Initiation of Nursing Service Development in the Outpatient Department Using Kotter's Change Theory

Outpatient nursing services are an important element for hospitals to produce many patients, particularly inpatients. Outpatient nursing services are currently still not optimal. Nurses are responsible for providing good service to increase patient satisfaction. Aim: This case report aims to describe the implementation of planned changes to optimize the outpatient nursing service planning function. Method: The method used is a case report. Data collection uses interviews, questionnaires, and field observations. The results of data exploration are then analyzed using SWOT (strengths, weaknesses, opportunities, threats) and fishbone diagrams, then formulating a plan of action (PoA), followed by implementation and evaluation. Results: The results of the study showed that the priority problem in nursing services was that the implementation of the planning function was not optimal. Making outpatient nursing service guidelines is a strategy for solving problems in developing outpatient nursing services. Implementation of problem-solving uses a theory of change approach by the stages of Kotter's eight-step plan. Recommendation: Kotter's eight-step plan theory of change approach can be continued by hospital management as a form of initiation of service development.


INTRODUCTION
Outpatient nursing services currently are still not optimal.The results of research conducted by Zendrato et al., (2019) found that the implementation of outpatient nursing services in several hospitals in Indonesia was not optimal (56.8%), especially in carrying out diagnosis (63.7%) and implementation (62% ).Currently, outpatient nurses still lack autonomy, leadership, and practice management; so every health service location is still not ready to accept the challenge of creating solutions for the increasing volume of patients, especially in nursing services (Start, Matlock, & Mastal, 2016).In Australia, nursing services are not optimal due to missed actions in ambulation (87%), patient education (79%), interdisciplinary conference attendance (78%), oral care (78%), intake and output (77%), and turnover.patients (75%) (Sarpong et al., 2023).
Outpatient services are services that must be provided by hospitals that have been regulated in public policy.One of the types of hospital services that hospitals must provide is outpatient services (Minister of Health of the Republic of Indonesia No. 129, 2008).According to Minister of Health Regulation Number 11 of 2016, concerning the implementation of executive outpatient services in hospitals, mention that the Executive Outpatient Services are the provision of non-regular outpatient health services in hospitals which are provided through the services of specialist-subspecialist doctors in one special integrated room facility without stay in a hospital with facilities and infrastructure above standard.
Outpatient nursing services are services in hospitals that are a benchmark for the quality of services.
Outpatient departments are the first entry point for people to gain access to the health system, especially in hospitals, directly influencing patient satisfaction (El-Jardali, Sheikh, Garcia, Jamal, & Abdo, 2014).The diverse needs of patients make hospitals carry out continuous evaluations and changes in outpatient care to meet patient care needs and still pay attention to workload and patient composition (Yao, Zhao, & Xiangping, 2013).The implementation by nurses makes the outpatient unit an essential area for patients to obtain optimal well-being and service.
Management of outpatient services has challenges from various factors.The previous research conducted by (Budana & Ardana, 2022) Supporting factors for service management at outpatient departemen from an internal perspective are the availability of competent human resources and the existence of facilities and infrastructure that support services.The external supporting factor is the existence of a health service referral system which causes the number of patient visits to the clinics to decrease significantly.Meanwhile, the inhibiting factor is that the budget managed is much reduced due to the decreasing number of visits.The reduction in the managed budget results in the number of services received by employees also decreasing.(Gab Allah et al., 2020) mention that the common problem faced by nurses in the workplace were stress, work overload, conflict, workplace violence, poor performance, staff turnover, demotivation, lack of empowerment, and staf absenteeism.
The role of nurses in outpatient care determines the satisfaction and results of patient care.The nurse profession plays a significant role in creating coordination between outpatient care professions, especially for patients with chronic diseases who require education and disease management, thereby reducing the frequency of patients' consultations with doctors (Jeffers & Baker, 2016).Good communication and coordination between nurses in outpatient care have been proven to create a relationship of mutual trust between patients and nurses, making patients more likely to follow the advice and input given regarding their health (Northwood et al., 2022).Optimal outpatient nursing services can reduce anxiety, depression, and the number of hospitalizations while increasing patient self-efficacy in transitional care from the outpatient clinic to the home by emphasizing continuity of care, patient discharge planning, and telephone follow-up to provide education health education, and consultation (Yuroong et al., 2021).
Efforts to manage outpatient nursing services are closely related to the management roles and functions carried out by nursing managers.As a manager in the outpatient departmen, the head nurse has functions including planning, organizing, managing personnel, directing, and controlling, which are essential in managing outpatient care (Marquis & Huston, 2017).According to (Agusti et al., 2022), in improving the quality of service in outpatient rooms, nurse managers need to pay attention to the patient's perspective and the perspective of professional staff.A survey conducted at a private hospital in Depok regarding the role and function of management found that the planning function in outpatient nursing services still needed to be improved.The data obtained is that there is no outpatient nursing service guide available, there is no regular meeting program to discuss job descriptions and standards for outpatient nursing services, and 48.1% of nursing staff said there are no written regulations available in the room, 11.1% of staff are not active in taking decisions in outpatient care, 40.7% of staff hesitate to promote the excellence and effectiveness of care from outpatient nurses to patients and other professions.Only 45% of staff implement it well.Based on this phenomenon, initiating outpatient nursing services is needed through a planned change approach.
Planned change aims to achieve better goals and get maximum results from an organization.Changes can occur, planned or unplanned.Planned change is a deliberate, goal-oriented change in activity.Planned changes are changing activities deliberately and goal-oriented (Robbins & Judge, 2019).One approach that can be adopted to manage organizational change is Kotter's eight-step plan approach (Marquis & Huston, 2017).This case report will describe the implementation of planned changes to optimize the planning function in outpatient nursing services.

METHOD
The method used in this writing is a case report.The study results are then analyzed using SWOT analysis and fishbone diagrams to determine problem priorities.Problems that have been determined as priorities will be planned for their resolution, followed by the preparation of a Plan of Action (POA), carried out with the nursing manager, head nurse, and related departments through directed discussions.The problem resolution plan is carried out based on a planned change approach.Anticipation of the planned problem-solving cannot be optimal, so there needs to be another approach in the form of an agreed follow-up plan that has been approved by the key person and is known to the nursing manager.

RESULTS AND DISCUSSION
The results of a survey conducted in the outpatient department of Hospital X found that the outpatient unit had 14 service groups/clusters.The service groups are based on the expertise (Specialists) available according to each polyclinic, followed by nurses specializing in that field.The head nurse and CCM supervise 29 nursing staff.The distribution of nursing staff will be explained in Table 1.The study results were then analyzed using SWOT Analysis, as seen in Table 2 and the fishbone diagram in Figure 1.The fishbone diagram is based on the five management functions namely planning, organizing, staffing, actuating, and controlling.The main problem was that implementing the planning function in nursing services was not optimal.The findings that support this main problem are the unavailability of a guideline for Outpatient Nursing Services and the absence of a regular meeting program to discuss job descriptions and standards for outpatient nursing services.The finding also confirms that 11.1% of staff are not active in decision-making in outpatient care, 33.3% of staff are afraid to take responsibility for coordinating all aspects of the delegated nursing process, and 40.7% of staff are hesitant to promote excellence and effectiveness of care to patients and other professions.
This problem-solving strategy is compiled into the plan of action.The hospital management has agreed upon the PoA formulation through focus group discussion (FGD) activities and the implementation.The planned change approach used in implementing problem-solving is Kotter's eight-step plan, which consists of 8 steps.However, this outpatient nursing service development initiation only includes steps 1-3 because it is still in the planning change stage.The first stage is building a sense of urgency by creating a solid reason for the need for change.In this stage, the author carried out activities by identifying problems at the Hospital.The following process involves collecting primary and secondary data.The data collection process uses interview, observation, and questionnaire methods.The identification results are then analyzed, and the main problems and causes of the main problems are determined.The analysis results show that the planning function of the head nurse in implementing outpatient nursing services has yet to be optimal.It was found that there was no Guideline for Outpatient Nursing Services available, and there needed to be a regular meeting program between the head of the room and staff to discuss job descriptions and standards for outpatient nursing services.Then there is no precise nursing assignment method, 11.1% of staff are not active in decision-making, 33.3% of staff are afraid to take responsibility for coordinating all aspects of the delegated nursing process, 40.7% of staff are hesitant to promote excellence and effectiveness of care from nurses to patients and other professions, Supervision from HNs is rarely carried out and no follow up is carried out, 22.2% of staff do not contribute to sharing information/learning with fellow staff, Clinical Judgment from nurses is still not optimal, Quality and care audits are Inconsistent internal implementation, there is no internal audit program for implementing outpatient SOPs and 29.8% of staff do not dare to admit mistakes and take corrective action.
The second stage is to form a coalition with enough power to lead change.After creating urgency, the change agent forms a team to lead the change to achieve the change goals.The head nurse led this change.This change was also fully supported by the nursing division, all head nurses, and CCM, who were involved in formulating the POA to resolve the problem.
The third stage is creating a new vision to direct change and strategies to achieve the vision.At this stage, the team agreed to make changes by creating draft guidelines for outpatient nursing services.After agreeing, a POA implementation strategy was prepared with the nursing, HN, and CCM outpatient departments.The strategy used was to hold discussions with the HN of the outpatient unit in preparing draft guidelines, consult on the draft guidelines for outpatient nursing service standards with the nursing division and all stakeholders in the related units, conduct literature and journal studies related to outpatient nursing services, hold discussions/brainstorming to improve the draft.Then, there is a presentation of the results of the guideline that has been created by the PIC and a joint discussion with stakeholders or leaders in each related unit to discuss the draft that has been prepared.The meeting was attended by the nursing committee, nursing department, outpatient manager, head of the outpatient unit, head of the outpatient section, HN, CCM, and representatives from the PN/Nursing in charge for each room in Hospital X.
Analysis of the problems found shows that changes are needed in outpatient nursing services.The purpose of changes is to improve the situation (Marquis & Huston, 2017).The purpose of planned change is to increase the organization's ability to adapt to changes in its environment and change member behavior.The change agent is responsible for managing change activities and seeing a future for the organization that others still need to identify and can motivate, discover, and implement the vision within the organization (Marquis & Huston, 2017;Robbins & Judge, 2019).Therefore, a particular change is needed in the management function, namely in the nursing service planning function, to improve service quality and patient satisfaction.
Nursing services are implemented based on guidelines and policies set in the planning function by nursing managers.The policy is a plan reduced to statements or instructions that direct the organization in decision-making and define broad boundaries.Every organization needs to develop facility-wide policies and procedures to guide work (Marquis & Huston, 2017).Nurses are at the forefront of policy implementation and are uniquely positioned to see the impact of health policies on actions taken with patients (Edmonson et al., 2017).It is caused by nursing implementation requiring coordination with specialists with high levels of education, positioning nurses as vigorous advocates for change in the workplace and externally within nursing organizations and government agencies, as well as directly with political stakeholders (Drury et al., 2023).Policies are one of the critical elements that influence individuals in carrying out something and become the background in implementing interventions (Damschroder et al., 2009).Therefore, making nursing service guidelines in outpatient care is needed as clear instructions for carrying out the duties and responsibilities of nurses.
Ambulatory care nursing service guidelines contain standards for ambulatory care practice and management.These standards are authoritative statements describing the responsibilities of nurses and nursing managers as providers of services and care to patients (American Academy of Ambulatory Care Nursing, 2017a), divided into Clinical Practice and Professional Performance.In the clinical domain, six Clinical Practice Standards address the science of nurses' clinical practice in ambulatory nursing care to the nursing process.The nursing process is a rational and systematic method of planning and delivering nursing care applicable to individuals and groups from assessment to evaluation (American Nurses Association, 2019).Professional performance standards include activities related to ethics, education, research and evidence-based practice, performance improvement, communication, leadership, collaboration, professional practice evaluation, resource utilization, and the environment (McAteer & Moyer, 2022).
Outpatient nurse job descriptions are essential in delivering high-quality, evidence-based care.Nursing leaders provide job descriptions to improve patient safety, reduce adverse events, increase patient satisfaction, support and promote optimal health, reduce readmissions, and help manage efficient patient costs.According to American Academy of Ambulatory Care Nursing (2017b)the job descriptions of nurses that must be carried out in outpatient settings include implementing clinical standards of professional practice and professional nursing organization standards; Supporting and empowering patients/families for ongoing care and health promotion; Advocating for patient rights from a patient/family perspective; Anticipating ethical, spiritual, and cultural needs in interventions performed; Document all patient care activities, according to documentation standards, and assist healthcare team members with documentation; Respect and understand other clinical disciplines; Demonstrate effective and persuasive communication skills and assist with conflict resolution among healthcare team members, patients and families; Assist other staff to assess patient learning needs for evaluation of educational outcome measures.
Outpatient nursing services require suitable staffing arrangements and assignment methods.Outpatient staffing arrangements are an essential part of the health system and are critical in preventive health measures to keep people healthy and out of hospital (Auraaen et al., 2018).The results of a study conducted by Adynski et al., (2022) mention that when nurse staffing in outpatient settings is adequate, patient outcomes are improved, lower costs and nurse turnover decreases.The Primary Nurse assignment method can be applied in the outpatient setting because a nurse is responsible for planning, delivering, and evaluating the care of one or more patients from admission to discharge (Marquis & Huston, 2017).This method results in a continuum of care, as there will always be a primary nurse responsible for coordinating decisions and clinical supervision throughout the patient's stay in the hospital (Huber, 2010).This method gives nurses greater autonomy and higher quality of care, increases patient/family satisfaction, and maximizes staff performance (Parreira et al., 2021).
Nursing supervision is needed in the implementation of nursing services.Supervision is an activity in determining the conditions or personal and material requirements needed to achieve nursing care goals effectively and efficiently (Marquis & Huston, 2017).The types of nursing supervision that can be applied in the outpatient department include Retrospective Supervision (carried out by identifying the results of nursing services through documentation studies from attendance documentation, nursing care records, and internal and external patient satisfaction surveys.The results of this documentation assessed and compared according to established success indicators such as standard operating procedures (SPO), nursing care standards, and other quality indicators), Prospective Supervision (carried out by making references, guidelines, guidelines or standards set to provide guidelines for nurses in carrying out nursing care services) and Concurrent Supervision (carried out by supervisors when nurses carry out scheduled or unscheduled nursing care activities if there are activities that are not standardized / according to guidelines, the supervisor will provide input, direct, and provide direct solutions for improving nursing care) (Hariyati, 2014).Supervision affects the motivation of nurses to carry out nursing care documentation (Gustini et al., 2022) and affects efforts to improve patient safety in hospitals (Purnomo et al., 2022).
Outpatient services require quality indicators to ensure the services are provided to all quality patients and uphold patient safety.The quality indicators of outpatient nursing services explain that professional nurses are leaders and transformers in their services (Start et al., 2016).According to (Battaglia et al., 2016), the following types of Nurse-Sensitive Indicators and descriptions of measuring instruments in outpatient care: Ambulatory Care Nurse Readmission Across the Lifespan, pain assessment and follow-up, high blood pressure screening and follow-up, documentation of patient falls, fall risk assessment, body mass index (BMI) assessment, nursing staff demographics, and patient satisfaction.

Implementation of Change
Change requires a change agent who uses a theory of change approach to achieve goals.The change agent is responsible for managing all change activities, providing motivation, finding and implementing a vision in the organization, and seeing the possibilities that will occur (Robbins & Judge, 2019).(According to David et al. 2020), The theory of change model is well known for its use in business and often used in healthcare.Kotter's model has been widely used for health advocacy systems and developed according to a more general healthcare context, making its use easier.Szadkowski et al., (2016) mention that Kotter's theory of change has made the Pediatric Rapid Response Team (PRRT) feasible and well-accepted by inter-professional stakeholders to become a policy.In this case, the implementation of change is carried out in steps 1-3, while steps 4-8 are transmitted to the key person to continue the program according to the agreed follow-up plan.
The first stage in Kotter's stages of change is building urgency.Based on the results of research conducted by (Vale et al., 2022), it can be done by reviewing the literature and developing and distributing it to the organization that will change.Creating urgency in this stage also includes creating a climate for change.Organizational climate is related to organizational commitment and perceived performance in the organization.Organizational climate is an essential factor in healthcare settings regarding employee commitment and how employees perceive organizational performance, leading to significant outcomes regarding service provision in healthcare organizations (Berberoglu, 2018).This stage aligns with what the researcher did through an initial assessment and exploration of the phenomenon at X Hospital.
The second stage was to form a coalition with enough power to lead the change.At this stage, the outpatient HN has chosen to be responsible for solving the problem as the key person in the change.(Vale et al., 2022) revealed that one of the successes in implementing Kotter's theory is determining the person responsible for the change through cooperation and involvement with key stakeholder organizations.A previous study conducted by Maclean & Vannet (2016) mentioned that to improve the practice of trauma computed tomography (CT) in Wales using change techniques, the team formed a coalition with a small group of senior consultants in the Radiology department and cooperated with emergency consultants.Creating a coalition that produces leaders for change is critical to success in change projects.
The third stage was to create a new vision to drive the change and a strategy to achieve the vision.According to (Toor et al. 2022),this stage focuses on outlining the technical requirements and how to work together with leaders and stakeholder representatives.A detailed work plan is created to be implemented over time to solve problems and make changes.This statement aligns with research conducted by (Najjar & Ascione 2020), where making changes needs stages to create a vision.In this stage, the leadership has approved five strategic goals for successfully implementing Interprofessional Education (IPE).The initiation program team agreed that creating nursing service guidelines was a strategy to solve the problem.
Stages four, five, and six are declaring change.This stage is contained by communicating the vision throughout the organization, empowering others to act on the vision by removing barriers to change and encouraging risk-taking and creative problem-solving, as well as planning, creating, and rewarding short-term wins that move the organization towards a new vision (Robbins & Judge, 2019).The behavior of each organization member towards change, including readiness, openness, and commitment to change, must be considered for successful implementation in the organization (Chaudhry, 2018;Hower et al., 2019).The stage of promoting cultural change in the organization must be done in a focused manner and use team members to change slowly (Najjar & Ascione, 2020).Rewarding is one factor influencing employee engagement in organizations (Sun & Bunchapattanasakda, 2019).At this stage, good leadership skills are needed from the change leader.
The seventh stage is consolidating improvements, reassessing changes, making necessary adjustments in the new program, and building on the changes themselves.At this stage, the change leader and stakeholders regularly communicate and motivate each unit that has achieved implementation (Maclean & Vannet, 2016).The challenges in this stage can include uncontrolled situations from external parties of the organization, such as schedules and patient numbers, that have the potential to derail growth momentum.It is, therefore, essential to maintain a continuous sense of urgency (Toor et al., 2022).
The final stage is to reinforce the change by demonstrating the link between new behaviors and organizational success.An important aspect of change management is creating lasting change.The purpose of the strategy is to make an inventory of existing changes and provide education/direction to each new staff (Toor et al., 2022).Constant transformational change in organizations can be achieved by iterative and effective learning and change of organizational processes.Acceptance of mistakes as part of a learning culture results in transformational change and can drive sustainable change in the long term (Rass et al., 2023).The commitment of organizational leaders and staff and organizational communication is critical to successful change (Maçães & Román-Portas, 2022).

LIMITATION OF THE STUDY
This case report was only implemented for 1 month and required further evaluation in the outpatient nursing service development program.

CONCLUSIONS AND SUGGESTIONS
The non-optimality of the planning function is the main problem that causes outpatient nursing services to be not optimal.The development of outpatient nursing services programs starts by drafting service guidelines as a reference and direction for outpatient nurses in providing services.The application of implementation in solving the problem can use a planned change approach following Kotter's eight-step plan theory.
Kotter's theory of change model is suitable for changing the organization.Kotter's model is very familiar, especially for health advocacy systems.It has been developed in a more general health service context so that its use is easier to apply in implementing the changes.The stages carried out are still at stages 1-3.Steps 4-8 in asserting and sustaining change have been transitioned to the critical person through the follow-up plan.Steps 4-8 are expected to be carried out by the person in charge of change.To increase patient satisfaction, outpatient nursing services must be a significant concern for hospital management.
Nursing service guidelines in outpatient care is needed as clear instructions for carrying out the duties and responsibilities of nurses.Nursing services are implemented based on guidelines and policies set in the planning function by nursing managers.Nurses are at the forefront of policy implementation and are uniquely positioned to see the impact of health policies on actions taken with patients.Policies are one of the critical elements that influence individuals in carrying out something and become the background in implementing interventions.Outpatient department also require quality indicators to ensure the services are provided to all quality patients and uphold patient safety.The quality indicators of outpatient nursing services explain that professional nurses are leaders and transformers in their services.Nursing supervision is needed in the implementation of nursing services.Supervision is an activity in determining the conditions or personal and material requirements needed to achieve nursing care goals effectively and efficiently.

Table 1 .
Characteristics of Outpatient Nurse Staff in X Hospital