11Jones Leadership(F)-ch 11 168 1/14/07 3:42 PM Page 168 Skills for Being an Effective Leader C hange is nothing new In fact, it is often said that change is the only constant Change, particularly in the health-care environment, is complex and is occurring at an unprecedented rate Change is driven by many factors: the increasing cost of health-care delivery, the nursing shortage, the rapid advancements in technology and information management, and new expectations by the public to have a more active role in health-care decisions Meeting the health-care needs of the world requires that the nurse be proactive and creative in guiding change The ability to create and manage meaningful change is an essential skill for nurses in the 21st century Change fosters growth and innovation; progress cannot occur without change If nurses are to be leaders of change, it is imperative that they understand the changes occurring in the health-care arena, use political clout to have a hand in the changes, and master the change process This chapter will introduce readers to the principles of planned change, barriers commonly encountered when introducing change, strategies for overcoming barriers, and the role of the nurse as the change agent Elements of Change Change is an integral part of any organization, and the process can be uncomfortable and disturbing to those who are affected An awareness of the elements common to the change process is important DEFINING CHANGE Change means to be different, to cause to be different, or to alter Change may be personal or organizational and can occur suddenly or incrementally Change may be planned or unplanned Unplanned change, or reactive change, usually occurs suddenly and in response to some event or set of circumstances For example, an unanticipated rise in patient census may precipitate the need for a change in patient assignments Decisions are made—and change follows—as a reaction to an event Planned change, however, entails planning and application of strategic actions designed to promote movement toward a desired goal Planned change is deliberate and proactive For example, changing staffing patterns from extensive use of unlicensed assistive per- sonnel to an all-professional staff requires time and planning Specific strategies need to be developed and implemented before such a sweeping change is adopted Generally, planned change is more likely to occur incrementally, over time Planned change responds to anticipated events in the environment or community Change may be initiated in response to internal or external forces Internal forces stem from within the organization Internal forces include organizational values and beliefs, culture, and past experiences with change External forces come from outside the organization These can be social influences, economic factors, or legislation For example, a 1996 legislative mandate put the federal Health Insurance Portability and Accountability Act (HIPAA) in place (Public Law 104-191) This piece of legislation forced all health-care agencies, schools of nursing, and their governing bodies to plan and implement major system-wide changes in the way personal information is collected, handled, and stored Another factor essential to change is the presence of a change agent A change agent is one who generates ideas, introduces the innovation, and works to bring about the desired change In fact, the one who assumes the leadership role of change agent in today’s health-care environment is the nurse Members of an organization assume different roles in a change, depending on the nature of the change and their role in the organization A leader often assumes the role of change agent and initiates change; an effective follower actively participates in the change effort and is essential to the successful implementation of change Registered nurses are frequently in a position of leadership within healthcare organizations and, as such, are well positioned to be the leaders of change ASSUMPTIONS REGARDING CHANGE When initiating change, the following assumptions are important to consider Assumption Change of any kind represents loss Even if the change is positive, there is a loss of stability This loss of the familiar may produce anxiety and even grief in many individuals The leader of change must be sensitive to the loss experienced by others 11Jones Leadership(F)-ch 11 1/14/07 3:42 PM Page 169 Nurses Leading Change Assumption The more consistent the change goal is with the individual’s personal values and beliefs, the more likely the change is to be accepted Likewise, the more different the goal is from the individual’s personal values, the more likely it is to be rejected The change agent needs to know and respect the values and beliefs of those most affected by the change Assumption Those who actively participate in the change feel accountable for the outcome The more people who are involved in the process, the more the group will feel responsible for the outcome Assumption With each successive change in a series of changes, individuals’ psychological adjustment to the change occurs more slowly It is for this reason that the leader of change must avoid initiating too many changes at once Timing is important Assumption Power is important to the change process Organizations with many layers of hierarchy between the initiator of change and the ultimate decision makers may have difficulty with implementing change The shorter the distance the change proposal must travel from the initiator to the decision maker, the greater the likelihood that the change will be accepted Conversely, the greater the distance, the more likely resistance will occur ASSESSING READINESS FOR CHANGE Assessing readiness for change is generally the first step in any change project Until participants are ready for change, little can be done to bring about change According to Terry (1993), readiness for change is assessed by answering the following questions: What is the ultimate purpose of the action/ change? Why might I lead or be involved in this change? What is at stake if I lead or participate in this change action? 169 What structures are in place either to foster success or hinder the change? Are the necessary resources available to achieve this change action? What is the stakeholders’ level of commit- ment to the change? Practice to Strive For 11-1 Betty R is a practicing registered nurse who has worked in the intensive care setting for several years and is highly respected by her peers, supervisors, and hospital administrators She is also a graduate student in a family nurse practitioner program and has developed strong rapport with the faculty in the program Being in graduate school has given her new perspective on the value of researchbased practice Her clinical manager has also been attending graduate classes in nursing education and likewise values research as a basis for practice Betty has implemented a new evidence-based patient care initiative at work The facility is not new to change as it recently underwent a massive redesign in facility and organizational structure We will use Betty’s questions in the analysis of this new evidenced-based change initiative The purpose of the change is to enhance patient care by using evidence-based practice in the delivery of care Betty is in a position to lead this change because she can use the information she gained in her master’s program to help other nurses use research findings concerning patient care School has given her a fresh perspective on the nursing profession and the importance of using research rather than tradition in providing patient care One of Betty’s concerns was that her peers might view her as a “prima donna” or “stuck up.” Her motivation was that patients would receive care based on evidence, which would result in optimal patient outcomes Betty has a good rapport with individuals who are the informal leaders Her clinical manager and the vice president for patient services have already indicated their support for this change The organization has demonstrated an ability to manage other types of change effectively Betty’s relationships with faculty in the graduate program also provided resources One of her faculty members works part-time at the hospital as a house supervisor and is respected for her knowledge and expertise Betty’s clinical manager is prepared at the graduate level in another discipline and is currently pursuing a master of science degree in nursing as a nurse educator Moreover, as a stakeholder, Betty herself is committed to the project as a part of her graduate degree requirements The administration has a very high level of commitment as it is committed to achieving the best patient outcomes through excellent nursing care 11Jones Leadership(F)-ch 11 170 1/14/07 3:42 PM Page 170 Skills for Being an Effective Leader Strategies for Leading Planned Change Those wishing to bring about change must develop strategies to foster change Bennis, Benne, and Chin (1969), in their classic text, The Planning of Change, identified three strategies to promote change: rational-empirical, normative-re-educative, and power-coercive Decisions about which strategies to employ depend, to a great extent, on three factors: the type of change planned, the power of the change agent, and the amount of resistance expected These strategies may be used independently or together More often than not, some combination of strategies is indicated: the larger the change and the more resistance expected, the more strategies the change agent must employ RATIONAL-EMPIRICAL This strategy assumes that people are rational beings and will adopt a change if it is justified and in their self-interest When using this strategy, the change agent’s role includes communicating the merit of the change to the group If the change is understood by the group to be justified and in the best interest of the organization, it is likely to be accepted This strategy emphasizes reason and knowledge It presents those affected by the change with the knowledge and rationale they need to accept and implement the change This strategy is most useful when little resistance to a change is expected The power of the change agent is typically not a factor in changes amenable to this strategy This strategy assumes that once given the knowledge and the rationales, people will internalize the need for the change and value the result NORMATIVE-RE-EDUCATIVE A second strategy takes into account social and cultural implications of change and is based on the assumption that group norms are used to socialize individuals This strategy requires “winning over” those affected by the change Success is often relationship-based; relationship, not information, is the key to this strategy The success of this approach often requires a change in attitude, values, and/ or relationships Sufficient time is essential to the successful use of the normative-re-educative strategy This strategy is most frequently used when the change is based in the culture and relationships within the organization The power of the change agent, both positional and informal, becomes integral to the change process For example, one of the most powerful changes in recent history occurred when the norm changed regarding when to wear surgical gloves for preventing the spread of infection More than knowledge (rational-empirical) and administrative directives were needed to bring about this change: it took a change in cultural values that redefined the practice norms POWER-COERCIVE This strategy is based on power, authority, and control Political or economic power is often used to bring about desired change The change agent “orders” change, and those with less power comply This strategy requires that the change agent have the positional power to mandate the change Change effected by this strategy is often based either on the followers’ desire to please the leader or fear of the consequences for not complying with the change This strategy is very effective for legislated changes, but other changes accomplished using this strategy are usually short-lived if people have not embraced the need for the change through some other mechanism (Table 11-1) Barriers to Change and Strategies to Overcome Them All changes have the potential for both gain and loss It is important to identify all the potential barriers to change, to examine them contextually with those affected by the proposed change, and to develop strategies collectively to reduce or remove the barriers Barriers most common to change within the health-care environment are discussed below, along with some strategies to overcome them Additional barriers appear in Table 11-2 Change requires movement, which, as physics indicates, is a kinetic activity that requires energy to overcome resistance Also, as in physics, an object at rest (and that includes an organization) prefers to remain at rest Movement over barriers requires an 11Jones Leadership(F)-ch 11 1/14/07 3:42 PM Page 171 Nurses Leading Change TABLE 11-1 171 Change Strategies SITUATION CHANGE STRATEGY DISCUSSION HIPAA Power-coercive Agencies were mandated to implement policies and practices to bring them into compliance with legislation There are negative consequences of not following the mandate, including legal actions and financial sanctions Therefore, personnel have no choice but to accept the change Changing visitation hours in ICU Normative-re-educative This policy change, driven internally, represents social and cultural adaptation within the organization As society has become less structured, visitation policies need to adapt to allow interaction between family members and the critically ill patient Changing from centralized to decentralized staffing Normative-re-educative As nurses gain more autonomy in the profession and in their roles in patient care settings, they also desire more autonomy in scheduling their work hours The formal and informal leadership collaborate to foster and lead change Implementation of evidencebased research in practice Rational-empirical As nurses become more immersed in and committed to evidence-based practice, the knowledge gained from research drives change TABLE 11-2 Common Barriers to Change and Strategies to Overcome Them BARRIER DISCUSSION STRATEGY Desire to remain in our comfort zone Those who become increasingly attached to a familiar way of doing things (comfort zone) often view change as an unwelcome disruption Rational-empirical strategies can be used effectively to allow people to become comfortable with exploring new ideas Give people all the information available For example, a change in staffing patterns would be sooner accepted if the nursing staff was part of the change process from the beginning As invested players in the change, staff nurses are more likely to accept a change in staffing pattern if they know and understand what the policies are and the rationales for them Inadequate access to information Do not rule out a lack of information as a barrier to change Just because information has been made available does not mean it has been read and understood by all This is one of the easiest barriers to overcome Use the rational-empirical strategy Provide information to the members of the organization through every possible means: e-mail, phone calls, memos, staff meetings, mail, and informal gatherings to be sure everyone knows about the change that is under way Lack of shared vision It is critical to have widespread involvement, input, and ownership of the change The lack of a shared vision will cripple a change effort The normative-re-educative strategy work effectively to remove this barrier Through dialogue and discussion, the affected members can gain new insights and new perspectives on the change proposal This process is an integral part of building trust and sharing vision and values (Continued on following page) 11Jones Leadership(F)-ch 11 172 1/14/07 3:42 PM Page 172 Skills for Being an Effective Leader TABLE 11-2 Common Barriers to Change and Strategies to Overcome Them (continued) BARRIER DISCUSSION STRATEGY Lack of adequate planning To manage change well, ensure that the people affected see it coming Involving people in the planning gives them a sense of control and decreases their resistance to the change Rational-empirical and normative-re-educative strategies are helpful in overcoming this barrier The leader’s role in envisioning the future is vital Efforts must be made to keep all members of the organization informed about and involved in organizational changes Lack of trust Trust is key to bringing about change People must trust the change agent; they must also trust that the change is in their best interest Use both rational-empirical and normative-re-educative strategies to develop trust Provide all the information people need Include all individuals who are willing to participate in the planning of change Resistance to change Achieving lasting and effective change requires the cooperation and involvement of the whole team, not isolated individuals The normative-re-educative strategy is needed to help overcome resistance to change Work to empower people Offer them opportunities to develop skills and to use those skills to become leaders in the change process Poor timing or inadequate time planned Even desired change can fail due to poor timing or a lack of planning It is important to predict and anticipate system responses to change For instance, when planning how fast the change will occur, remember that the larger the change, the more people will be affected, and that more time will be required Timing is everything It is imperative that careful attention be given when a change plan is made public and when it is implemented Introducing a change at a time when the staff is already feeling overwhelmed is a certain guarantee for failure Likewise, not move too quickly Change that is made too rapidly removes the opportunity for meaningful dialogue and discussion that is essential for planned change to occur effectively Conversely, not lag When people are ready to move, get moving Fear that power, relationships, or control will be lost Every change represents the potential for loss to someone Normative-re-educative strategies are needed to alleviate these fears Employ strategies that include all those for whom the change seems to represent loss Help members of the organization reframe the change so they can see that what will be gained is greater than what will be lost (Emphasize direct and open communication and addressing of fears here Maybe individual meetings would prove most effective) Even when a change is desirable, the amount of personal energy required for the change to occur is deemed too great Sometimes change is desired but people are not willing to what is necessary to effect the change This is not the time to give more information or employ peer pressure The best strategy may simply be to slow the change process Give people a chance to catch up and reenergize Remember the power of timing ... supervisor and is respected for her knowledge and expertise Betty’s clinical manager is prepared at the graduate level in another discipline and is currently pursuing a master of science degree in nursing. .. Agencies were mandated to implement policies and practices to bring them into compliance with legislation There are negative consequences of not following the mandate, including legal actions and financial... the profession and in their roles in patient care settings, they also desire more autonomy in scheduling their work hours The formal and informal leadership collaborate to foster and lead change