JONA Volume 37, Number 9, pp 388-391 Copyright B 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Models of Change Carol Reineck, PhD, CNAA-BC, COI Implementing change in organizations is a key nursing leadership competency. At the same time, it is a daunting responsibility. Fortunately, models of successful change illustrate useful concepts for leaders. Change concepts embedded in successful models include careful use of power, reason, reeducation, structure, behavior, and technology. This article discusses models of change. Learning from models may help nurse executives avoid perils such as change fatigue and may promote smoother movement toward safer systems of care. Effective models of change in healthcare organizations bear some resemblance to diamonds. A diamond forms partly by nature and partly by the human touch. Similarly, organizational change often occurs in response to natural forces, and ultimately, change is shaped by people. Diamonds take millions of years to form under pressure between 75 and 120 miles below the earth’s surface. Indestructible, diamonds are characterized not only by carat, color, and clarity, but also by Bcut^ added by the human touch.1 In stark contrast, however, organizational change may happen in an instant and certainly does not last forever. Nor does change render organizations indestructible. Models abound in almost every aspect of healthcare from new business models to architectural models to models for specific types of patient care services. Because nursing is central to services in healthcare organizations, most of these models have an impact on nursing in some way. The nurse executive’s responsibilities include not only contributing to the implementation of broader organizational models, but also leading the development or Author’s Affiliation: Amy Shelton and V. H. McNutt Professor and Associate Professor, Department of Acute Nursing Care, University of Texas Health Science Center School of Nursing, San Antonio, Texas. Correspondence: University of Texas Health Science Center, 7703 Floyd Curl Dr, MC 7975, San Antonio, TX 78229-3900 (
[email protected]).
388
application of models for patient care organization and delivery. Ensuring that the models used throughout the organization are aligned is critical to success. Also critical to success is managing the changes. Models may help staff members survive the heat, pressure, and chemistry of relentless organizational change. The phenomenon of change fatigue opens the discussion, followed by a review of selected conceptual orientations on change. Examples of successful change models from 3 clinical nursing arenas present alternative strategies for nurse leaders to consider.
Change Fatigue Change fatigue2 is a result of relentless change, during which employees lose trust. It is one reason nurse leaders search for effective models of change management. Change fatigue threatens realizing the vision. Table 1 displays 6 signs of change fatigue accompanied by quotes from practicing nurses enduring relentless change.
Nurse Executive Competencies Related to Change The American Organization of Nurse Executives’ Nurse Competencies Assessment Tool3 lists 5 competency items related to change management. The first competency is using change theory to plan for the implementation of organizational change. The American Organization of Nurse Executives’ Guiding Principles for Future Patient Care Delivery4 speaks to the challenge of managing the journey. Concepts of change are plentiful; some are helpful. Selected concepts help nurse leaders develop change management competency.
Change Concepts A useful way to view change is to consider organization behavior, structure, and processes.5
JONA Vol. 37, No. 9 September 2007
Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 1. Signs of Change Fatigue With Exemplars Signs of Change Fatigue2 The value and objectives of the change effort are increasingly questioned Resources become diverted to other strategic initiatives Impatience with the duration of the change effort Data and results of the change are shared with hesitation Key leaders no longer attend status updates about the change project Change leaders become stressed and often leave
Exemplars From Experienced, Practicing Nurses Nursing care policy changes were historically plagued with thoughts on practice going in many different directions affected by every different figurehead. Most of the time, ideas are started but never finished. New programs are initiated but most of the time never completed. For the floor personnel, such experience becomes exhausting. During the renovation of our NICU, nurses were quite concerned due to the fact that the unit is trying to keep their census down because of construction. Word got out that the nurses wouldn’t get their hours and would get pulled to other units. I heard statements like Fthere goes our raises` when word got out just how much was being spent on this project. The medicine unit closed due to construction. Staff lost familiar surroundings, group cohesion, and a support systemIseveral of the nurses lost statusItaking no active role up-keeping the units they work onIwith no managerial support. In the meantime during the NICU renovation, a new nurse manager started. The nurses were uncertain about how the unit would run and how many more changes would occur.
Traditional models of change are often linear and, unfortunately, do not account for the circular, chaotic change experienced today. Contemporary, alternative strategies, shown in Figure 1, involve managing change through power, reason, or reeducation, or taking structural, behavioral, or technological approaches. These strategies may be implemented at all levels. This multifaceted approach is particularly useful in today’s environment which often involves simultaneous change in structure and process. In traditional change, organizations were guided to select the avenue or approach to change most likely to be successful, such as installing new software. The thinking is that both structure and process would be incorporated in the change process as indicated along the way. The structural approach involves focusing on job, workflow, or organizational redesign with the goal of improving morale and performance. An excellent example of a structural approach would
be the use of bundles. Bundles are groups of evidence-based interventions that result in better outcomes when implemented together rather than individually.6 The behavioral approach is organizational development with the goal of improving communication and problem solving. The technological approach could involve computers, information technology, or automation of work with efficiency and quality as anticipated outcomes. In all 3 approachesVstructural, behavioral, and technologicalVit is expected that change will penetrate aspects of the organization so that in the end, all may be affected. One creates a model for change by designing change that shows the relationship between and among them. Leaders of change lead by example, demonstrate that the coming changes are critical, and help others engage in the process of making their own changes.7 The following 3 examples illustrate that models of change management have many facets, each of which (power, reason, reeducation, behavioral, structural, and technological) contributes to the degree of success realized by change leaders.
Three Models
Figure 1. Selected change management strategies.
Model 1: Instituting Patient-Focused Care The American Association of Critical Care Nurses’ Standards for Establishing and Sustaining Healthy Work Environments and the American College of Chest Physicians’ Patient-Focused Care project are complementary initiatives. The initiatives provide a road map for creating practice environments where interdisciplinary, patient-focused care can thrive.8
JONA Vol. 37, No. 9 September 2007
Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
389
Their approach incorporates structural, behavioral, and reeducation approaches to promoting patient safety. The structural approach includes (a) a vision to merge selected experiences in medical and nursing education so that each group enters practice with a respectful, accurate knowledge of each other’s contribution, (b) establishing ethics committees, and (c) nurse managers and medical directors are considered peers with equal accountability for clinical outcomes and team performance. The behavioral approach includes interdisciplinary patient rounds, dealing with competence issues directly and respectfully, and encouraging personal integrity in the behavior of all team members. The reeducation approach includes seeking and engaging in interdisciplinary educational programs that improve communication and collaboration. Education on the situation-backgroundassessment-recommendation techniques, presented at the unit level, increases effectiveness of communication especially in critical situations. Model 2: Improving Rehabilitative Handling for Stroke Patients Following a stroke, many patients have complex handling and mobility needs, most especially shoulder pain affecting 70% of stroke survivors.9 Nursing leaders in a stroke unit in the United Kingdom aimed to help nurses take ownership of their moving and handling practice.10 The primary aim of the project was, in the short term, to facilitate changes in moving and handling practice that were consistent with manual handling regulations. In the long term, the project sought to move the unit toward rehabilitative handling in caring for patients with stroke. Change agents in this setting used an action research project. An insider participatory action research approach was used. Data came from focus group meetings, brainstorming, observation, and from written, reflective accounts. Nurses identified that equipment, environment, communication, and teamwork strategies would improve their moving and handling practice. Participants felt involved and valued and reported changes in their understanding (reasoning), their handling practice, and enhanced teamwork (behavior). Kotter11 explained that people find change stressful, and as a result, some may resist change more than others. Assuming staff resistance is to blame when efforts fail is unhelpful.
Change agents need to scrutinize their own efforts to seek the cause for failure. BPeople change what they do less because they are given analysis that shifts their thinking than because they are shown a truth that influences their feelings.^12(p1) The key to the success of this change with stroke nursing practice was that those directly involved in moving and handling were facilitated to take ownership in their moving and handling practice. Staff members are closest to problems and closest to potential solutions.13 Model 3: Building Capacity for Magnetism Action research is an example of change through power. It has been described as social research jointly carried out by a researcher and participants of the organization or community working together to improve their situation.14 Nurse executives in organizations pursuing magnet designation need strategies to develop Magnet healthy workplaces at both nursing unit and organizational levels. Parsons’15 Health Promoting Organizations Model is an open-system, participative approach to whole-systems change. Key concepts are unit-shared leadership, participatory management, and empowerment. Participatory action research methods are used to implement the intervention as this methodology facilitates the 3 key concepts. Participatory action research incorporates future search conferencing, which is a collaborative method that provides people with the means to take systematic action to resolve specific problems. Global, exemplary efforts further illustrating participatory action research as a powerful model for change include efforts to implement change in public health nursing in the United States,16 strategies to develop role clarity in advanced practice nursing in Canada,17 and ways to improve medication safety in residential aged care settings in Australia.18
Summary and Conclusion Implementing change is a key nursing leadership competency which can be informed by successful models of change which use constructs of power, reason, reeducation, structure, behavior, or technology. Learning from existing models may help nurse leaders avoid perils of change fatigue and may promote and sustain successful change.
References 1. Gem Sutra. Diamond formation. http://www.gemsutra.com/ diamonds.html. Accessed March 3, 2007. 2. Tracy MF. Taming runaway change. AACN News. 2006; 23(11):2.
390
3. American Organization of Nurse Executives. AONE Nurse Competencies Assessment Tool. 2005. http://www. healthcareleadershipalliance.org/directory.htm. Accessed February 1, 2007.
JONA Vol. 37, No. 9 September 2007
Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
4. American Organization of Nurse Executives. AONE Guiding Principles for Future Patient Care Delivery. 2004. http:// www.aone.org/aone/resource/toolkit.html. Accessed January 20, 2007. 5. Gibson J, Ivancevich J, Donnelly J, Konopske R. Organizations: Behavior, Structure, Processes. 12th ed. Boston, MA: Irwin/McGraw-Hill; 2006. Chapter 17. 6. Litch B. How the use of bundles improves reliability, quality and safety. Healthc Exec. 2007;22(2):13-18. 7. Porter-O’Grady T, Malloch K. Quantum Leadership: A Textbook of New Leadership. Sudbury, MA: Jones and Bartlett; 2006. Chapter 1. 8. McCauley K, Irwin R. Changing the work environment in intensive care units to achieve patient-focused care: the time has come. Am J Crit Care. 2006;15(6):541-548. 9. Bender L, McKenna K. Hemiplegic shoulder pain: defining the problem and its management. Disabil Rehabil. 2001;23: 698-705. 10. Mitchell R, Conlon A, Armstrong M, Ryan A. Towards rehabilitative handling in caring for patients following stroke: a participatory action research project. Int J Older People Nurs. 2005;14(3a):3-12.
11. Kotter JP. Leading change: why transformation efforts fail. Harv Bus Rev. 1995;73:59-67. 12. Kotter JP, Cohen DS. The Heart of Change: Real Life Stories of How People Change Their Organizations. Boston, MA: Harvard Business School Press; 2002:1. 13. Smale G. Managing Change Through Innovation. London: The Stationary Office; 1998. 14. Greenwood DJ, Levin M. Introduction to Action Research: Social Research for Social Change. Thousand Oaks, CA: Sage; 1998. 15. Parsons M. Capacity building for magnetism at multiple levels: a healthy workplace intervention. Part 1. Top Emerg Med. 2004;26(4):287-295. 16. Kelly P. Practical Suggestions for community interventions using participatory action research. Public Health Nurs. 2005;22(1):65-73. 17. Bryant-Lukosius D, Decenso A. A framework for the introduction and evaluation of advanced practice nursing roles. J Adv Nurs. 2004;48(5):530-540. 18. Cheek J, Gilbert A, Ballantyne A, Penhall R. Factors influencing the implementation of quality use of medicines in residential aged care. Drugs Aging. 2004;21(12):813-824.
JONA Vol. 37, No. 9 September 2007
Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
391
