced both prolonged labor from 6.4 to 3.4 % of labors and the percentage of labors which requiring augmentation which is from 20.7 to 9.9% to 8.7 %, There was also a reduction in the mean number of vaginal examinations during labor probably leads to the

drop in cases of postpartum sepsis by 59%. Improvement in maternal morbidity and fetal mortality which took place among both multiparous and nulliparous women. The participants in WHO trial agreed that the partogram improved the discipline communication about management of labor and freed midwives time, this may be an important element of the partograms success as more time can be devoted to ‘companionship’. The WHO trial points the way towards effective management of labor where reduced but timely intervention is the key to success.

(James et al., 2011).

Partographs are tools that allow labor progress to be graphically recorded and assessed visually . Partograph helps in early detection of abnormal progress of labour and are credited with decreasing rates of prolonged labor, oxytocin use, cesareans, and intrapartum morbidity or mortality as compared to regular care. Eventhen, partograph is not so used widely but only rarely in countires like U.S. A. A research team has made a partograph which is physiologically based for hospital use in assessing the labors of nulliparous women with spontaneous onset of labour. They shows that their tool greatly improves the outcome which in turn, optimize the safety of the mother and the fetus during labour. (Neal et al., 2011).

A study conducted to evaluate the Partogram programme in the University Center of Health Science in Cameroon, Africa and Yaounde. It ia a retrospective study with 686 patients and a prospective study with 1045 patients . The institution which has this program shows that the perinatal mortality has been reduced by 10 deaths per 1000 births because of use of partograph and it provides accurate and reliable results for early identification of abnormal labor. About two-thirds of the morbidity and mortality related to labour and 72% of deliveries with medical or surgical conditions has also occurred in the clinical area where the labor curve crossed the action line in the partograph. (Drouin et al., 1979).

STATEMENT OF THE PROBLEM

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE, ATTITUDE AND SKILL REGARDING PARTOGRAPH AMONG MULTIPURPOSE HEALTH WORKERS IN SELECTED MATERNITY CENTRES IN COIMBATORE.

OBJECTIVES

• To assess the level of knowledge, attitude and skill regarding partograph among multipurpose health workers in selected maternity centres.
• To identify the effect of structured teaching programme on knowledge, attitude and skill among multipurpose health workers in maternity centres.
• To associate the findings with demographic variables.

OPERATIONAL DEFINITION

STRUCTURED TEACHING PROGRAMME

Refers to a well planned instruction which is designed to improve knowledge, attitude and skill.

KNOWLEDGE

It refers to the actual understanding of Mutipurpose health workers on partograph as elicited by knowledge questionnaire.

SKILL

It refers to the ability to use partograph which is assessed by using checklist.

ATTITUDE

It refers to the belief of the multipurpose health workers towards partograph.

PARTOGRAM

The progress of labour depicted in the form of graphs.

LABOUR

The process of child birth.

HYPOTHESIS

H

₁

: There will be a significant difference in the knowledge level of multipurpose health workers regarding partograph before and after administration of Planned Teaching Programme.

H

_2:

There will be a significant difference in the attitude level of multipurpose health workers regarding partograph before and after administration of Planned Teaching Programme.

H

_3:

There will be a significant difference in the skill level of multipurpose health workers regarding partograph before and after administration of Planned Teaching Programme.

ASSUMPTION

1. Multipurpose health workers may have previous knowledge on partogram.
2. Planned Teaching programme will enhance the level of knowledge ,skill

and attitude among Multipurpose health workers.

CONCEPTUAL FRAMEWORK

A conceptual framework or models is a set of concepts, assumptions, principles and rules which provides an outline for conducting research.

Thus the investigator adopted Donabedian’s Program Evaluation Model (1982).

Avedis Donabedian

a physician and health services researcher at the

University of Michigan

, developed the original model in 1966.

This model consists of three aspects such as structure, process and outcome.

1. Structure:

Structure includes all the factors that affect the context in which care is delivered. It includes infrastructure, equipments, supplies, manpower etc. In this present study the infrastructure is the selected corporation maternity centres in Coimbatore where the teaching has been taken place. Equipments and supplies are the audio visuals aids used for teaching (pamphlet & handout). The human resources are the multipurpose health workers

2. Process:

It is the activities carried out with the help of structure to achieve the outcome. In this study, it is the structured teaching program regarding partograph done by the investigator with pamphlet and handout.

3. 
   Outcome:
   

It is the result of execution of the process through the structure. In this study, the outcome is the improvement in knowledge, attitude and skill regarding partograph among multipurpose health workers.

If the outcome is positive, it ensures that both the structure and process is functioning effectively. In this study the result shows that the teaching has improved the knowledge, attitude and skill regarding partograph among multipurpose health workers.

In the last five years, United Kingdom has experienced a significant change in its national health services (NHS). This paper therefore focuses on that change. The first section is a detailed description and the main objective of the change. Using appropriate models and frame works, the second section identifies the key drivers to the change and how their interaction has affected the issues addressed by management. Drawing upon the examples of best management practices, the third section assesses the appropriateness of the approach taken by management in effecting the change and how effective management implemented the change strategy. The final section examines the extent to which the change has been successful in meeting its objective and assesses the need for any further related change.

2. Organisational change overview

2.1 The National Health Service

The National Health Service (NHS) is the public funded health care system in the United Kingdom (UK) that provides the majority of health care to the UK residents. Its areas of health care coverage are the primary health care, in-patient care, long term health care, ophthalmology and dentistry. The Department of Health (DOH) headed by the Secretary of State of Health is the UK government department that is responsible for the NHS (Department of Health 2007).

2.2 Major change in the NHS

Since 2005, the United Kingdom’s NHS (UK NHS) has been implementing an innovative technology that will help patients stay healthy and maintain their independence. This technology is targeted at terminally ill patients with long term health condition that require regular monitoring. It also covers elderly people suffering from dementia and individuals with Down syndrome who may be at risk of injury. Thus, with this new technology, patient’s emergency room visits as well as unnecessary nurse visits to patients’ homes are reduced. Furthermore, this technology increases clinical efficiency and reduces the mounting financial cost of institutional health care in the UK. The implementation is said to be the world’s biggest trial of remote monitoring of chronically ill patients in their homes. Patients in New Ham, East London and Hull Yorkshire have benefited from this programme.

This programme, funded by the department of health is been implemented by Philips, the world’s leading electronic companies. Philips electronics is hoping to prove to the NHS that it can immensely reduce the financial burden of institutional health care by implementing ultra-modern diagnostic equipment that uses internet technology to link patients from their homes to care providers in the hospitals. Since over 14.5 Million people in Britain have long term health conditions, it is expected that they will require regular monitoring (Department of Health 2007).

I am a trained Electrical Engineer and have been providing tele-health equipment installation consultancy for Philips UK since 2008. I am directly involved in the implementation going on presently in Hull and New Ham. Patients in New Ham and Hull are been monitored at Home using diagnostic equipments linked via broadband internet connected to local hospitals and clinics. These patients are able to use the diagnostic equipments to take their vital signs and blood sugar level. Subsequently, the information is wirelessly uploaded to patients TV for their own monitoring and electronically sent via broad band to staff at the primary health trust.

Further implementation is underway in Cornwell and Kent and will gradually expand to all cities in the UK as the department of health targets technology efficiency that could save the NHS Millions of pounds.

Although the technology enables people to live independently in their homes, it is not intended to replace hospitals and care homes but to make better use of recourses and reduce financial burden on the system.

3. Drivers for NHS change

Force field analysis by Lewin (1951) is a diagnostic tool used in looking at the variables involved in determining whether organisational change will occur. Once change priority has been agreed, a force field analysis can be used to identify actions that will enhance or deter their successful implementation.

Applying Lewin’s force field analysis as shown in figure 1 below, it can be seen that the NHS Tele health technological implementation has some internal and external driving and forces.

3.1 Internal Drivers

Among the strongest internal driving forces as can be seen in figure 1 below are; strong leadership and the need for accurate and consistent patients information availability. Strong leadership and commitment of top management are often cited as the most important factor for implementing a successful change programme (Bashein et al, 1994). NHS leadership is effective, strong and was able to provide a clear vision of the change programme.

Other internal driving forces are the fact that the technology will aid patients to be independent and free up nurses and doctors to concentrate on other important task. This motivated medical practitioners in looking forward for the change.

3.2 External Drivers

The identified external driving forces as can be seen in figure 1 are Government’s desire to reduce the cost of administering health care in the UK, New European Union legislation in support of tele-montoring and the recent economic recession. Since 2005 the UK government has been researching on ways of bringing down the cost of instructional health care. Limited resources availability as a result of the recent economic down turn and an increasing UK population has necessitated the need for a cost effective alternative as the status quo is unsustainable.

Another external driver is the new European Union legislation in support of tele-monitoring.

Figure 1: Lewin’s Force Field Analysis of health care change in the NHS

DRIVING FORCES

INTERNAL

Strong leadership and shared goal across the NHS

Accurate and consistent information availability

Patient’s independency

Free up nurses and doctors to concentrate on other important task.

EXTERNAL

Government’s desire to reduce the cost of administering health care in the UK

European Union legislation in support of tele-monitoring

The recent economic down turn necessitating the need for fiscal responsibility

Adapted from Lewin (1951

4. Main objectives in making the change

4.1 Reduce cost of administering health care in the UK

As the case load in primary care in the UK is increasing in size and complexity and the number of people with multiple long term disease is also increasing, there is increasing financial burden of administering primary care in the UK. The tele-health technology will in the long run help to reduce the mounting financial burden of institutional care.

4.2 Reduce nurse visits to patients’ house.

Prior to the implementation of the tele-health technology in the NHS, each patient with long term condition is assigned a care taker nurse who’s duty includes regular house visit. The nurses are required to take patient’s vital signs, blood sugar level and other related data that are necessary in monitoring the patient’s health condition. Upon implementation of the tele-health technology, the required data are taken by patients and are automatically sent via the internet from patient’s house to the hospital through the diagnostic equipment. As a result, nurse visit to patient’s house is considerably reduced.

4.3 Maintain patients independent.

The technology ensures that nurses only visits when it is necessary and as a result allows patients to leave more independently. From a medical point of view, it is usually helpful for patients to be independent as it can give them the agility they may need to remain healthy.

4.4 Reduce patient’s emergency room visits.

As patient’s health situation is monitored on a daily base, doctors and nurses are able to know when a patient’s condition is deteriorating and therefore avoid emergency situation. In Hull and New Ham it has been noticed that emergency room visits by monitored patients is much reduced.

4.5 Increase in clinical efficiency

The diagnostic equipment interacts with the patient through a user friendly interface. It provides reminders, collects vital data and asks questions that help assess the condition of the patients. It also gives warning when a patient’s condition is changing. This in general allows doctors and nurses to intervene more quickly and accurately and as a result increases the overall clinical efficiency.

6.0 How action required was planned

Management tools for problem analysis are very crucial for success in change management. One of such tools is the ‘Cause and Effect’ analysis. ‘Cause and Effect’ analysis is also referred to as the Fishbone diagram because the diagram has a fish bone appearance. The technique was proposed by Ishikawa in the 1960’s and as a result called the Ishikawa diagram. The diagram is used to determine the root cause of a problem and identify areas that changes can be made. (Ishikawa 1985)

In applying the ‘Cause and Effect’ analysis to the NHS in determining what change is required and what action is to be taken. The first step is to get a clarity and consensus on what the problem is. Among many others, the focused problem statement identified in the NHS is the mounting financial burden of institutional health care in the UK. The economic recession and increasing overseas debt is forcing the UK government to look for ways of cutting cost and saving money. This necessitated the need for fiscal accountability and cost cutting in the NHS (NHS Centre for Reviews and Dissemination 2008).

In constructing the Fishbone diagram for the NHS, the problem statement forms the head of the fish bone alone with the fish backbone as illustrated in the figure 5 below.

The next step is to brainstorm potential causes of the problem. The major causes are laid out as large bones connected to the backbone. In the NHS, the major causes identified as responsible for the increasing financial burden are staffs people, technology, procedures, and policy. The fish bone diagram is then developed based on the identified causes.

The final step is to probe deeper into each cause. A question asking-technique included in Senge et al (1994) ‘Five Ways’ model can be used. It involves asking repeated ‘why does this happen’ until it is clear that the root cause have been found. The answers are then added as sub-bones to the cause as shown in figure 5 below.

Fig. 5 Fishbone Diagram stage three

Too many admin staffs

Increased number of nurses

Too many Doctors

Increased ageing population

More sick patients

More hospital admissions

Expensive bureaucracy

Productivity failure

Expensive medical equipment

Increased drug prescriptions

Pay increase by government

Increasing fixed cost

Inflation policy

Staffs

People

Procedure

Policy

Equipments/Materials

Mounting Financial Burden of Institutional Health Care.

There is increased spending in the NHS as there are now more people been treated in the hospitals than ever before. This is the direct consequence of increase in population and immigration over the years. Increase in the number of sick people and the ageing population has also contributed to increase spending. These increases in people requiring attention have necessitated an increase in Nurses, GP consultations and a large increase in drugs prescriptions. (Slywotzky and Morrison 1997)

Furthermore, pay increases offered by the government to medical practitioners were in many cases over generous. Economic inflation and increased cost of fix asses has in no little way affected NHS budget. The office of the national statistics (ONS) has shown that NHS productivity is falling as spending is increasing.

As output has not kept pace with rise in spending it is important to implement an efficient and cost effective way of administering health care. As the tele-health technology will ensure that the increasing number of people requiring health care is efficiently covered with little resources, it will therefore provide an efficient and cost effective way of administering health care in the UK.

Looking at it critically, it is important to know that cause and effective relationship may not be easily apparent and that an intervention in any part of a health care organisation will have outcomes in many others, not all of them anticipated, and not all of them desirable. Smith (1995a; 1995b) in his work on response to performance indicator highlighted that change can lead to unanticipated and indeed dysfunctional consequence.

Additional technigues that was used.

The NHS employed process modelling technique in order to gain understanding of how the current process works and provide a clear articulation of how the new process is to be different. The process modelling technique provided clarification of the expected process so that the NHS is able to plan the required action.

Fig. 6 Current and expected process flow

Current process flow Expected process flow

Is he in the clinic?

Doctor decides that a patient needs monitoring

No

Yes

Specialist nurse visits patient for information and counselling

Vital information register created for patient and care nurse assigned to patient

Care nurse visits patient and takes vital readings

Vital readings recorded in patients information register

Doctor assesses patients register

Necessary actions take for abnormal readings

Process repeated daily

Action suspended

Is he in the clinic?

Doctor decides that a patient needs monitoring

No

Yes

Specialist nurse visits patient for information and counselling

Tele-Monitoring equipment is install and doctors assesses patients information remotely

Necessary actions take for abnormal readings

The process flow in fig.6.0 above is a diagrammatical representation of all the staged involved in a patents monitoring task. It shows both the current and process and what the process is expected to be after the implementing the tele-health system. The current process requires 9 steps and would take between 12 to 24 hours to complete a cycle while the expected process will require 5 steps and would take 10 minutes to complete a cycle.

With the process modelling technique, the NHS identified that in order to successfully implement the change; it must fundamentally re-think the way work is done and adequately prepare the organisation for change.

How management implemented change

Having understood the situation, knowing why change is needed in the NHS, who and what needed to change, it is important to examine how these insights and what framework can be used to deliver the results that are needed.

The technique of Business Process Re-engineering (BPR) is employed in the NHS in order to implement the change that is needed. Davenport and Short (1990) defines BPR as a technique for redesigning the way work is done. They also stated that it enables organizations to rethink work process so as to improve customers satisfaction, reduce operation cost and become more competitive. In addition, Hammer and Champy (1993, p32) stated that ‘BPR is the fundamental rethinking and redesigning of business process to achieve dramatic improvement in cost quality service and speed’.

In the health sector, Walston and Kimberley (1997) observes that over 60% of hospitals are involved in re-engineering initiatives. In the NHS, the re-engineering initiative of the tele-health system is focused on optimizing productive work time, automating process to increase productivity and quality and resource management. The steps that were employed to implement BPR in the NHS are show in the model below.

Fig.6 Change process model

Communication the need for change

Effective communication is considered a major key to successful BPR change implementation (Jackson 1997). The NHS implementation process began with series of meetings between the NHS management and stake holders inside and outside the HNS that would be involved in the change process. The purpose is to communicate the need of the change and the technology that would be implemented to effect the change. The meeting also helped to ensure patience and understanding of the structural and cultural change that are needed. Cooper and Markus (1995) suggest that communication should be open, honest, clear and in both direction between those in charge of the change initiative and those affected by them. Effective communication continued in the NHS throughout the change process. This formed the base that prepared the entire organization for change.

Preparing the organization for change

Hammer and Champy (1993) stated that organizational culture is a major factor to consider in preparing for a successful BPR implementation. Organizational culture influences the organizations ability to adopt to change. In the NHS, management ensured that the organization can understand and can conform to the new values and management process that are created by the newly re-designed process. This is so that a culture which upholds the change is established. Benjamin and Levinson (1993) argue that preparing the organization to respond positively to BPR related change is critical to success.

In preparing for change, the NHS ensured that adequate trainings were given to staff that are involved in the change process. The New Ham University in conjunction with tele-health engineers from Philips UK provided the required trainings to staff. This is in line with the suggestion made by Tower (1994) that training and education is an important component in preparing an organization for change. Bruss and Roos (1993) also state that IT skills and techniques are important dimension of training for BPR.

Fundamentally rethinking the way work is done

After identifying and analyzing core business process, the NHS was able to define key performance objectives and design new processes to achieve the objectives. Davenport and Short (1990) define a process as a set of logically related tasks that are performed to achieve a defined outcome. Patient monitoring involves process with a great number of intermediate steps.

The objective of the NHS is to reduce the processes involved in to single process that takes part directly to the final outcome. The single process designed with the needs and wants of patients in mind will allow the NHS to gain important advantages in the following ways; It reduces process steps and the time it takes to accomplish task; Improving the accuracy of patients medical information; Eliminate human mistake inherent with complex and repetitive task; Improve NHS efficiency and effectiveness and drastically cut down the overall cost of health care

Implementing new technology to achieve change

In order to make changes, certain known elements are required Harrington (1991). These are elements that act as variables for processes to change. Thus, , adequate IT infrastructure is considered as a vital factor in successful BPR implementation Moad (1993). Also, identification of enabling technology for redesigning business process and proper installation of IT components contributes to building an effective infrastructure for business process Barrett (1994) .

In the HNS, the IT based tele-health system aimed at people with long term condition is the enabler for achieving change. The equipment connected to users television allows user to measure their vital signs. The results are automatically sent over the internet to monitoring centre. The results are monitored daily by health care professionals who can take immediate and appropriate action if there is any abnormality in the result. The system is designed to be user friendly, clear and straight forward.

After installation, the technician will go through the system with the user to explain how it works and how to use it. Users are also able to call the monitoring centre at any time should they have any issue with the system.

Extent to which change was successful

Despite the significant benefits gained from the successful implementation of BPR, it is noted that not all organization embarking on BPR projects achieve their intended result. Hammer and Champy (1993) estimate that as many as 70 percent do not achieve the dramatic result they seek. This in most cases is attributed to poor implementation of BPR rather than a problem with the concept itself. Implementation process is complex and needs to be checked against several factors to ensure successful implementation (Alter 1994).

However, it is important to note that the process re-engineering change initiative in the NHS can be said to be successful as it has implemented a modern technology which can be the way of the future for in-home patient care in the UK. It has helped increase productivity through reduced process time and has also drastically reduced cost. It has also improved quality and greater patient satisfaction in the NHS.

Comparing the periods before and after implementation of the tele-health technology in the NHS, there has been a reduction in GP and Nurse Visits to patient and also a reduction in hospital admission of patients with long term condition. General satisfaction with the tele-health technology and the use of the equipments is high for all groups of patients. Patients felt comfortable using the technology and did not find it difficult. They also felt it helped improved the awareness of their condition (Department of Health 2009).

To the 1.75 Millions who now rely on the tele-health service in the UK, it offers peace of mind and the certainty that there is always someone to help them in times of difficulty.

Resistant to change in the NHS

Cultural Issue

Johnson (1992) in his cultural web model shown in fig 6 below suggests that until the paradigm at the heart of culture is changed, there will be no lasting change. Based on Drennan (1992) definition that ‘culture is how things are done around here’ it is a general believe that organizational culture is a very strong resistant to any change implementation program.

Figure 6. Garry Johnson Cultural Web

In the NHS, evaluation has shown that the central principles of BPR – radical, revolutionary approach to change is fundamentally incompatible with the traditions, culture and politics of the NHS. This in no small measure is a major resistant to change in the NHS (Buchanan 1997).

Threat to Status

One of the resistant to change in the NHS is that many of its staff perceived the change as a threat to their personal position. This is in agreement with Hanner and Champy (1993) who argued that the fear of job loss by employees is a major resisting factor to the success of management change program.

Dawe (1996) added that, change moves the whole organization as well as every single employee out of their ‘comfort zone’ and as a result, there are always going to be some people who would try to resist the change process. This is true for the NHS as some of both its management and medical staff try to stop or ignore the process of change. This is because the management failed to make a compelling case for change to its staff. Some NHS employees believed that the change was initiated only for the sole aim of saving money and cutting cost, that there is nothing in it for them. As a result they were not motivated to support the change process. This is supported by Kotter (1998) when he suggests that failure to create a win over hearts and minds will reduce the impact of a change program.

Privacy issue

Another major resistant experience in the implementation of tele-health change program in the NHS is fact that some people for personal reasons do not like to be watched over. They did not welcome the idea of been monitored on a daily base as they felt it violate their privacy right. The NHS management was able to resolve some of this problem by identifying patients who has indicated such fears and assuring them that only authorized medical officials would have asses to their information and that monitoring was mainly for their own good. Patients who were still skeptical and would rather not want to be monitored were all together exempted from the program.

Recommendation for future improvement

The overall improvement in patient health condition and reduction in hospital admission observed after implementing the tele-health system in the NHS supports continuation and further improvement of the scheme.

A recommendation for further improvement is that the NHS could develop an assessment and measurement system that would help to register the build-up of momentum and identify early victories. Success in management is of little value unless they are supported by best practices and hence Senge (2003) suggest that success depends on the application of best practice.

Nelson et al (1998) argues that although measurement is essential if change are to be sustained, the measurement them self must be defined practically. In the light of this, the NHS could adopt outcome and cost measurement, qualitative and quantitative measurement and a balances set of process to build measurement into the daily work routine and display it so that it tell a story of where they are, where they should be and where they are going in the change process.

Furthermore, the management of the NHS should be aware that resistant is part of the change program and that anticipation and planning for resistant is important in implementing a successful change program (Clemons 1995).

It is observed that the NHS management communicated change information only to stakeholder that was directly involved in the change program. This was only able to disfranchise the other stakeholders and strengthened the resistant. It is important that communication with a wide range of stakeholders directly or not directly involved in the change program be made so that they become involved and motivated (Stanton et al. 1993).

The major future challenge that the NHS may encounter is how to engender a culture of continuous change in which change is on-going, evolving and cumulative. It would require a major shift in assumptions made by the organization and its members. Many of the individuals and groups whose assumptions and behaviors must change if this cultural shift is to be achieved are perceived to be of high status and are used to the exercise of individual and professional autonomy.

Conclusion

As people are living longer and there are more and more people who are unwell, going into residential and nursing home and living with long term conditions, the NHS which is the public service most valued by the British people must be able to keep pace with these change in society.

The Remote monitoring tele-health technology will enable the NHS to effectively cope these increases in demand for health care. It would also help to reduce the overall cost of administering institutional health care in the UK.

Although there are still pockets of issues and resistant, the program is generally termed as successful as it is already yielding the desired objective of improving life and saving cost.

This paper presented an analysis of the approach take by management to effect the change and how effective management implemented the change strategy. It also demonstrated the extent to which change was successful and made recommendations for future development.