Applicability of Lewin’s Change Management Model for Optimization Management Function in Nursing Delegation between Head Nurse and Team Leader: A Mini Project in Jakarta Military Hospital

. The role of nurses in healthcare systems is diverse, including being a health care provider to clients, client advocates, educators for clients and families, and nursing service managers. This study's goal was to assess Kurt Lewin's change management method to analyze the management function in nursing delegation between the head nurse and team leader. This project was conducted at Jakarta Military Hospital using a fishbone diagram approach, and solving problems using Plan-Do-Check-Action (PDCA) tools starting with Plan Of Action (POA), implementation, evaluation, and follow-up. The study results showed that the head nurse performed nonoptimal delegation in terms of delay to complete the nursing documentation, non-uniformity of delegation format, and lack of control from superiors. Guidelines are used as a reference in delegating nursing to the head of the hospital room. The documentation of nursing delegates is done because representatives work better when the reporting structure is clear. In conclusion, the application fishbone diagram, Lewin's change management model, and PDCA cycle can optimize management function in nursing delegation between head nurse and team leader in Jakarta Military Hospital. Recommendations are given to the nursing department, head of the room, team leader, and executive nurses to increase self-awareness, knowledge, and ability in delegating nursing.


INTRODUCTION
The role of nurses in health care systems is diverse, including being a health care provider to clients, client advocates, educators for clients and families, and nursing service managers (1).In the nursing manager's role, a nurse is expected to implement a strategy for maintaining the service quality to create a balance between the performance and work outcomes of nurses (2).This balance could form excellent or bad hospital services closely related to the knowledge, skills, and professional attitude of a nurse.
One strategy that can be applied in managerial nursing is delegation.Delegates are completing tasks through other people or directing functions to one or more people to achieve organizational goals (2).The Hospital Accreditation Commission (2017) in the National Standards for Accreditation of Hospital Guidelines states that hospital managers must ensure that each competent nurse must carry out nursing care independently, delegate, or mandate so that nursing services are safe and effective.Optimal delegation can be realized if the head of the room delegates according to the procedure and can review his subordinates before giving assignments.Representatives that are not implemented are among the causes of increasing patient complaints and declining quality of care for care rooms (3).
There are several benefits of delegation.With delegation, the head of the room can complete routine tasks that cannot be completed or implemented because of constraints of time constraints (4).Delegation is also a means for the head of the room to get a lot of time in making decisions, formulating policies, and planning to prioritize which work will be done and build the ability of subordinates or nurses implementers (4).Also, delegation can reduce fatigue in the head of the room, where a study explains that 25.5% of the time, the head of the office is spent on patient affairs, performs many short and fragmented tasks that can cause fatigue (5).
Military Hospital is a health service facility under the auspices of the Indonesian National Army throughout the archipelago.The hospital's unique feature lies in the command unit system that is applied in the entire working environment of the Indonesian Armed Forces.The command unit is a hierarchical command system from the highest to the lowest authority.There have been no studies on nursing delegation at Jakarta Military Hospital.

OBJECTIVE
This paper aims to analyze the application fishbone diagram, Lewin's change management model, and the PDCA cycle for an optimization management function in nursing delegation between head nurse and team leader in Jakarta Military Hospital.

METHOD
A mini project was conducted at military hospitals in Jakarta.The application project is based on Kurt Lewin's change management model between 29 November-13 December 2018 with the permission letter number of B / 38461 / IX / 2018.This mini-project consists of the case reports of the application fishbone diagram, Lewin's change management model, and PDCA cycle for an optimization management function in nursing delegation between head nurse and team leader in Jakarta Military Hospital.
The data was gathered from 4 head nurses using the interview method based on the planning-Organizing-Staffing-Actuating-Controlling (POSAC) management function approach.The data was analyzed using a fishbone diagram and resolved by Kurt Lewin and Plan-Do-Check-Action (PDCA).

RESULTS
The results showed that the nursing delegation among head nurses had no optimal implementation.The main crucial point because the delegation process was conducted using the group chat or WhatsApp application rather than book documentation.About 80% of the head nurses do not understand the regulation of nursing delegation.Other causes related to the main problem were that 100% of nurses stated that there were no guidelines or operational standards for the procedures governing delegations at the military hospital.
Kurt Lewin's model, including unfreezing (search), movement, and refreezing, were approached to solve the problem.The unfreezing stage carried out the information about nursing delegation, workload, vision, and mission of the hospital, and guidelines for doing nursing delegation.In the movement stage, we carried out making nursing delegation guidelines and operational standards in those hospitals.In addition, we evaluate changes that have been made and produced, maintaining the situation with the nursing delegation guidelines that have been approved by the Head of Hospital in Jakarta on the refreezing stage.Three stages of Kurt Lewin model can be seen in Figure 2

Man Method Environmen t
The ratio of patient nurses is not ideal at 1: 27 at outpatient & 1: 7 inpatient.

High workload
The types and formats of delegation documentation are very diverse.
Monev was not carried out related to delegation.

The limited number of nurses in quantity and quality
There is no delegation guide.In the planned change, Kurt Lewin achieved from the stages of unfreezing, movement, and refreezing only covered the scope of the nursing department.However, planned changes made cannot be resolved if faced with the range of the hospital.With proposed changes made if faced with the scope of the hospital is still at the unfreezing stage.This is due to hospitals' complexity, which is military hospitals with complex bureaucracies and many nursing staff.In resolving the main problem, it was also carried out using the PDCA approach.There are four stages in this PDCA approach; namely, plan, do, check, and act.Problem-solving uses the PDCA approach, as seen in Figure 3. Through this activity carried out in the planning stage, namely by identifying problems and analyzing problems.Identification and analysis of issues are made using the Fish Bone diagram.Problem-solving planning is outlined in the form of a plan of action (POA) to optimize the nursing manager's planning function in the nursing delegation.The next stage is the stage where the researcher applies and develops the existing solutions.The solution to overcoming the main problems that exist is to develop guidelines for the delegation of care and disseminate these guidelines through brainstorming.The instructions are based on policies, regulations in military hospitals in Jakarta, journals, and consultations with academic advisers.
At the check (evaluation) stage, the activities carried out to evaluate the results and objectives that have been set.Evaluation is done through observation and interviews.The evaluation results were in the form of positive responses from participants who attended the socialization of the nursing delegation guideline draft, and they approved the draft guidelines for the nursing delegation.The evaluation stage was also carried out by observing four head nurses.It was found that 75% of the head of the room had formatted new content in documenting nursing delegations.
In the last stage of the action, the researcher proposed a draft nursing delegation guide that must be approved by the Head of the Military Hospital, socialization to the Head of the Nursing Division, Head of Rooms and nurses in all of the work units to improve professionalism and quality of care.

DISCUSSION
Various efforts have been implemented to solve the main problems related to the nursing delegation.Attempts were made using planned changes from the Kurt Lewin approach, which consisted of unfreezing, movement, and refreezing.This is done because the Kurt Lewin approach's proposed changes can improve the quality of services to patients and help achieve organizational goals (6).Another effort made by nursing managers is to solve the problem of using Plan-Do-Check-Action (PDCA).Hariyati (7) states that PDCA can be used to control and guarantee the quality of nursing resources.The unfreezing stage carried out includes the study of the need for changes related to the nursing delegation, consisting of the head nurse's statement regarding the importance of nursing delegation, high workload and activities outside the main task of the head of the room that is not in line with the hospital vision and mission.The results of the assessment also showed that there were no rules governing nursing delegations (6).The unfreezing stage is then integrated by identifying and analyzing problems.Problem identification and analysis is carried out using the Fish Bone diagram.Problem-solving planning is described in the form of a plan of action (POA) to optimize the planning functions of nursing managers in nursing delegations.
The next stage is the phase of movement and stages by applying and developing solutions that are good and maximum.The answer to overcoming the main problem is to develop guidelines for nursing delegation.This guide is an instruction in conducting delegation activities (7).Policies and procedures also contain instructions on what tasks are possible and impossible to delegate (8).Distribution of draft guidelines to delegate care through brainstorming to the head nurses, team leaders.The implementation regarding procedures and management of proper and correct nursing delegates in hospitals.All legal aspects and the importance of providing clear instructions in the delegation process must be communicated (9).Nurses need knowledge, skills, and attitudes in delegation practice (10).The head nurse is responsible for ensuring that the nurse given by the delegation has the right skills and knowledge so that she must provide specialized training and education regarding nursing delegations (9).The guideline draft contains procedures for carrying out delegations and delegating delegation activities that have been carried out.Studies show that delegates work better when the structure report is carried out clearly (8).The nurse must ensure that documentation is following the delegation process (9).
The next stage is the re-examination phase, which evaluates the changes that have been made and maintain changes by applying the nursing delegation guidelines that have been approved by the head of the military hospital in Jakarta.The head of the room responsible for delegation must periodically monitor and evaluate the delegation process so that the ability to delegate can be routine and effective (8,11).The final stage of the action (follow-up plan) is to propose a draft nursing delegation guide that must be approved by the Head of the Military Hospital, socialization to the Head of the Nursing Division, Head of Room, and nurses in all work units.The head of the Nursing Department is also expected to have a design proposal for the development of nursing education and training in improving professionalism and quality of care and is expected to be consistent in implementing and monitoring and evaluating nursing delegates.The organization must also provide development education and training regarding effective delegation (12)(13)(14).According to Kurt Lewin, all stages have been applied at Jakarta Military Hospital and have proven effective in improving the nursing delegation process.However, further studies are needed on the long-term application of these models in improving the quality of nursing care in hospitals.

CONCLUSION
Several things can cause the implementation of the delegation process at the military hospital in Jakarta, which has not been optimal.Researchers have conducted an analysis using fishbone diagrams and found several problems that led to one major problem mentioned above.Preliminary research conducted by the researchers showed that the survey of nurses' perceptions of the head of the room's function showed that 62% of the service was not optimal, and 57% of the control function was not optimal.The results from observations and interviews regarding the nursing delegation's implementation in military hospitals showed that the head of the room had many priority tasks to be completed immediately and immediately.
The approach of a planned change of Kurt Lewin and problem-solving using Plan-Do-Check-Action (PDCA) was carried out by researchers to nurse managers in hospitals to change the pattern of the delegation process to be more optimal in their activities.One of the implementations by making guidelines for nursing delegation reference at the hospital.
In conclusion, the application fishbone diagram, Lewin's change management model, and PDCA cycle can optimize management function in nursing delegation between head nurse and team leader in Jakarta Military Hospital.

Managerial
The delegation process's importance becomes an urgency for nurse managers to propose authorization guidelines and operational standards for nursing delegation procedures by the head of the hospital to be implemented immediately.Other activities that can be carried out by nurse managers are to disseminate nursing delegation guidelines and SPO that have been approved by the head of the hospital to the Head of Room, team leader, and nurses in the Work Unit.Nurse managers can schedule monitoring and evaluation of nursing delegation activities carried out by the nursing work unit and conduct training, map formal education to improve discipline, knowledge, and ability of the head of the room and team leader through monitoring of delegation books and direct observation of delegation activities done in the room 2. Head nurse and team leader The roles that can be performed by the head nurse include optimizing the role and function of management in delegating nursing and increasing the knowledge and ability of the head nurse and the team leader about delegating nursing to train and training.The head of the room and the team leader must have self-awareness and self-management for discipline in delegation in improving the quality of nursing care 3. Executing nurse Some of the things that can be done include increasing the knowledge and abilities to implement nurses about nursing delegation by attending training and training and increasing self-awareness and self-management of nurses to produce discipline in a delegation to improve the quality of nursing.care

Figure 1 .
Figure 1.Analysis of the main problems using the Fishbone Diagram

Figure 2 .
Figure 2. Problem-solving using Lewin's change management model