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HEALTH CARE CHANGES & NURSING.
Term Paper ID:27050
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Overview of industry changes since 1950s, managed care, economics, insurance, technology, restructuring, responsibilities, impact of change, focusing on role of nurse.... More...
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Paper Abstract:
Overview of industry changes since 1950s, managed care, economics, insurance, technology, restructuring, responsibilities, impact of change, focusing on role of nurse.
Paper Introduction:
This research will examine the phenomenon of change in the design or redesign of health care, focusing on the role of the nurse. If there is any single issue on which health-care theorists, practitioners, policy makers, and consumers agree in the current period, it is that health care in general and the profession of nursing in particular have been permanently marked by change. Lancaster (1999) cites nursing literature that cautions nurses to seize the initiative in managing change in health-care venues, so that they will have a voice in the shape that change assumes in institutional systems.
Structural change in health-care delivery systems has occurred since the 1950s in part because of the success of medical interventions and the increase in life expectancy. These factors, together with the increase in medical insurance cover
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Only at Step 8, with implementation of theproject, does Lancaster's plan seem to directly intersect with Lewin's.Implementation can be seen as an unfreezing act, but so can Step 9,handling and managing resistance. Meckler, L. 279). Structural change in health-care delivery systems has occurred sincethe 195 s in part because of the success of medical interventions and theincrease in life expectancy. Effective leadership andmanagement in nursing. Change perforce points in the direction of undiscoveredcountry, and the unfamiliar can be an emotional minefield. Another study (Bailit, 1997) cites the fragility of the managed-care market for institutions per se, based on a decline in competition and"few rewards for higher-quality care." Forces driving redesign and restructuring of health care begin withcost increases and a concomitant industry interest in cost containment.Lancaster (1999, p. Health care changes hold uncertain future foreveryone. It might seem that such positive changes asadvances in medical science and technology, would generally make medicalcare more accessible. NewYork: Harcourt Brace. To be sure, Lancaster is against it because it is not cooperative buttop-down in style. 15 ) as it is, "represents the biggest slice of the organizationalbudget" (Sullivan & Decker, 1998, p. Specifically, this can be connected to theimplementation of DRGs (diagnostic research groups), which identifytreatment procedures and symptom sets approved for reimbursement. Retrieved October 4, 1999, from the World Wide Web,http://www.pueblo.gsa.gov/press/healthne.htm. Another, more bureaucratic, change flowedfrom the Government Performance and Results Act of 1993, which, in linewith accountability policy, requires all government agencies to addressstructural organization and change, i.e., to "set goals, measureperformance, and report on their accomplishments. Change must bedeliberately embarked upon, carefully planned, patiently but firmlyimplemented, and carefully nurtured by those in charge if it is to beeffective and beneficial. 162) and Sullivan and Decker (p. On the other hand, this focus has shiftedresponsibility for patient welfare out of the institutional setting andinto the private setting of the patient and family. House of Representatives of "a sweeping bill meant to rein in .. General Accounting Office. Sullivan, E. Retrieved from World Wide WebOctober 4, 1999, athttp://www.amcity.com/kansascity/stories/1997/ 2/ 3/editorial4.html. Also implicated are thecosts of technology, even though the intent and indeed effect of usingfancy machines may be to reduce the costs associated with patient care.Consider the ability to conquer the problems of organ transplant and more,to overnight transplant organs across the country, which is in line withLancaster's comment that technology fosters the expectation of fast change.This is especially relevant to patients who are candidates for organtransplantation and whose expectations may take the form of vain hope,inasmuch as it is a commonplace that availability of donor organs is not atthe same level as the ability to transport them efficiently. Public discourse and public policy have also driven structural changein health. Whether they seize the change and make it their own projectwill depend in no small part on whether they have been able to recognizethe benefits of strategic thinking and planning. It is perhaps sufficient to note that the term "managed care" had notentered the popular lexicon in 197 to see how dramatically theinstitutional character of health care has shifted since that time.However, some changes in care delivery have been made as a matter of publicpolicy. The overriding strategy for managing the process of change in a waythat involves all necessary people must be strong communication methods:"Communication is critical to effective change," says Lancaster (1999, p.165). (1998). To this point, Lancaster's method mostnearly intersects with Lewin's idea of force fields, since identifying theplayers and the issues, pro and con, is so important, although ifdeveloping a strategy can entail the project of dislocating people'scomfort level with the status quo, then there is a certain amount ofLewin's unfreezing going on. Thus as a practical matter,responsibility for implementing change, whether market-driven or care-driven, devolves onto nursing managers and staff. But of course the emotional costs of change as perceived by health-care practitioners are really the core project of motivating acquiescence,assent, and cooperation in change strategies. From consumers this takes the form of "redirect[ing]"inpatient to outpatient care, while from "major payors" of costs it takesthe form of demands for "better management of resource consumption"(Sullivan & Decker, 1998, p. House approves HMO bill. Hastings G. 267). Itis also descriptive, inasmuch as it defines what change in general lookslike, leaving to those involved in change the task of plugging inspecifics. Effects of changes in the structure of health-care delivery and theimplications for change in nursing praxis are identified by Lancaster(1999) and Sullivan and Decker (1998), who focus chiefly on the demands forcost containment. (1999, October 8). Hadley, J., & Mitchell, J. J. (1997). Veterans Administration, whichhistorically provided $17 billion in publicly funded health care to armedservices veterans every year, in 1996 began to decentralize the managementstructure of hundreds of hospitals, outpatient clinics, nursing homes, andother facilities while also initiating efficiency and consolidation offacilities, programs, and services, "borrowing ideas" from privateindustry, such as shifting from costly inpatient care to less costlyoutpatient care, managed care practices, and preventive medicine: "VA istrying to reengineer its system, while maintaining its core mission" (GAO,1999). General Services Administration. (1998, August 28). The instant availability of information and the need to move itquickly, via a host of technologies, has been an aspect of health-carerestructuring. The degree to whichauthority for managing change accompanies responsibility has historicallybeen a matter of some dispute, given the tradition of physician leadershipin treatment settings of all kinds. Segmentation and decentralization of institutional care provision haveundoubtedly been driven by market forces, but the back end of responding tocost pressures can be discerned in the effects on day-to-day administrationof hospital and health-care administrators. Consider the relationships between the Lewin and Lancaster modelsof change stages, the former cited by both Lancaster and Sullivan andDecker. Inevitably, these various models, distinct as they are, overlap andconverge. . Lancaster (1999, p. These changes are taking placeto support short-term-profit corporatism at a time when demand for nursingpersonnel is increasingly scarce, particularly in remote geographicalareas. For example, one study found a 14 % increase in the number ofAmerican workers declining medical insurance offered through employer plans(Cooper & Steinberg, 1997), a disquieting comment on access to medical carein an environment where costs of care for patients tend to increase, notdecrease. A report for the International Council of Nurses ICNworkforce forum, Stockholm, Sweden. But it is difficult to see why more attention is notpaid to the fact that change managers who have an emotional investment intheir change strategies can do quite as much damage to the process as thosechange-resistant line staffers who have an emotional stake in or experiencegrief over the way things used to be. Therationale behind this "politically popular" proposal for HMO reform is theevidence that patients fear they will be denied care they need by HMO ormanaged-care bureaucracies far removed from treatment situations. On that point, Lancaster says, managers should be"flexible and adaptable"; this goes back to the dangers of an emotionalinvestment in the new plan and an implicit obligation to continuallyrethink the strategy. Inparticular, they advise managers to take the time to explain negativeconsequences of not changing and positive consequences of changing,although advocacy that is too fervent, they say, may actually increaseresistance (p. This does not mean that every single staffer goes to every planningmeeting. . Lancaster sums up the strategic responseto resistance as one involving observation, communication, group processskills, and political astuteness (p. In otherwords, there may be a gap between the expectation and the fact ofstructural change. Malone, B. On the other hand, implementation fromone point of view captures the notion of moving to and positivelyreinforcing new behavior, and of refreezing new behavior, as well asidentifying watching for the force-field oppositions that encourage andretard change dynamics. The present point, however, is that there has been systemicchange, not simply changes in policy of one hospital or indeed one $17-billion care agency. The health-care system respondedto the crisis by focusing on costs and fostering a structural "revolution":"From physicians to hospitals to managed care firms, the test in the yearsahead is to continue to improve quality in the face of relentless costpressure. Bethesda, Md.: Agency for Health Care Policyand Research. But the statistics do not bear that out. These factors, together with the increase inmedical insurance coverage, funded by private underwriters and governmententities alike, help explain the rise in the number of patients seekingaccess to care. (1999). But the quality of on-line information,including technical and medical data, is of highly variable reliability; alittle medical knowledge could be not only dangerous but life-threateningas well. There have been certain positive effects of decentralization andoutpatient structures on nursing, notably an increase in clinical autonomyfor nurse managers and practitioners. While thisincreases nurses' skill sets, there is a trade-off in time management,particularly nursing time spent with patients. However, there are even more obviousbarriers. R. Lancaster's first three steps deal with diagnosis of theorganization's situation, including resources and personnel, leading up tostep 4, selecting a change strategy (e.g., Lewin's, but it could beanother) suited to the organization's needs. 165). Kansas City Business Journal. Senatepassage of this proposal is doubtful but public policy can well informbureaucratic structures, which inform practitioner behavior, which affectspatient experience. 149) mentions "beepers, cellulartelephones, voice mail, satellite and fiber-optic broadcasting, electronicmail, faxes, and overnight mail delivery." Technology-driven instantgratification in this area is connected to the effect on practitioners,which perforce is connected to the effect on patients. todefine what desired results [the agency] wishes to achieve, identify thestrategy to achieve the desired results, and then determine how well itsucceeded in reaching results-oriented goals and achieving objectives"(GAO, 1998). If there is anysingle issue on which health-care theorists, practitioners, policy makers,and consumers agree in the current period, it is that health care ingeneral and the profession of nursing in particular have been permanentlymarked by change. This point is also made bySullivan and Decker (1998, p. In the case of the VA, forexample, the intent of decentralization, which includes site-specificmanagement responsibility and authority for budgets and resourceallocations, was to increase both systemic efficiency and executive-administrator accountability. AssociatedPress. Hence the textbooktreatment of nursing's leadership in managing change, as well as the factthat so many different models of organizational change are offered to nursemanagers (Lancaster, 1999; Sullivan & Decker, 1998). In this regard, the U.S. 279), listeningentails observing such nonverbal cues as bad work habits and deliberateindifference to the new systems. Retrieved on theWorld Wide Web, October 4, 1999, at http://www.ahcpr.gov/. Approximately six million workers--typicallyyounger, racial-minority, and/or lower-wage employees--refuse employment-related health insurance even when available, owing to such reasons asincreases in employee contributions to plans vis-à-vis real-wage declineand legislation meant to enhance insurance coverage that, ironically,increased costs, as care providers seized the opportunity to obtain a sliceof the legislative increase (Cooper & Schone, 1997). Nursing issues in leading and managing change. Lancaster's eleven-step model of change, by comparison, can beconsidered as tactical, collapsing what change looks like into what to doabout it and how. It does mean, as Sullivan and Decker state, that change managershave to make a project of identifying resistant employees and bringing theminto the process, specifically making sure that they are heard on theissues and that everyone involved knows it. Steps 5-7 involve developing,testing, and revising the strategy. Change managers must also listen, since some frustrations may indicateproblems with the plan. 278). Ironically, as theorists point out (and as thepractical features of organizational systems develop a life of their own),those in charge in millennial nursing care must be prepared to see the veryprecision and utility of their new vision enlarged, diffused, andtransformed. The effect of this entrenched, subsidized system,particularly after Medicare and Medicaid were instituted as a government-subsidized health-insurance systems for the elderly and the indigent,respectively, in the mid-196 s (General, 1997), was to conceal the costs ofhealth care, which rose so dramatically during the 197 s and 198 s that bythe 199 s they were simply beyond control. Malone and Marullo (1997) forcefullyargue that nursing as a profession has been negatively impacted by market-driven health-care restructuring, "whose defining characteristics are costcutting, reduced utilization of services, and maximization of revenues andreturn on investment." Specifically, they describe erosion of staffinglevels, involuntary shift rotation, and the piling-on of multiple skill-setduties in ways that displace patient care as well as nurses' rights asemployees and workplace health and safety. Purchaser's View of Health Care Market Trends.Bethesda, Md.: Agency for Health Care Policy and Research. 162) refers to fear of losing identityand security on one hand and feeling trapped on the other, all of which canresult in everything from anger, frustration, mistrust, and hostility toliteral grief for the comfortable old ways. Hastings(1997) describes strides made in the 199 s in this area, noting "theenormous progress made in driving down costs while sustaining quality," inparticular at his hospital in Shawnee, Kansas. Lancaster's last two steps, which deal withevaluating changes made and recommending future actions, do not necessarilyfall entirely outside Lewin's classical formulation; however, what isimportant about them is that they anticipate the persistence and permanenceof change that is characterizing health-care systems in the modern period,as well as the real-world fact that nurses are going to be at the center ofthe change. Both Lancaster(1999, p. Shorter inpatient length of stay can beinterpreted as one aspect of this. The working poor who cannot afford to buymedical insurance yet cannot qualify for publicly funded health care arepart of this universe. Evidence for this is as recent as October 1999, with the passagein the U.S. But the autonomy is strictly withincost limits, which explains nursing's persistent advocacy of patient-carequality (Malone and Marullo, 1997). In general, of course, health care in institutional settings hasbecome much more expensive for receivers of care, even as the health-caresystem--decentralized on one hand, consolidating via mergers andacquisitions on the other hand--has become more elusive, less accessiblefor certain populations. J., & Decker, P. According to Sullivan and Decker (p. ahcpr.gov/. (1997, April). 152). The intent is . Workforce trends among U.S.registered nurses. But as Lancaster (1999, p. Lancaster, J. Lewin's "classic" change theory is captured in three stages:unfreezing existing behavior, moving to a new level of behavior, andrefreezing new behavior. Leaving aside thelimits of technology and long-distance treatments, it is difficult toignore the benefits of allowing physicians to engage in internationaldiagnostic conference calls and the life-saving value implied by sucheasily transferable expertise. Chapter Report,GAO/HEHS-98-226). Part of managing resistance,in Lancaster's model, is the nurse manager's ability to recognize the pain(p. The texts make clear that the human element--and thepsychoemotional vicissitudes that it implies--will figure prominently intochange management. In theory this could be seen as a method of lessening demand oncostly institutional health care, with well-informed patients using on-lineresources to avoid unneeded care. Retrieved on the World Wide Web,October 4, 1999, at http://www.nursingworld. Such issues are in thebackground of the injunction to "keep resisters involved in face-to-facecontact with supporters" (Sullivan & Decker, 1998, p. Relevant in this regard would be theinstant availability of medical information to all who have access toInternet. Whether these fears and feelings are irrational or not, saysLancaster, it is the obligation of the change manager to allow people tovent their frustrations. More offers, fewer takers foremployment-based health insurance: 1987 and 1996. Restructuring is specifically andprogrammatically embedded into that strategy, for medical center directorsare accountable for both efficiency and improving the range of access tocare for hitherto underserved veterans who are eligible for care. But he adds: "these changesrequire us to constantly adjust our own long-held beliefs, cherishedassumptions and traditional strategies about the health care business."This can be connected to the rise of HMOs and managed-care plans as opposedto traditional fee-for-service insurance plans. If there is an overarching lesson for nurse managers to learn aboutthe continual restructuring of health care in the U.S., it is that desiringchange, or even coming up with objectives and goals that can be reached "ifonly" certain behavior or resource allocations in an organization change,will not make change happen, still less make it work. org/readroom/usworker.htm. Health care changes.News for Consumers. But it is not accurate to say that Lancaster's 11 stepsshould be squeezed into each of Lewin's three categories; rather,Lancaster's ideas can also be considered strategic in nature, to the degreethey develop a total picture of changing organizational systems. (1997). (1997). (1999). 161) cites research showing that the health-care system oftengets forced into changes imposed from above. By the 196 s, the care-delivery system had been wellinstitutionalized: "Hospitals were the focus of care; physicians were incharge; providers told patients what to do; patients were dependent"(Healthcare, 1999). Whether all patientsare well positioned to engage in responsible self-care that in formerdecades might have been administered in a hospital has been the subject ofongoing debate. Studies sponsored by the Agency for Health Care Policy and Research in1996 and 1997 found that decentralization, also known as segmentation, ofhealth-care organizations, has erected barriers to institutional andpractitioner care access. Class notes. 278) cite the resentments thatmay grow if the change plan involves downsizing or reassignment of duties,titles, reporting, compensation structures. Healthcare systems redesign historical overview. These forces are really issuefronts and factors of analysis for the change manager, and they may rangefrom personnel attitudes and behavior to budget, time limits, protocols,and beyond (Lancaster, 1999, p. Lancaster (1999) connects this to the need for medicalpersonnel, including nurses, to become proficient (i.e., be trained) in theuse of the new machines if they are to accomplish their goals. Another aspect of this issue relates to access: Patients who mayhave the acuity to surf the Internet for medical information may not havethe computer suited to the task, and in that case are actually deniedaccess to information that their more affluent counterparts may have. Cooper, P. 279). Within this scheme is a "force-field analysisframework," which comes down to the tension between driving forces towardchange and restraining forces on change. Indeed,they assume that change is a core reality of organizational systems, whichreflects real-world health care. Retrieved on the World Wide Web, October4, 1999, at http://www. Retrieved on the World Wide Web, October 4, 1999, athttp://www. HMO Penetration on Physicians'Work Effort and Satisfaction. Retrieved from World Wide Web, October 4, 1999,http://www.hadit.com/library/gao/hehs98226.html. 279). VA health care: Moreveterans are being served, but better oversight is needed. Now the pain is real whetherthe facts upon which it is based are real or imagined. The structure of change and the strategic approach to it seem to offera systematic response to what we have seen are systemic operations. Oneaspect of this was a policy change that lifted historical restrictions oncoverage for outpatient care. Lewin's model can be seen as strategic in nature to the degree itprovides a structure into which individual change issues can be placed. Lancaster (1999) cites nursing literature that cautionsnurses to seize the initiative in managing change in health-care venues, sothat they will have a voice in the shape that change assumes ininstitutional systems. Now the shape that such changestake will be highly variable, venue to venue, which means that no singleplan for change is likely to apply in all cases. Union organizations, Sullivanand Decker point out, may be strong advocates for status quo staffingpatterns for their membership even if the organization as a whole needsstaffing revisions. S. F., & Schone, B. This research will examine the phenomenon of change in the design orredesign of health care, focusing on the role of the nurse. Retrieved on the World Wide Web October 8, 1999, fromhttp://newsroom.compuserve.com/nr/story.asp?art=..\..\apo/Washington/Washington_151.htm&Top=1&CoView=. One emotionalhazard that neither Lancaster nor Sullivan and Decker directly address--though it is implied--is that of "coercive change" (Lancaster, 1999, p.151). 266). . The focus on getting the patient out and not in the hospital hascharacterized health-care delivery in general, to the degree it waspossible for patient and caregivers to realize good patient outcomes withless inpatient time. In 1992,when the decade's debate on health care and the public discourse aboutnational health insurance began in earnest, the number of medicallyuninsured Americans was said to be 37 million; by 1998, that figure was 43million (Bavley & Sanchez, 1998). But theattraction of order, structure, and system, especially if they respond to ahighly structured (or anyway highly bureaucratic) situation, can bemisleading. H. 161) being experienced by those who think change is worse than thestatus quo and to turn the perception around. 15 ) pointsout, nurses are uniquely positioned to facilitate and manage change inhealth-care organizations because they "often realize that quality care iscentral to the organization's effectiveness." Tension between responsibility and authority aside, the hard fact ofchange where nursing is concerned is that the structural changes are goingto come whether nurses like them or not. References Bailit, M. Nursing, labor-intensive and "at thepoint of patient care that is the business of health care" (Lancaster,1999, p. ahcpr.gov/. Bethesda, Md.: Agency forHealth Care Policy and Research. This is especially the case sinceLancaster (p. L., & Marullo, G. (1997). As a society, we can no longer afford the enormous cost increasesthat characterized health care in the 197 s and '8 s"(Hastings, 1997). [and] give patients more leverage against HMOs" (Meckler, 1999). New York: Addison-Wesley. Sullivan and Decker suggestspecific political strategies, e.g., knowing the formal organizationalchart backward and forward, plus the informal leadership and loyaltystructure among staffers, which can be even more important to makingpsychoemotional communication pay off (p. Advances in medical science and technology have driven health-carerestructuring. Lancaster (p. M. (1997). 149) cites the setting of qualifications for costs thatwill be reimbursed by insurers. Next, if they respond, it must be without anger ordefensiveness, according to Lancaster; Sullivan and Decker emphasize theneed for rational, not emotional, responses by change managers. Honesty and openness are corerequirements of communication, as is the need for communication to move notonly from the top down but from the bottom up. Sullivan and Decker (1998) say that increased patient acuity hasdriven structural health-care changes.
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