Running head: ORGANIZATIONAL ASSESSMENT

Volunteers of America Western Washington Organizational Assessment

Christan Mulder and Shamila Hashimi
Western Washington University

ORGANIZATIONAL ASSESSMENT

Volunteers of America Western Washington Organizational Assessment

Traumatic brain injury (TBI) is defined as an alteration in brain function caused by an
external force (Brain Injury Association of America, 2012). The brain is a highly complex system
which makes every TBI different in regards to how it alters brain function. According to the
Center for Disease and Control (CDC), there are 1.4 million new cases of brain injury each year
in the United States and many people who experience a TBI will sustain some form of cognitive
impairment. Survivors of TBI require extensive assistance with completion of daily living
activities and some individuals require assistance for the rest of their life. Physical, emotional,
and behavioral changes occur in a person that sustained a TBI and its estimated that over
123,750 individuals in Washington State are living with a TBI related disability (Washington
State Department of Health, 2009). In many situations, family members take on a primary
caregiving role after an individual sustains a TBI. Brain injuries are lifelong medical conditions
that requires highly complex and specialized care (Dr. J.M., personal communication, May 25,
2016).
In June 2015, the Volunteer Services of America Western Washington (VOAWW) was
granted the opportunity to begin providing assistance to a client who sustained a TBI prior to age
18, and the agency has plans in place to take on two additional TBI clients this year. A new home
is being constructed within Snohomish County for the three individuals and the VOAWW will
provide supportive living services for these clients including 24-hour in home care. The
VOAWW is well known for providing basic needs assistance to residents of Western Washington
for over 100 years. The agency currently offers six different program areas, the largest being
personal support services which encompasses the supportive living program. This is a very
exciting opportunity for the VOAWW and for the community in which they serve.

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This paper will serve to describe the second phase of a project completed by two
registered nurses working toward their bachelors degree at Western Washington University. The
goal of the second phase was to assess the VOAWW and provide recommendations for change in
organization practices. Based on the results of our community assessment, it was determined that
the caregivers working for the VOAWW do not have experience caring for brain injury clients
and managing the behavioral concerns specific to TBI. Communication barriers, outbursts of
agitation, refusal of cares and medication non-compliance are issues that the VOAWW has
already been experiencing with the new TBI client. Luaut, Plantier, Wiart and Tell (2016)
suggest that agitation is a hallmark symptom of TBI and often the most difficult behavior for
caregivers to manage.
Change Theory and Planning Phase
Logic Model
After collecting and analyzing our data, we determined that in order for the VOAWW to
provide safe and effective care to their new clients, additional caregiver training would be
required. We discussed our proposed plan with Brian Smith (Senior Director of personal support
services) at the VOAWW and began drafting a Logic Model and Focus PDCA to guide the rest
of our project work. Our Logic Model and Focus PDCA assisted us to understand and identify
how our recommendations could impact the VOAWW long-term. The Logic Model also
identified our primary stakeholders and the possible barriers to implementation of our
recommendations by the VOAWW (see Appendices A and B).
Kurt Lewins Change Theory
The second portion of the planning phase consisted of utilizing Kurt Lewins change
management model (Sare & Ogilvie, 2010). Lewins model consists of three phases; Unfreeze,

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Change, and Re-freeze. Within the unfreeze phase, the VOAWW would begin the change process
and understand the need for change within the organization, in this case additional caregiver
training. The VOAWW initiated collaboration with Western Washington Universitys nursing
program indicating to us that they recognize the need for change. Additionally during the
unfreeze phase we reached out to identified stakeholder and highly respected community
member Janet Mott, PhD, CRC, CCM Clinical Case Manager for the Brain Injury Alliance of
Washington. The support received by Dr. Mott was tremendously helpful in the planning phase
of this project. During the change phase, the VOA would implement new caregiver training to
staff. The VOA is currently caring for one TBI client with plans to take on two more clients in
the next few months. The third and final phase of freezing would mean the VOA has fully
adopted our recommendation and is implementing it consistently within the agency (TBI
education/training provided to all new hire caregivers).
Organizational Readiness for Change
There are multiple factors to consider when assessing the VOAWWs readiness for
change, or its likeliness to adopt our recommendations. The final planning step of this project
consisted of identifying the potential barriers for implementation of our recommendation.
A model developed by Kurt Lewin, the force-field analysis is a framework for problem solving
and planned change (Mitchell, 2012, p.35). The force-field analysis outlines the restraining and
driving forces of a proposed change. After developing our force-field analysis, we were able to
identify the potential barriers to the VOAWW in adopting our recommendations (see Appendix
C).
The financial constraints associated with additional training could be a potential barrier
for the VOAWW. We created a binder with training and educational resources on TBI, and by

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providing our deliverables in this manner, the VOAWW will be able to choose which training
materials they want to use and can determine the amount of training time allotted to each
caregiver. Allowing the VOAWW control over additional training costs provides a greater chance
that our recommendations could be implemented. As mentioned previously, the VOAWW
sought our assistance in this project indicating the likeliness to adopt and readiness for change
fairly high.
Recommendations
In order to enhance the quality care being provided by VOAWW caregivers and to
promote and strengthen the new program, we recommend utilizing and providing additional
training materials to the caregiving staff about TBI and behavior management. In collaboration
with Dr. Mott and introducing her work to VOAWW director Brian Smith, we hope that both
these organizations may form a partnership possibly opening doors for additional funding for the
VOAWW. The risk for compassion fatigue is high when caring for clients with traumatic brain
injuries. If the staff at the VOAWW are provided and given the tools and education necessary to
care for TBI patients, they will feel confident in their job and have a lesser chance of feeling
emotionally and physically strained.
At the system level, a policy change is recommended by changing the training materials
provided to new hires with the VOAWW. This recommendation may require employees to have
additional training hours and would focus primarily on the challenges of caring for a patient with
a TBI and how to manage the emotional and behavior changes that often occur.

All caregivers to watch a short film that interviews four different individuals that have
suffered a traumatic brain injury titled Living with a Traumatic Brain Injury.

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The caregiver workbook Surviving and Thriving with TBI has excellent caregiver
information and recommendations on how to provide care to those with TBIs. We
recommend the VOAWW review this workbook and implement many of the modules
into training sessions.

After the above recommendations have been implemented, it would be beneficial to conduct
a survey of the caregivers with the VOAWW to find out which resources or trainings were
beneficial and if additional training or education in a particular area is desired.
Conclusion
The need for additional education and training is already apparent to the VOAWW
administration. Barriers include financial resources to provide the recommended training and
possibly staff retention due to the difficulties caring for TBI patients. The interventions that we
have recommended to the VOAWW are provided by credible and established organizations
experienced in caring for TBI clients. Dr. Mott has expressed interest in working with the
VOAWW and in providing any additional educational materials they may need.

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References
Brain Injury Alliance of Washington. (2015). Retrieved from http://biawa.org/
Brain Injury Association of America. (2012). About brain injury. Retrieved from
http://www.biausa.org/about-brain-injury.htm
Centers for Disease Control and Prevention. (2016). Injury Prevention & Control: Traumatic
Brain Injury & Concussion. Retrieved from
http://www.cdc.gov/TraumaticBrainInjury/index.html
Kay, Anita. (2013). Strategies for Surviving and Thriving. Retrieved from
http://tbiwashington.org/professionals/documents/TBI_video_workbook22713.pdf
Luaut, J., Plantier, D., Wiart, L., & Tell, L. (2016). Care management of the agitation or
aggressiveness crisis in patients with TBI. Systematic review of the literature and practice
recommendations. Annals of Physical and Rehabilitation Medicine, 59(1), 58-67.
doi:10.1016/j.rehab.2015.11.001
Mitchell, G. (2013). Selecting the best theory to implement planned change. E-Journal of Art &
Science, management theory. 20(1), 32-36.
Sare, M. & Ogilive, L. (2010). Strategic Planning for Nurses: Change management in Health
Care. Burlington, MA. Jones and Bartlet Learning.
University of Washington TV (Producer). (2007). Living with a traumatic brain injury [DVD].
Washington State Department of Health. (2009) Traumatic Brain Injury: Prevalence, External
Causes, and Associated Risk Factors.
Washington State Department of Health. (2007). Traumatic Brain Injury. Retrieved from
http://www.doh.wa.gov/Portals/1/Documents/5500/IV-TBI2007.pdf
(2016, May 25). Retrieved from http://www.voaww.org/

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Appendix A
Logic Model
Statement of Need: Improve the knowledge and skill set of VOAWW employees on managing
unwanted behaviors of patients with TBI.
Resources/Inputs
Community partnership with
Dr. Mott and the Brain Injury
Alliance of Washington

Brian Smith-Director of
VOAWW

Technology/Data
collection/Research/Evidenc
e Based Resources

Caregivers

Activities
Meeting with
Dr. Mott and
explaining
project goal.
Asking for
assistance
with project

Outputs
Ability to
provide
VOA with
high quality
information
and
education
materials
Meeting and
Project
inquiring with direction and
VOAWW in
ability to
the
provide
organizations needed
needs
assistance
Conducting
Data
literature and collection
research
analysis
review on
difficult
behaviors of
TBI clients

Outcomes
Improve client
care by VOA staff

Impact
Increase
number of
TBI clients
served by
the VOA

Confidence in
VOA staff in
dealing with
difficult client
behaviors

Staff
retention

Recommendation
s are evidence
based

Informal
Insight on
interview
education
with caregiver needs of
VOAWW

Ability to provide
new education or
what we believe
to be new
knowledge to
staff

Patient
centered
care, safe
quality care,
and
increased
staff
knowledge
Increased
staff
education
level

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Appendix B
Focus PDCA
Find a process to Improve
After conduction of a community assessment, our group determined that VOAWW
caregivers would benefit from additional education materials and resources on caring for
traumatic brain injury clients. Specifically, the VOAWW staff had trouble in managing difficult
client behaviors and refusals of care.
The VOAWW is attempting to expand the population of clients served starting with
identified traumatic brain injury patients who have already qualified for services. The caregivers
working for the VOAWW are unfamiliar with this specific population group and require
additional training to provide safe and efficient client care. It has already been noted by the
VOAWW staff that these patients are unlike any others they have cared for and the staff is
needing resources to specifically manage difficult patient behaviors and refusals of care.
The focus of this project is to provide a resource list and educational materials to the
VOAWW that is evidence based and will serve to inform and improve care provided by
VOAWW staff on traumatic brain injury clients.
Organize to Improve the Process

Dr. Janet Mott is a member of the Brain Injury Alliance of Washington and has graciously
volunteered to assist this group in project research and provide educational materials.

Brian Smith-VOAWW Director of Disability Services and our VOAWW contact person
for this program. Brian oversees the site supervisors with the VOAWW and ultimately

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oversees the caregivers providing client care. Brian is the person in charge of the pilot
program with the VOA in taking on the traumatic brain injury clients.
Clarify Current Knowledge of the Process

Identification of current caregiver education materials provided to VOAWW staff.

Identify current knowledge of VOAWW staff on TBI clients

Conduction of informal interview of VOA caregiver and client house tour

Identify what resources the VOAWW already has in pace for expanding knowledge

Future plans to provide expand caregiver education

Identify caregivers support network

Understand the Causes of Process Variation

English as a second language

Education levels

New Client Population

Lack of community awareness

Select the process Improvement

Caregiver training programs/teaching modules

The newly hired VOAWW staff members meet monthly to discuss what is working and
what is not working thus far, interventions that have been helpful

Add to New hire orientation (core training) section on traumatic brain injury

Plan the Improvement

Literature review performed focusing on evidence based care techniques

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Traumatic Brain Injury-Strategies for surviving and thriving Washington State

Caregiver TBI Modules as foundation for education material

Dr. Mott to provide training and education to VOAWW staff on managing behaviors

Do Improvement Process

Deliver the education materials

Monthly meetings to evaluate and discuss confidence level in caregivers knowledge/skill

set in managing behaviors

Caregivers providing feedback on personal observations and education that would

improve skill and confidence

Check and Study the Results

Analyze the caregivers after education has been taught

Discuss observations and unexpected findings with Brian and caregivers

Act to hold the gain and to continue to improve the process

Implement education into mandatory new hire education

Continue planning up to date education materials

Encourage and engage caregivers in providing best practice and high quality care

Promote community awareness of traumatic brain injury

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Appendix C
Force-Field Analysis
Driving Forces
Confidence in Employees
Staff Retention
Effective, safe patient care
Patient and staff safety

EQUILIBRIUM

Restraining Forces
Financial Constraints
Lack of demonstrated need for
additional training
Training time constraints
Company policy/new program