NR 528 Week 5 Change Model Application Example

Change Model Application: Lewin's Three Phases Filled From Our Unit's Head-of-Bed Change, With a Test That Says When Each Phase Is Finished and Nights Tracked Separately From Days

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College of Nursing, Chamberlain University

NR 528: Leading and Managing Evidence-Based Change in Nursing

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Month Day, Year

Change Model Application: Lewin's Three Phases Filled From Our Unit's Head-of-Bed Change, With a Test That Says When Each Phase Is Finished and Nights Tracked Separately From Days

Why Lewin, and Why Tests

Lewin described change in social systems as moving a group from one stable pattern of behavior to another, which requires first loosening the existing pattern, then moving to a new one, then stabilizing it so it holds (Lewin, 1947). His description is often summarized as unfreezing, changing and refreezing. It fits the head-of-bed practice on our progressive care unit because staff already know the rule, and what holds them back is a stable habit: beds are lowered for care and not raised again, especially at night.

The model's weakness in practice is that its phases are easy to declare and hard to verify. A unit can announce it has moved to refreezing because teaching is over, while nights are still where days were a month ago. This application therefore attaches a test to each phase, a condition the phase has to satisfy before it counts as finished, and applies the tests separately to day and night shifts.

The Forces at Work

Lewin also described change in terms of forces pushing toward and against it. On our unit, the driving forces include a recent aspiration event on a night when a tube-fed patient's bed was flat, clear nutrition support guidance favoring a 30 to 45 degree backrest in high-risk patients (McClave et al., 2016), and staff who want to prevent a repeat. The restraining forces include the workload of raising beds after every repositioning, patients sliding down and asking to be lowered, concern about sacral pressure injuries, and the absence of any way to see the angle at a glance. The plan strengthens the driving forces modestly but concentrates on weakening the restraining ones, since removing a barrier usually moves behavior more than adding pressure does.

Phase 1: Unfreezing

What happens. Staff hear the case for change, including our own audit, only 41% of beds found at or above 30 degrees, and the aspiration event. Angle indicators are installed on every bed. The wound care nurse's guidance on repositioning and mattresses is written into the practice.

The test for finishing. At least 80% of staff on that shift can state the practice and why it matters when asked by a charge nurse during a huddle, and every bed has a working indicator.

Days and nights. Day shift is likely to pass this test in week 7, after its teaching sessions. Night shift, which was never taught during the first attempt and has its own sessions, may take a week longer. The plan does not move nights into the next phase until nights pass.

Phase 2: Changing

What happens. The practice goes live. Charge nurses check every tube-fed patient during the safety round. Weekly audits at four set times count how many of the checked beds sit at or above 30 degrees. Problems are fixed as they appear, for example by adding a pause-and-restart reminder label to feeding pumps if nurses report forgetting to raise the bed before restarting.

The test for finishing. At least 70% of observations on that shift meet the practice for two consecutive weekly audits.

Days and nights. Days may reach 70% within three weeks of go-live. Nights, starting from 28%, may take longer. If nights stall below 70% for four weeks, the plan returns to night shift for another round of the unfreezing work, asking night nurses what is getting in the way rather than repeating the teaching.

Phase 3: Refreezing

What happens. The practice is built into routines that do not depend on the project: the flowsheet field, the charge nurse safety round, new-hire orientation and the annual competency checklist. Weekly audits drop to monthly.

The test for finishing. At least 85% of observations on that shift meet the practice for three consecutive monthly audits after weekly audits have stopped. This target reflects what has been achieved elsewhere: in a study of an aspiration risk-reduction protocol, almost 90% of protocol patients had a mean head-of-bed elevation of 30 degrees or higher, compared with 38% in usual care (Metheny et al., 2010).

Days and nights. It is entirely possible for days to be refreezing while nights are still changing. The unit will report the phase for each shift separately.

What the Tests Add

Without tests, the model would have described the first attempt as complete: the case was made, teaching occurred, signs went up. With tests, the first attempt would have been recognized as stuck in unfreezing on nights, since night staff were never taught. The tests turn the model from a story told afterward into a tool for deciding what to do next, and they make visible the fact that the unit is not one group but at least two, moving at different speeds.

Where the Model Falls Short

Lewin's model assumes that once a new pattern is stable it will hold, and it says little about the ordinary turnover of a hospital unit. On our unit, roughly one nurse in six changes each year, and float and agency nurses cover shifts every week. A refrozen practice can thaw quietly as the people who learned it leave. The application answers this partly by building the practice into orientation and the charge nurse round, which do not depend on who is working. It also treats the monthly audit as permanent rather than as scaffolding to be removed, because the model offers no other signal that a stable pattern has begun to slip. A second limit is that the model describes groups, not individuals; a single agency nurse on nights can lower a bed and leave it there regardless of the unit's phase, which is why the charge nurse round checks each patient rather than relying on the unit's average.

Why Each Shift Passes Its Own Test

Our baseline shows why the tests are applied by shift: 52% on days and 28% on nights. A single unit-wide figure of 80% could be reached with days near 95% and nights still near 65%, and the change phase would be declared finished while the problem that started the project, a flat bed at night, remained. Each shift therefore passes or fails its own test. The unit may be refreezing on days while it is still changing on nights, and the plan treats that as normal rather than as a failure, because the night shift started further back and faces different pressures, such as 0400 weights and linen changes.

References

Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social change. Human Relations, 1(1), 5-41. https://doi.org/10.1177/001872674700100103

McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., McCarthy, M. S., Davanos, E., Rice, T. W., Cresci, G. A., Gervasio, J. M., Sacks, G. S., Roberts, P. R., & Compher, C. (2016). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211. https://doi.org/10.1177/0148607115621863

Metheny, N. A., Davis-Jackson, J., & Stewart, B. J. (2010). Effectiveness of an aspiration risk-reduction protocol. Nursing Research, 59(1), 18-25. https://doi.org/10.1097/NNR.0b013e3181c3ba05