Case Study & Analysis: Standardizing Neurovitals

Written on April 7, 2025 as an assignment for MHST 621: Organizational Change, a course in the Master of Nursing program at Athabasca University.

Case Study

            This case study is based at a large, high-tech, urban hospital. Several years ago, this hospital adopted the latest in electronic health record (EHR) technologies, being the first in their country to do so. Since then, the hospital has funded and prioritized many initiatives to customize features of the technology to improve standardization and automatization of practices, particularly for nursing documentation, in an effort to improve overall quality of care. One such initiative is the standardization of the neurovitals assessment and documentation by nurses across the organization. At this hospital, neurovitals orders are part of adult and pediatric patient order sets and could be placed by physicians for stroke indications, and non-stroke medical indications, such as for patients with hepatic encephalopathy or diabetic ketoacidosis. The physician order dictates only when to do the first assessment and the frequency at which the assessment needs to be completed thereafter.

            Prior to the initiative for standardization, when a physician placed an order for neurovitals, there was no linked action with that order. The order had not been optimized for the EHR based on the way that nurses utilize the EHR. For instance, the order existed only under the “Orders” tab, which nurses infrequently visited and so it would sometimes be missed. Instead, the nursing workflow involved the use of the “Brain” to track which tasks and assessments they needed to complete throughout their shift, but the neurovitals had not been coded to appear as a task on the “Brain”. Additionally, there was inconsistency across the organization as to what neurovitals assessment included. Nurses in different departments were being taught different combinations of systemic assessments to comprise neurovitals, since the order was not linked to any particular flowsheet.

After a series of safety incident reports around missed stroke symptoms and missed neurovitals assessments, the Quality Team of the hospital held a meeting with EHR analysts, stroke nursing and physician specialists, and nursing Professional Practice representation. This meeting was to bring awareness to the problems and explore solutions. Jane, the nursing Professional Practice representative, was tasked with forming a working group and project managing the solutions.

Jane recognized that the main decision for this project would be to select which systems assessments would comprise the neurovitals. Furthermore, this decision would require a practice change. Jane conducted an environmental scan to understand how other local hospitals were completing neurovitals. Jane also met with the stroke specialists to obtain an evidence-based provincial best practice guideline for the basic adult and pediatric neurological assessments paralleling what was considered neurovitals. Prepared with this information, Jane put together a meeting with key stakeholders, including Clinical Nurse Educators of all affected units, as well as the stroke specialists and EHR analysts, to begin discussing the proposed changes.

While the Educators agreed that standardization of neurovitals across the organization would be appropriate and helpful, they were uncertain about the composition of proposed neurovitals. Particularly as one of the adult unit Educators explained she had been teaching her staff differently, and the pediatric Educator was concerned about the nurse capacity to complete the expected assessment components. Jane decided to meet separately with the Educators that had particular concerns to see if she could bridge the education gap they had identified. In her meetings with them, she was able to review the provincial guidelines in further detail. She adopted their suggestion to embed guidance for the nurses in the form of diagrams and charts directly into the EHR.   The nurses could then reference it as they documented their assessment. For the pediatric patients, the EHR was able to be optimized so that the language within the pediatric neurovitals assessment was modified to better align with variations for pediatric patients, as compared to adult patients. With these recommendations from the Educators incorporated into the project, Jane was able to establish key stakeholder support from the nursing representation.

Having established the foundational assessment components of neurovitals, Jane’s next step was to engage physician stakeholders; since they were the ones who would place the order, they needed to approve what the order would represent. Luckily, having established a plan for the neurovitals build that had been workshopped with previous stakeholders, all the affected physician leads readily approved. With all the required approvals obtained, the EHR analysts completed the build in a couple of weeks. Analysts pushed it to a Play environment where the stakeholders could test the design before pushing it into the Live environment for nurses to utilize the new neurovitals assessment and documentation tool.

As part of going live with the project, Jane also collaborated with the Educators and EHR analysts to develop an informational poster of the changes, as well as develop EHR tip sheets to guide nurses through using the new tool. These were shared with all affected nursing staff and complemented by coordinated in-person rounding by Jane and other members of the nursing Professional Practice team and Educators to reinforce the new neurovitals assessment. An informal feedback and auditing process was shared and implemented during the in-person rounding to evaluate the changes. This ensured nurses were actively using the documentation tool and addressing any issues that may arise in the process. While the new neurovitals assessment components were a major learning curve for some nurses, many of them appreciated the standardization of the assessment.  They reported it reduced confusion and allowed for improved continuity of care, especially when patients were transferred between units.

Analysis

Change management in modern healthcare is particularly challenging, requiring a highly collaborative approach to address diverse needs from interdisciplinary stakeholders and to effectively incorporate best practices between participants that may often be working autonomously from one another (Silvola et al., 2024). Despite the challenges with change in healthcare, however, with increasing technological advancements, change continues to be a necessity occurring at a rapid pace (Silvola et al., 2024). Change leaders, and project managers, therefore require the skill set, conceptual tools, and mindset to approach projects with increased awareness of the contextual factors that will impact the change initiative (Silvola et al., 2024). The case study about the standardization of neurovitals across an organization is a microcosmic example of the complexities associated with driving change in healthcare organizations, particularly in the context of technological advancement and impact across different specialties. In the case study, various elements of the change process are evident, including concepts of collaboration and communication, preventative and responsive approaches to resistance, and change models such as Lewin’s three-step process and the research action model. In this paper I will analyze the neurovitals case study according to the mentioned elements, incorporating theoretical perspectives around systems design thinking and hard systems models of change.

Systems Design Thinking

            In a global environment of increasing technology and complexity, as reflected in this case study which is set in a high-tech, cutting-edge urban hospital, design thinking has become an important way for organizations to frame system-wide process improvement initiatives (Kolko, 2015). Design thinking is an innovative approach to problem solving that emphasizes the user experience in process improvement and incorporates brainstorming and creativity to address complex organizational problems (Thuan & Antunes, 2024). Design thinking follows the traditional model of problem identification, deep thinking activities and ideation, and finally solution development and implementation; however, the distinctive factors of design thinking are the principles of critical thinking when identifying the problem, persistence and determination in trial and error when engaging in deep thinking activities, and enthusiastic, collaborative pursuit of innovation when implementing the final product (Thuan & Antunes, 2024).

            In the neurovitals standardization case study, elements of design thinking are evident in solving a complex organizational issue that involves the intersection of advanced EHR technology, nursing user experience, and stakeholder engagement for problem identification, idea testing and innovation. With the hospital’s EHR system being highly customizable to reflect the needs of the organization, it presents an opportunity to apply design thinking to ensure that nurses have the available resources and tools to complete the documentation of the neurovitals assessment. Moreover, a structure within that documentation can allow application of best practice when completing the components of the assessment on the patient. The design approach allows the project team to consider how nurses interact with the EHR, and during the problem identification stage. They can understand the gap between the location in the EHR that nurses usually seek information from and the actual location of the neurovitals order. Understanding this discrepancy would be foundational to informing the idea-testing phase, ensuring that solutions are functional and targeted at addressing that gap. Without a critical understanding of the end-user, in this case nurses behaviour and engagement with the product and the EHR, solutions may be misguided and ineffective (Thuan & Antunes, 2024). Furthermore, problem solving for the neurovitals discrepancy issue is conducted in the context of intentional stakeholder collaboration, drawing on the expertise of various leaders and integrating teamwork into the solution development. These are key elements of design thinking to further drive innovation (Thuan & Antunes, 2024).

Hard Systems Methodology

            Hard systems methodology also aligns with the systems design thinking approach; both are focused on an improved end-user experience, often tied with leveraging technology and innovation (Talmaciu, 2014; Thuan & Antunes, 2024). The hard systems approach to organizational change is based on the philosophy of logic and rationalization (Talmaciu, 2014). The management of projects or process improvements with the hard systems approach focuses on system design and engineering to respond to a particular issue or problem. The process of the project generally follows an iterative series of steps that involves critical analysis of the problem, idea testing, and driving meaningful solutions (see Appendix A; Talmaciu, 2014). Additionally, the hard systems approach is useful in projects where people issues, such as personal politics, culture, and variability of opinions, are relatively minor to the nature or implementation of the change (Talmaciu, 2014).

            In the case of the neurovitals standardization project, the hard systems approach is evident in the nature of the project, as well as the process that it followed. While the project team does initially consider nursing behavior regarding where they access information in the EHR, that is a technical consideration more so than an emotional or personal one, aligning with the hard systems approach. The project solution for neurovitals, then, is more focused on engineering of the EHR build to align with existing nursing practices so that its implementation is targeted to a specific part of the nursing workflow. In addition to its focus, the neurovitals standardization project is also managed according to the hard systems process, starting from problem identification which involves an opportunity to improve the current way nurses are completing and documenting neurovitals assessments. Once the problem was clear, the project team analyzed the existing situation to better guide their solution development. They completed an environmental scan to source solutions and consulted provincial guidelines to align with best practice. Next, when Jane engages the larger stakeholder group of Educators, she is identifying objectives and constraints, and trying to align the needs of all the people affected (Talmaciu, 2014). To Jane’s credit, upon encountering concerns and misalignment between some Educators, she sets up additional meetings with efforts to generate routes to the shared objectives by exploring different ways of achievment and application to the specific groups affected (Talmaciu, 2014). In this case study, only one option appears to be provided and tested, but that option was developed through extensive collaboration with Educators and analysts, and intentionally tested in an EHR play environment; thereby, ensuring its efficacy prior to implementation, which follows the hard systems methodology (Talmaciu, 2014). However, there is a notable lack of establishing measures of performance for the initiative prior to implementation, and the evaluation framework in the case study is noted to be informal. From a hard systems approach, it would have been beneficial for the project team to identify measurable outcomes to track, especially since it is driven through an electronic means such as the EHR. cite Background data reports could have been leveraged for evaluation of the solution (Talmaciu, 2014). Overall, this case study demonstrates a project that followed the hard systems methodology, with the opportunity to improve data and performance metrics tracking in the future.

Lewin’s Three-Stage & Research Action Models of Change

            Two models of change are evident and parallel to one another in the neurovitals case study: Lewin’s three-stage process, and the research action model. Lewin’s process is evidenced broadly throughout the case study. The project begins with unfreezing existing practices around neurovitals assessment and documentation, aims to transition the practices to an optimized tool based on best practice guidelines, and ultimately freezes the new practice by integrating the neurovitals tool within existing EHR nursing workflows, ensuring its sustainability (Talmaciu, 2014). While Lewin’s model is composed of three key phases: unfreezing, transitioning, and refreezing, it is a complex, iterative process that involves action research, group dynamics, and force field analysis to understand driving factors of a project and contextualize within the organization, much like Jane tries to do in the various meetings she is part of in the case study (Rosenbaum, More & Steane, 2018).

In ongoing alignment with design thinking and the hard systems methodology evident in this case study, Lewin’s model also focuses on the importance of a clear understanding of the problem when embarking on a project. cite There needs to be consideration of multiple sources of information and an inquisitive approach, which Jane demonstrates in the case study (Talmaciu, 2014; Rosenbaum, More & Steane, 2018). However, an important element to unfreezing current practices, which is the first stage in Lewin’s model, is also to understand the rationale for the project, as identified through the problem (Levasseur, 2001). In the case study, the need for a standardized neurovitals assessment arose from a multitude of critical safety events that resulted in patient harm, which the initial Quality group effectively communicated to Jane, inspiring her commitment to the project. Presumably, this would have been part of Jane’s communication with the rest of the stakeholders as well, though that is not explicitly outlined in the case study. Regardless, group decision-making is evident in the case study as Jane is intentional about holding additional meetings with concerned Educators to consider all affected perspectives and resolve issues in a way that will strengthen the final solution.

These elements of the early stages of the Lewis model are parallel to some degree by the research action model, also exemplified in the case study. In the research action model, there is also a cyclical process of problem identification, but with a specific focus on drawing from the experts in the field and collecting data that will guide the future workflows (Talmaciu, 2014).ü However, in the final stages of the process, the research action model includes an evaluative component of project implementation to assess the efficacy of the initiative and determine whether further changes or improvements are required (Talmaciu, 2014). In Lewin’s final stage of refreezing the new organizational practice, the focus is on the change agents that actively implement the change, with little mention of the evaluative components (Levasseur, 2001; Talmaciu, 2014). In the case study, the educational roll out plan and implementation of the neurovitals tool are robust. There is a strong representation and visibility of the change agents on the units conducting in-person rounding, empowering and enabling nurses to utilize the new tool, which satisfies Lewin’s stages. However, the feedback and evaluation process implemented is not especially detailed nor specific. It is safe for noting it to be informal, which could mean that data collection is not consistent and as comparable as it could be if it were a systematic process. The lack of a formal evaluation process for the neurovitals tool could result in missed opportunities for further improvement and innovation, leaving the project ineffectively completed in the context of the research action model (Talmaciu, 2014).

Collaboration & Communication

            Despite the final stages of the neurovitals standardization project presenting areas for improvement, in the earlier stages of the project Jane demonstrates strengths as a leader by intentionally incorporating principles of collaboration and effective communication. The literature supports that managing stakeholder involvement and prioritization of their concerns is complementary to the change management process and, therefore, a vital component of leading change (van Offenbeek & Vos, 2016). In the case study, Jane’s approach to involving stakeholders and addressing their concerns can be interpreted as pivotal to the success of the neurovitals implementation. A challenge that does occur when project managers involve stakeholders is a knowledge gap between the parties, resulting in misunderstandings and malalignment of vision (van Offenbeek & Vos, 2016). However, rather than allowing the knowledge gap to persist, Jane engaged the specialist Educators further in separate meetings with the goal of better understanding their issues and bridging the knowledge gap. Jane’s approach was to treat the issues brought up by the specialist Educators as opportunities for “knowledge transfer, translation, and transformation”  rather than hindrances to the project gaining buy-in and trust from stakeholders, were essential elements for effective collaboration (van Offenbeek & Vos, 2016, p. 55).

            Another foundational element of both effective collaboration with stakeholders and effective change leadership is communication. In some studies, poor communication has been directly linked to project failure, emphasizing the value of multidimensional, clear communication as critical for project success (Albuali, 2020). Communication is even a specific component of various models of change, including Lewin’s three-stage model demonstrated in the neurovitals case study. During each stage of Lewin’s model, communication needs to be consistently and continuously clear and effective to drive the change forward, organize the participants in each stage, and maintain clarity of vision (Albuali, 2020). Communication is dynamic in nature, multi-level, and can be designed in a way to establish rationale and importance for the project (Albuali, 2020). While continually building on previous information, participants of the change can be guided through the process and establish trust. Jane’s communication approach is multi-level, which is a strength (see Appendix B). She incorporates high-level methods such as in-person rounding with the nursing staff and meetings with the stakeholder groups, which drives the most staff satisfaction related to their jobs (Albuali, 2020). She also incorporates low-level methods such as written documents such as posters and tip sheets for the nursing staff to refer to; these methods are less engaging and satisfactory for staff, but may be essential to support training and education (Albuali, 2020). Jane’s communication approach is multifaceted and effective. This is an opportunity for improving the project communication plan in the future. Jane can consider moderate-level methods such as leveraging email and the hospital’s internal website as additional resources and means for staff to receive information about the change initiative, as these methods are more engaging than low-level methods (Albuali, 2020).

Responding to Resistance

            Communication is also vital in responding to resistance, which Jane encounters in the neurovitals case study and manages effectively to drive the project forward. Resistance is a common theme in change management, and developing a strategy for involving key participants, having a plan for communication and training, and anticipating resistance are essential for overcoming it (Silvola et al., 2024). Additionally, individuals with high seniority or experience are the most expected to resist change (Silvola et al., 2024). Given that Educators typically are more experienced, senior nurses, it is strategic of Jane to incorporate them early in the change initiative. This allows buying into the project early and minimizing the degree of resistance she might later encounter. Despite her efforts, though, Jane does encounter some resistance from two Educators who present concerns with the plan regarding their particular units. Jane’s response to strengthen collaboration, rather than being defensive and upset by the resistance, is not only appropriate, but also impactful. While some perceive resistance negatively as a form of project failure or insurmountable obstacle, resistance can also be perceived positively as an opportunity for enhanced understanding, clarity of vision, and improvement (Rosenbaum, More & Steane, 2018). The latter appears to be the approach that Jane adopts, and her strategy is effective; she is able to re-engage the concerned Educators in a way that improves the project’s efficacy by incorporating elements that may have previously been missing or overlooked.

Conclusion

            Change management is a complex process impacted by forces both external and internal to the organization, particularly in the context of modern technology that is rapidly increasing the pace of change (Silvola et al., 2024). As such, leaders require a diverse skill set that encompasses effective communication, strategic thinking, relationship building for collaboration, and a solid understanding of change models to establish the framework for project planning. Overall, Jane demonstrates many of these skills and navigates elements of the change process well, including stakeholder and resistance management and an engaging implementation plan. However, there is a significant opportunity in the project plan for a systematic evaluation approach once the project is implemented. The team could leverage the EHR technology to create data reports tracking the utilization of the neurovitals tool, for example, to better understand how nurses are engaging with it and identify opportunities for improvement. Additionally, the team could have developed a standardized survey for nurses to respond to, which would have offered comparable data and opportunity to draw on nursing experience and ideas for improvement. Change does not end with implementation; rather, resources and strategies must also be in place to ensure the sustainability of the change and any improvements to its operation. Perhaps that is a case study on its own.

References

Albuali, M. (2020). The relationship and impact of communication on change management. International Journal of Responsible Leadership and Ethical Decision-Making 2(2): 1-9. DOI: 10.4018/IJRLEDM.2020070101

Kolko, J. (2015, September). Design Thinking Comes of Age. Harvard Business Review. Web: https://hbr.org/2015/09/design-thinking-comes-of-age

Levasseur, R. E. (2001). People skills: Change management tools— Lewin’s change model. Interfaces, 31(4): 71-73. DOI: 10.1287/inte.31.4.71.9674

Rosenbaum, D., More, E., & Steane, P. (2018). Planned organisational change management : Forward to the past? An exploratory literature review. Journal of Organizational Change Management, 31(2), 286-303. DOI: 10.1108/JOCM-06-2015-0089

Silvola, S., Restelli, U., Croce, D., Basu, D. (2024). Change management for services redesign in healthcare: a conceptual framework. Journal of Preventive Medicine and Hygiene, 65(3):E410-E433. DOI: 10.15167/2421-4248/jpmh2024.65.3.3023

Talmaciu, I. (2014). Comparative analysis of different models of organizational change. Valahian Journal of Economic Studies, 5(4): 77-86.

Thuan, N. H. & Antunes, P. (2024). A conceptual model for educating design thinking dispositions. International Journal of Technology and Design Education, 34: 1879-1902. DOI: 10.1007/s10798-024-09881-x

van Offenbeek, M. A. G. & Vos, J. F. J. (2016). An integrative framework for managing project issues across stakeholder groups. International Journal of Project Management 34: 44-57. DOI: 10.1016/j.ijproman.2015.09.006

Appendix A

(Talmaciu, 2014, p. 82, figure 2)

Appendix B

(Albuali, 2020, p. 6, table 1)