Both management and the emergency nursing staff have identified the need to improve the practice of triage in the emergency departments. Each has expressed, in written documents, the recommendation to change and implement the new national triage guidelines.
At the same time, the emergency department staff has expressed dissatisfaction with how changes have been implemented in the past. They have expressed their perception that there is no formalised plan to implement change. In addition, they have also expressed, in meetings and discussions within the department, their unhappiness with the multitude of changes that have occurred within the organisation itself.
The emergency staffs, themselves, have also undergone changes in their unit's management. They have gone from having their own individual managers to one manager for multiple facilities. They have also had a number of different managers over the past few years and identified a lack of consistent leadership within the department.
Another issue that has also been identified in staff meetings and discussions within the department is the staff's unhappiness with how decisions are made within the department. It is their expressed perception that the system of decision making within the organisation is top/bottom. Decisions are made by management at the top and flow down to staff at the bottom, who are expected to follow them. The emergency department staff has expressed their feelings of not being listened to. They have also expressed their perception that others are making decisions and implementing changes that affect them, but no one has consulted them in the process. Lack of input and obvious planning are seen as fundamental problems. Changes are seen as being imposed without consultation or any visible change management planning or strategy (Paton & McCalman, 2008). According to Senge (1990), most organisations create fundamental learning disabilities by the way they have been taught to think, interact and do their jobs. In this top/bottom system there is a sense of "I am my position" from the top and "the enemy is out there" from the bottom (p.18-19). These learning disabilities limit the organisation's ability to implement effective and lasting change. A change that is planned and has the commitment of the emergency department staff could be implemented successfully and be of benefit to both the patients encountering the emergency department, and the organisation itself. Identifying the Problem Nurses value quality care and patient safety (Henderson et al, 2007). Accurate decision making is important to them. Nurses want to make the right decisions but do not necessarily like the idea of change. Emergency nurses like many other professionals resist change (Paton & McCalman, 2008). In addition, the tremendous amount of change the facility emergency departments have been through in recent years can be expected to increase this resistance. "However people attracted to a field as diverse and chaotic as emergency care are usually aggressive and motivated and do not tolerate stagnation any better then they tolerate change" (MacPhail, in Budassi-Sheehy, 1992, pl). One cause of the problem is continuous change within the organisation and the perception that change is implemented without consultation or a plan of action (Harvard Business Essentials, 2003). The root cause of the problem is a lack of trust. When employees trust the management they are more likely to be more prepared and open to undertaking change but less likely if they do not feel trust. Trustworthiness needs