Nursing: Internal and External Forces of Change

Nursing: Internal and External Forces of Change

The Change Project

This paper explores possible internal and external forces that could impact the planned implementation of an organization change project – reducing D2B time for STEMI patients. Evidence demonstrates that most change efforts fail across various sectors and organizations. Both internal and external forces play critical roles in change management failure or success. However, effective implementation of the change project using an appropriate implementation plan can mitigate restraining forces.

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External Forces

While multiple external forces are available, the initial step should begin from the patient and family, relatives, and friends. Reducing D2B time for STEMI patients should start with patients and close families to avoid patient time delays (American College of Cardiology Foundation & American Heart Association, 2013). Most of these delays are ignoring symptoms, reluctance to bother others, and lack of knowledge of some factors related to STEMI.

Despite the wide coverage of the US population with emergency response services, some studies have established that most STEMI patients do not use 911. In fact, only about 60% of STEMI patients use ambulances (Mathews et al., 2011)Nursing: Internal and External Forces of Change.

This situation affects the response time of emergency dispatchers if they are called at all. Most STEMI patients transported by personal vehicles suffer cardiac arrest en route to STEMI PCI-capable centers.

It also noted that prehospital ECGs by trained personnel are linked to shorter reperfusion times and positive clinical outcomes. This situation requires communication of diagnosis and means of transport used.

Not all STEMI patients will be able to get to a PCI center within the required time. Thus, it is vital for all PCI centers, in collaboration with EMS and STEMI referring hospitals in different areas, to have shared and common STEMI protocols to enhance timely access to reperfusion for all STEMI patients or suspected cases. Besides, all STEMI referring hospitals should have a STEMI protocol connected to the PCI center to avoid longer processes in communication and notifying a PCI hospital (American College of Cardiology Foundation & American Heart Association, 2013). In this regard, change to reduce D2B time delays is most likely to originate outside the hospital.

Internal Forces

Once STEMI patients arrive at the PCI-capable center, internal factors could affect the D2B time. PCI is known to reduce mortality and morbidity, but delays may affect its effectiveness (Levis, Mercer, Thanassi, & Lin, 2010). Internal factors that could lead to delays include a single call for the EM physician to activate the CCL. This process should occur when the patient is en route to the hospital. However, a failure to achieve this procedure could result in delays. Moreover, it is also expected that the staff, including nurses, techs, and paramedics, also the PBX personnel who are in charge to activate the STEMI team and the STEMI team itself integrated by two nurses from Cath lab, 2 Cath lab technicians, and the invasive cardiology should only take 20 to 30 minutes to arrive at the center.

Communication can either drive or derail a change plan. Real-time case feedback should focus on major change resisting forces. For instance, patients may not be in a condition to grant informed consent immediately once they arrive at the hospital (Victor, Gnanaraj, Vijayakumar, Pattabiram, & Mullasari, 2012)Nursing: Internal and External Forces of Change. Hence, the communication system should be real-time and coordinated among all care providers to ensure that delays are eliminated. Human factor resisting force in this context can be controlled through effective communication, leading to collaboration.

Besides, a team-based approach as a driving force can ensure that various departments, including departments of emergency response, cardiology, and interventional cardiology, among others, all work together to reduce delays while sharing knowledge on the best practices.

Administrative support should be considered as a vital driving force that can ensure effective change project execution. The lack of that support implies that the change project will fail. Nurse leaders should promote open communication develop standard procedures, protocols, and other guidelines to enhance care delivery. A multidisciplinary team of nurses, physicians, other non-medical teams, and hospital administrators should collaborate to realize both administrative support and positive team efforts, for instance, by developing procedures that reduce lengthy notification systems (Stowens, Sonnad, & Rosenbaum, 2015). Thus, the driving force here should exceed the resisting force in order to implement the change project. Overall, administrative support is necessary to empower the entire care provision system.

Strategies for Overcoming Obstacles by Using Driving Forces and Minimizing Resisting Forces

Reducing delays associated with D2B time for STEMI patients requires an administrative system that empowers triage nurses to start the STEMI page process without ED physicians. This action, coupled with the nurse, physician, and patient education, will reduce any attempts to resist change significantly. Effective solutions can only emanate from individuals involved in the care processes, which will communicate prognostic factors with all care providers to improve the quality of care and eliminate delays (Peterson, Syndergaard, Bowler, & Doxey, 2012). At the same time, as previously mentioned, communication through enhanced notification and feedback processes would lead to faster processes and facilitate the required change.

Once care providers are sufficiently empowered to contribute toward a change project, they will contribute and give their feedback freely. Constructive feedback is necessary to improve the change project and outcomes. Further, standardized processes and procedures can be used to overcome delays noted in care provision. The hospital administrators should develop processes and procedures that facilitate care provision while providing the necessary support to ensure that the change project succeeds.

Contribution to Nursing Knowledge and/or Practice

The change project to reduce delays associated with D2B time for STEMI patients is most likely to meet internal and external forces that could either support or derail the project. However, these forces present new opportunities for nurses to take an active role in care provision as they strive to define new roles when adequately empowered to deliver care. Nurses should therefore focus on change driving forces while minimizing restraining forces to overcome change obstacles. Thus, human factors, processes, procedures, and organizational factors will play critical roles in influencing outcomes of the change project to reduce D2B time for STEMI patients.


American College of Cardiology Foundation & American Heart Association. (2013)Nursing: Internal and External Forces of Change. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation, 127, e362-e425. Web.

Levis, J. T., Mercer, M. P., Thanassi, M., & Lin, J. (2010). Factors Contributing to Door-to-Balloon Times of ≤90 Minutes in 97% of Patients with ST-Elevation Myocardial Infarction: Our One-Year Experience with a Heart Alert Protocol. Permanente Journal, 14(3), 4–11.

Mathews, R., Peterson, E. D., Li, S., Roe, M. T., Glickman, S. W., Wiviott, S. D.,… Wang, T. Y. (2011). Use of Emergency Medical Service Transport Among Patients With ST-Segment–Elevation Myocardial Infarction. Circulation, 124, 154-163. Web.

Peterson, M. C., Syndergaard, T., Bowler, J., & Doxey, R. (2012). A systematic review of factors predicting door to balloon time in ST-segment elevation myocardial infarction treated with percutaneous intervention. International Journal of Cardiology, 157(1), 8-23. Web.

Stowens, J. C., Sonnad, S. S., & Rosenbaum, R. A. (2015). Using EMS Dispatch to Trigger STEMI Alerts Decreases Door-to-Balloon Times. Western Journal of Emergency Medicine, 16(3), 472–480. Web.

Victor, S. M., Gnanaraj, A., Vijayakumar, S., Pattabiram, S., & Mullasari, A. S. (2012). Door-to-balloon: Where do we lose time? Single centre experience in India. Indian Heart Journal, 64(6), 582–587. Web. Nursing: Internal and External Forces of Change


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