Change Management and Change Fatigue

CH 15: Effecting Change, Large and Small

Introduction

From an organizational perspective, as we think about affecting change, big and small, there is a strategic plan (a written plan of action that anticipates the future so that an organization can adapt and survive in a changing and competitive environment) that drives both planned change and unplanned change. The strategic planning process allows for an organization to conduct a realistic examination of its current state, where it needs to be, how to get to where it needs to be, and how people determine how well they are doing (Rasouli et al., 2020).

In an effort to effect change, big and small, nurses throughout a healthcare organization need to be involved in the strategic planning process and consider how the overall plan influences the work throughout the organization. Although an organization is guided by its strategic plan, the reality is that the strategic plan is made up of goals and tactical plans that must be executed. The organization has to be ready for change when executing the strategic plan because change is inevitable. Nurse leaders, nurse managers, and frontline nurses must know that they can influence the strategic plan and affect change. In an effort to assist nurses in this endeavor, remember that the only thing constant is change. To that end, all of us nurses should participate in our organization’s strategic plan and strategic planning process because of the instrumental role we can play with affecting change and to support the vision of the organization you are aligned with.

Take a moment and ask yourself the following: how comfortable am I with change; how comfortable am I at accepting change; and am I willing to embrace change? To be effective, nurses must understand the nature of change and how to effectively navigate the change process. Nurses working in any setting (at the bedside, in clinics, in ambulatory centers, and in patients’ homes) not only support patients in changing their behavior and making healthy choices but also must now foster innovation and promote change in the workplace to adopt best practices, advance patient safety, and improve patient outcomes.

Nurses have the ability to excel as change leaders, no matter the role. As the change process transpires, nurse leaders are focused on ensuring the delivery of safe and effective care. Specifically, the nurse leader is assessing for any potential disruption and chaos of change to be transparent to the patients served as well as ongoing monitoring for sustainabilty. All nurses are change agents (Table 15.1) because of their ability to prepare for, implement, and sustain change (Gunty et al., 2019).

Table 15.1

Attributes Characterizing Change Agents

Attribute Key Points

Commitment to a better way Excited about designing a better future

Courage to challenge power bases and norms Closest to the work

Go beyond role, take initiative, think outside the box Assurance of change happening

Persona Self-motivated, generate enthusiasm

Caring Commitment to patients and their welfare

Humility About the change, not about “me”

Sense of humor Self-support through challenges

Data from Katzenbach, J. R., Beckett, F., Dichter, S., Feigen, M., Gagnon, C., Hope, Q., & Ling, T. (1996). Real change leaders. New York: Random House.

Strategic planning

The focus of the strategic planning process is designed to encompass the organization’s mission, vision, and values; environmental factors (internal and external); strategies; goals; and tactical plans, which are continuously being monitored, evaluated, and changed as needed (Fig. 15.1). Five phases comprise the strategic planning process:

• Phase 1—Conduct an environmental scan, SWOT analysis (strength and weaknesses are assessed from an internal perspective; opportunities and threats are assessed from an external perspective, outside of the organization).

• Phase 2—Strategic vision and mission are established and revised as appropriate.

• Phase 3—Strategic development whereby strategies are developed and a plan is written to address the SWOT analysis.

• Phase 4—Implement the strategy by selecting the best strategic options for the organization that balance its potential with the challenges of changing conditions, taking into account the values of its management and its social responsibilities; prepare the strategy and tactical plan to support the strategy; and execute the plan.

• Phase 5—Monitor the progress by evaluating the strategy to determine success. This phase is ongoing and can be changed as needed (unplanned change) and revised as appropriate.

A flowchart for key steps in the strategic planning process are as follows: • Phase 1: Assessment of the external environment: Markets, competition, healthcare trends, economic factors, technology, social factors, and educational factors. Assessment of the internal environment: Patient care, financial resources, human resources, information systems, research and development capabilities, and educational systems. • Phase 1 is followed by S W O T analysis where assessment of the external environment and assessment of the internal environment leads to opportunities and threats and strength and weakness respectively. • S W O T analysis is followed by phase 2 which includes vision, mission, values, and goals. • Phase 2 is followed by phase 3 strategies and plans which are followed by phase 4 implementation and phase 5 evaluation.

FIG. 15.1 Key steps in the strategic planning process.

Exercise 15.1

A chief nursing officer (CNO) is embarking on the Magnet® journey and is working with the nursing leadership team, various professional practice councils, and the frontline nursing staff to create a strategic plan for nursing. The CNO would like to complete an internal environmental assessment regarding the current status of nursing excellence. The nurse leaders and frontline nurses are assigned to examine the strengths and weaknesses of the nursing department, examine the quality patient care outcomes indicators, and examine the patient experience scores of a Magnet®-designated organization and review their outcomes on the website www.hospitalcompare.gov.

Select a hospital. Evaluate it and determine its strengths and weaknesses. Do the quality scores demonstrate excellence?

Reasons for strategic planning

The complexity of the healthcare environment means that it is ever changing. The strategic plan is fluid, agile, and adaptable (Posch & Garaus, 2020). It is the organizational vision for the future (Fig. 15.2). The strategic planning process leads to goal achievement, gives meaning to work life, and provides direction and improvement for operational activities of the organization (George, Walker, & Monster, 2019).

FIG. 15.2 A strong and dynamic strategic plan results in efficient and effective use of resources. (Copyright © Sarinyapinngam/iStock/Thinkstock.)

The strategic plan cannot happen in a silo—nurses can be instrumental in this process. Nurses can develop a nursing strategic plan that supports the goals and objectives of the organization (Lal, 2020). Nurses are the driving force that can implement and monitor the strategic plan to ensure success by demonstrating improvements in patient safety, quality, patient experience, and reducing the cost of care delivery (Lal, 2020). The fact is, without change (planned or unplanned) and without nurses as change agents, a healthcare organization is unlikely to actualize its vision and effectively execute its strategic plan (Lal, 2020).

The nature of change

The nature of change is constant and can be resisted by some. Yet, it is inevitable that change will occur either on a personal or organizational level. To that end, change can be initiated by the individual, the system, or imposed by either. Lewin (1951) opines that change can be planned and unplanned. Planned change is considered to be deliberate, organized, and has the goal of improvement. Unplanned change is considered to be disconcerting, unanticipated, and adaptive (Gunty et al., 2019).

All change, no matter how it is perceived, either positively or negatively, big or small, can be scary and generate fear because of the potential uncertainty and unknown. Some individuals embrace change more readily while others may be resistant to change (Miake-Lye et al., 2020). Nurses and nurse leaders can be successful change agents by understanding and being equipped to navigate and manage the change process (Posch & Garaus, 2020). Certainly, the American Association of Colleges of Nursing (AACN) (2022) competence to improve quality and ensure safety (6.2) implies the ability to plan for and respond to planned or unplanned change.

The change process

When implementing change, one must have a working knowledge of the change process in order to effectively navigate change (Nilsen et al., 2020). One must also be mindful of systems theory and how it can impact change—if one part of the system is changed, then it affects the overall system. Additionally, if a vulnerabilty or weakness is present/identified, the system will be able to adapt and remain stable. Of note, open systems are also influenced by both the internal and external environment. Here is an example that illuminates how both the internal and external environment of open systems can influence the change process: If one thinks about a healthcare system and the frontline nurses who work within, nurses are affected by internal factors such as the availability and quality of resources, the levels of staffing, and the processes used to manage patient care. External factors such as disease, social determinants of health, lifestyle patterns in the community population, healthcare regulation and reimbursement, and the supply of healthcare workers also affect the system.

Planned Change

Lewin (1947), one of the first theorists to study the process of planned change, determined that change has three stages. The first stage/preparation stage begins when assisting a person, group, or organization to move from the current behavior or process (unfreezing). The second stage begins when there is a move toward the new desired future state/reality (moving). The third stage begins when the new change is hardwired and sustained (refreezing). During the first stage (unfreezing), one must be cognizant that this stage involves helping others to overcome inertia—the desire to keep things the same. For example, unfreezing is when a nurse encounters a patient who realizes the need to adopt a diabetic diet after being diagnosed with type 2 diabetes or an organization acknowledges the need to change its delivery care model to achieve the goal of lowering the cost of care. Thus, unfreezing is the step during which individuals and organizations come to the realization that the need to change exists and then begin to implement that change.

During the stage of unfreezing, evaluation regarding the benefits and the costs of implementing the change must be considered. This decision could affect the motivation level generated to make the change. This evaluation is known as the force field analysis, which is described as the forces or influences that affect whether change occurs (Lewin, 1951). There are two forces in this evaluation. One force favors change—facilitators—in which case change will be more likely to occur. The other force is against change—barriers—in which case change will be less likely to occur. By understanding the force field analysis, nurses will have the perspective and insight as to what it will take to make and sustain a change. Specifically, it is key for change agents to assess and determine whether individuals see the need to unfreeze by listening to all participants involved in the change and answering the question, “Do they have a shared vision for the change?”

From an organizational perspective, change is accomplished through individual change. Thus, one must understand the power of maintaining the status quo. Unless individuals perceive that change will make things better, those demonstrating resistance and putting up barriers will limit the success of the change. As in the Challenge, the needed changes in getting the staff to speak up for safety and feel comfortable enough in asking a clarifying question to those who did not wash their hands upon entering a patient’s room is about unfreezing. During this stage of change, the change agent understands what people fear and how to best address those fears. Our normal tendency has focused on what needs to change and how we will make that change. What people want to know, however, is why change is needed. Change is a lot of work.

The second stage of change (moving) is when planned interventions and strategies are executed to support the implementation of the necessary change by utilizing methods such as education about the need for the change, vision building to conceptualize and bring life to the change, involving individuals/key stakeholders in the process of planning and making the change, and implementing small steps toward the change. Information gleaned during the analysis of the forces (facilitators and barriers) can be utilized to guide the change agent in making a plan and developing strategies to ensure effective implementation of the change goal.

The final stage (refreezing) focuses on sustaining the change. During this time, the change agent works to reinforce the new, desired behaviors and processes by way of positive reinforcement, reward and recognition, and providing feedback. The nurse manager must be the leader of change, taking ownership by continuing to monitor and reassess the successfulness of the change and compliance to required changed behaviors or processes, measuring the impact of the changes, and updating the frontline nurses on the progress being made.

Exercise 15.2

Think about Lewin’s force field analysis, which identifies facilitators and barriers, and apply it to the following situation. Use a scale of 1 to 5 to rate the potential strength of each in favoring or hindering attainment of the change. Use +  5 for the highest positive strength toward change occurring and +  1 for the weakest. Use −  5 for the greatest negative strength against the change and −  1 for the weakest.

Leaders at the Center of Excellence for Latino Health were concerned about the results from the Community Health Needs Assessment (CHNA) for the Latino/Hispanic population they serve. The assessment revealed that diabetes, hypertension, and obesity were negatively impacting their health. The nurses provided health education in the community following religious services. The nurses were culturally competent and culturally sensitive, able to develop a true trusting relationship with the participants, and able to communicate in their language. The frontline nurses provided education on the impact of diabetes, hypertension, and obesity and promoted various healthy choices to achieve their health goals. The participants learned how to take their own blood pressure with return demonstration as well as to recognize when the results were considered high, normal, and low. The house of worship was provided with blood pressure equipment for self monitoring and several participants agreed to be the blood pressure champion for ongoing support. Historically, programs held after their religious services offered soda, high-fat and high-calorie food options, and the food portions were large. The participants live in what is considered a food desert. Issues of food insecurity and very limited access to fresh produce were common. Many of the participants expressed their love of salt added to their food. Therefore, the frontline nurses created a dinner meeting and held a cooking demonstration, introducing participants to the use of a salt substitute. Some of the participants were willing to make the switch. When the frontline nurses instructed them on the particulars of portion size, the participants said they never realized what one portion size was. Some even verbalized that they were unknowingly overeating by two to three portions during a meal. Although some of the participants were enlightened and open to the potential of making healthy choices, others were less than enthusiastic about using the salt substitute. Last, but not least, another request for change was to switch out the soda for water and do away with the high-fat/high-calorie foods. One proposal was that if someone wanted soda, the person would have to pay for it.

Lewin’s work has been the foundation for many change theorists. Other theorists, such as Lippitt et al. (1958) have been able to further evolve Lewin’s theory of change to include three human factors that come into play during the second stage of change (see the Theory Box). The three human factors that set the stage to foster and embrace change are (1) asking probing questions to clarify the problem requiring the change; (2) examining the various ways to address the problem, developing commitment and buy-in to one of those plans; and (3) moving individuals/stakeholders to actually make the change—going from intending to change to actually making the change in behaviors and processes (Lippitt et al., 1958). The influence of the change agent cannot be underestimated. Lippitt et al. (1958) revealed that the effectiveness of the change agent due to the relationship the change agent had with the group made a significant difference in successfully accomplishing the change. The Literature Perspective illustrates a complex planned change.

Theory box

Planned Change

Key Contributors Key Idea Application to Practice

Seven Phases of Planned Change

Lippitt et al. (1958)

1. The client system becomes aware of the need for change.

2. The relationship is developed between the client system and change agent. The leader of a change must be committed to the change.

3. The change problem is defined. Creating a change team enhances the diversity of thinking about a potential progam.

4. The change goals are set and options for achievement are explored.

5. The plan for change is implemented.

6. The change is accepted and stabilized.

7. The change entities redefine their relationships. A group may disband or identify another issue.

Change can be planned, implemented, and evaluated in seven sequential phases.

Ongoing sensitivity to forces in the change process is essential.

Nurses are accountable for quality care and changes often lead to enhanced safety and quality.

Goals can drive change at any level of an organization.

Action must occur among the people involved in the problem.

Major goal attainment needs to be celebrated and reinforeced for the change to be retained.

Adapted from Lippitt, R., Watson, J., & Westley, B. (1958). The dynamics of planned change. New York: Harcourt Brace.

Unplanned Change

Although simplistic, Lewin’s theory described unplanned change. In evaluating the various theories that align with unplanned change, complexity theory aligns the best because it provides the framework to better understand how to navigate unpredictable events that we may encounter. Complexity theory describes change as the following: emergent, that is, it may appear chaotic but there is a balance between order and disorder; it is not considered to be episodic, rather, it is agile and adaptive because the system adjusts and realigns, recreating itself continuously; it is influenced by all individuals/stakeholders and subsystems in an organization; and a paradigm shift occurs. The change experience operates from a top-down model whereby leaders design the future state and impose it on the current system (command and control) to make it one in which change is organic and systemic, emerging throughout the system, across departments and professions, as an adaptive response fostered by decentralized decision-making and collaboration.

The second Literature Perspective provides thoughts about how frontline nurses can be innovators and change agents. An illustration of this is the Magnet Recognition Program® in the United States. The American Nurses Credentialing Center (ANCC) awards this status to hospitals that meet or exceed a set of standards designed to measure the quality and effectiveness of nursing in their organizations (ANCC, 2019).

Literature perspective

Resource: Nether, K., Thomas, E., Khan, A., Ottosen, M., & Yager, L. (2022). Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. Journal for Healthcare Quality, 44(1), 23–30.

This article provides an example of how nurses can be successful change agents. It focuses on the way in which neonatal intensive care nurses successfully reduced preventable harm to critically ill neonates and how they could hardwire their processes for sustained improvements to ensure patient safety. The nursing leadership team, staff nurses, medical staff, and parents/guardians of the critically ill neonates were engaged in implementing change that focused on three measurable outcomes for improvement: prevention of central line bloodstream infections (CLBSIs), improving the nutritional status for low-birthweight neonates, and avoidance of unplanned extubations.

The neonatal intensive care team members were on a journey toward high reliability and were committed to ensuring zero harm events for the neonates. The overall goal was to intentionally change the culture of safety in the neonatal intensive care unit and sustain those changes. It was paramount for the team members to improve their confidence and knowledge in safety concepts and safety tools. This was accomplished by online training and in-person classes on the management of the safety concepts and tools, mentoring, and change management. This was completed in two phases: the improvement phase (first phase) and control phase (second phase).

The results of this planned change by the nurses and the multidisciplinary team demonstrated not only significant improvement but sustained improvements. Specifically, post-implementation, there was a 67.1% reduction in CLBSIs, which was sustained for 17 months in the first phase of the change, followed by a 77.9% improvement in the second phase of the change. The nutritional status of the neonates improved by 63% in phase one and 35% in phase two with sustainability not yet determined. The amount of unplanned extubations was reduced by 22.7% in phase one and 54.3% in phase two and sustained for 20 months. Overall, the confidence and knowledge of the team demonstrated a positive impact and suggested that this improvement led to achievement in sustainability results and changing the culture of safety. The team followed the rules of engagement for planned change, which was also beneficial and led to achieving their three goals.

Implications for Practice

Specific strategies can foster efforts for frontline nurses to be successful change agents. The lived experience of frontline nurses prepares them to identify opportunities that can positively impact the care of those they serve and to contribute to the overall goals for the nursing strategic plan.

Literature perspective

Resource: Cusson, R., Meehan, C., Bourgault, A., & Kelley, T. (2020). Educating the next generation of nurses to be innovators and change agents. Journal of Professional Nursing, 36(2), 13–19.

The purpose of this article was to identify how nurses can be innovators and change agents. Introducing this concept into the nursing education curriculum is important. The article discusses the significance of nurses understanding the benefits of thinking creatively and becoming inspired to be engaged in change. Additionally, it allows for nurses to have a voice and be empowered to make change.

Implications for Practice

The strategy of providing education for nurses based on the principles of being an innovator and a change agent can lead to an empowered nursing workforce making a difference in the outcomes of their patients. When nurses are willing to think out of the box and be open to change, it may lead to new possibilities.

As a nurse leader, you need to be the champion of change, even if the chances of failure are great. A review of the literature demonstrates that close to 70% of all change strategies fail, whether change is planned or unplanned (Nilsen et al., 2020). Organization and individual stakeholders can articulate the vision and develop exceptional plans to execute change but still not be successful because they may have underestimated the impact of the human factor and how this change will affect people (Nilsen et al., 2020).

The nurse manager has an awesome responsibility to function as a change leader in the healthcare system. This requires developing a critical change management acumen that includes the ability to examine personal resistance against the change, assess for poor motivation to adopt new technologies, and be confident in gathering and communicating evidence-based practice strategies. Additionally, the change agent needs to be cognizant of the degree to which the change does not conflict with personal values, the context through how change advances in the organization, and the overall impact that the amount of substantive changes individuals must make in their behavior all influence change outcomes.

People and change

Change, whether planned or unplanned, has an impact on people. Change can be initiated, mandated, or directed by either internal or external sources. Change agents need to understand that the potential response/reaction to the change process by individuals/groups may vary across the continuum from full rejection to complete acceptance (Nilsen et al., 2020). This holds true when considering a person’s participation level in the change process; participation can vary across the continuum from total disengagement to full engagement (Miake-Lye et al., 2020).

Some initial responses to change may come across as reluctance and resistance, which may surface if people feel that it threatens their personal security (Nilsen et al., 2020). For example, when an organization is considering a restructure, the reality is that there is a potential for various changes of positions that will affect the staff. For example, a frontline nurse position might be eliminated from one department and the nurse offered another less desirable position. This could result in that frontline nurse feeling disgruntled, disheartened, and could even lead to survivor’s guilt if the frontline nurse retained a position over a colleague who lost a job/role.

The Institute for Healthcare Improvement (IHI) encourages organizations to consider making change that focuses on rapid, small tests of change which are often at the point of care (http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementImplementingChanges.aspx). This method allows for a nursing unit to experience unit-based decision-making to change processes and policies that revolve around staff members who have firsthand knowledge about working on the unit and depends highly on their ongoing adaptation to evolving realities.

All nurses have the capacity to be change agents because they proactively assist in helping others to transform by advocating for openness and improvement. Nurses who act as change agents fully understand the change process and are committed to the opportunity for growth. Additional characteristics of a change agent is being an optimist, having influence with colleagues, knowing how to build networks, and being able to facilitate communication. Nurses who function as positive change agents within the healthcare system are willing to try new things, stay abreast of new evidence about best practices, are open to change, are respected, and are role models. See Table 15.2 for an example of a self-assessment related to receptivity to change. Assessment of organizational culture and the readiness of staff and others to engage in making or participating in a change, whether minor or extensive, sets the stage for the selection and use of change strategies (Miake-Lye et al., 2020).

Table 15.2

Self-Assessment: How Receptive Are You to Change and Innovation?

Read the following items. Circle the answer that most closely matches your attitude toward creating and accepting new or different ways.

1. I enjoy learning about new ideas and approaches.

Yes Depends No

2. Once I learn about a new idea or approach, I begin to try it right away.

Yes Depends No

3. I like to discuss different ways of accomplishing a goal or end result.

Yes Depends No

4. I continually seek better ways to improve what I do.

Yes Depends No

5. I commonly recognize improved ways of doing things.

Yes Depends No

6. I talk over my ideas for change with my peers.

Yes Depends No

7. I communicate my ideas for change with my manager.

Yes Depends No

8. I discuss my ideas for change with my family.

Yes Depends No

9. I volunteer to be at meetings when changes are being discussed.

Yes Depends No

10. I encourage others to try new ideas and approaches.

Yes Depends No

If you answered “yes” to 8 to 10 of the items, you are probably receptive to creating and experiencing new and different ways of doing things. If you answered “depends” to 5 to 10 of the items, you are probably receptive to change conditionally based on the fit of the change with your preferred ways of doing things. If you answered “no” to 4 to 10 of the items, you are probably not receptive, at least initially, to new ways of doing things. If you answered “yes,” “no,” and “depends” an approximately equal number of times, you are probably mixed in your receptivity to change based on individual situations.

An example of the readiness of staff is found in Exercise 15.3. The willingness of the two nurses in this exercise to learn new skills and the combined talents of the nursing, clinical education, and administrative managerial staff to work together successfully helped achieve the very different nursing and organizational skills required by the new infusion center.

Exercise 15.3

Responsibilities for promoting change can vary depending on the role a nurse plays in an organization. View this short case study from the perspectives of a manager and a clinical nurse educator. Discuss the responsibilities each nurse would have in transitioning two frontline nurses to work in a new infusion center and identify the appropriate functions.

Both frontline nurses were long-term employees; one was from the medical-surgical float pool and the other was the logistics coordinator (responsible for determining all patient placement and bed assignments) whose position was eliminated because of budget reductions. The chief nursing officer developed the overall vision for this planned change and provided the following: (1) goals for the new infusion program, (2) activities essential for implementation goals, and (3) a timeline to accomplish the planned change. The nurse manager and the clinical nurse educator agreed to check in with each other daily and meet weekly for a more formal review of the team’s progress. Part of this plan includes the option to adjust it based on the potential for any unexpected changes. The two frontline nurses would begin their new position in 4 weeks and the plan would be executed.

What would be the nurse manager’s responsibility in implementing this change? What would be the clinical nurse educator’s responsibility in implementing this change? What are some unexpected issues that may occur requiring the nurse manager and clinical nurse educator to modify the goal, activities, or time frame of the project (dynamic quality of process)? What feedback from the nurse manager, clinical nurse educator, and the two frontline nurses transitioning would be important in guiding the overall process?

Exercise 15.4

Answer the self-assessment questions in Table 15.2 to determine how receptive you are to change.

We know that the more rapidly change can be incorporated, the more effective the organization is at remaining relevant. Connecting early adopters, such as the unit-based champions/change agents, to new ideas and to innovations, such as national peers of an IHI Web-based learning community, keeps them at the cutting edge. When these two groups are supported, an early majority can be recruited to support the change initiative. If as a frontline nurse you realize you are usually a laggard, look to be sure that rejection of new ideas is about some concern with the idea, not with just resisting change. Insight can be gained by using Exercise 15.5.

Exercise 15.5

Reflect on a time when a particular individual tried to get you or a group to do something in a work or personal situation. Share what rationale supported the decision of whether to go along with it. Looking back on it, do you believe that the idea was worthwhile? Was the person making the suggestion known, understood, and trusted? Would you say that the person making the request was aware of the real situation or had that person not received official sanctioning to influence activities? Does it resonate with you that change agents need specific qualities and abilities to be trusted by others?

Context and change

Although the people who make up an organization have a great impact on change processes, so, too, does the culture of the organization. Understanding the impact of organizational culture is key when it comes to change. When an organization is open and has its finger on the pulse of the realities facing the communities served and the larger industry and regulatory context, they are more viable, fluid, and responsive to change (Lal, 2019). From a nursing perspective, organizations that support the efforts to strive for Magnet® status or are designated as a Magnet® facility are an excellent illustration of learning organizations because they promote a shared governance philosophy grounded in the openness and empowerment of the nurse in shared decision-making power. Thus, the frontline nurses are engaged, their voices are heard, they have a seat at the table, and they know best what changes need to be made that will positively impact patient outcomes. To that end, when an organization fully supports nurses on the Magnet® journey, it not only benefits nursing but also transcends the entire organization. Since 2007, the Institute of Medicine (now the National Academy of Medicine) has encouraged organizational change that improves the quality of care and reduces costs by creating learning healthcare systems in America (Institute of Medicine, 2012). Nurses are instrumental in driving these results. Although implementing change can be complex, nurse leaders can use strategies to assist with the successful adoption of change. Box 15.1 provides an overview of six change support strategies that leaders can adopt.

Box 15.1

Change Support Strategies

• Promote acceptance of the change by viewing the change as a positive experience.

• Develop skills essential for supporting the change.

• Reduce negative influences and behaviors in the group experiencing the change.

• Mobilize positive peer support for the change.

• Create financial incentives that reward change agents.

• Make structure and process modifications to support the change initiative.

Adapted from Patterson, K., Grenny, J., Maxfield, D., McMillan, R., & Switzler, A. (2011). Change anything. New York: Hatchette Book Group.

Managing and inspiring change is a major task for all nurse leaders in healthcare (Nghe et al., 2020). The nurse leader must develop a positive working relationship with the nurses and staff based on reciprocal trust. Once this relationship is established, the nurse leader is more likely to be present in the moment and to truly listen and understand what matters to frontline nurses. This provides the nurse leader the opportunity to serve as a facilitator, promoting the sharing of ideas, fears, and honest reactions to the change proposal. Although nurse leaders can certainly inspire people to change, ultimately the individual must decide that the change matters (Austin et al., 2020). When nurses are inspired, the nurse leader can build on that and mentor frontline nurses as the change agents who are engaged in the change process (Nghe et al., 2020).

Today’s dynamic environment means that nurse leaders will have less time to plan and that plans must be constantly updated and amended (Fig. 15.3). Classic elements of effective change implementation can be found in Box 15.2. Past leadership theories place the leader at the helm, in command of the ship. Today’s leader must work to solve process problems with the team and empower them to be part of the solution. Nurse leaders will be the ones who keep patient care at the center of every decision, who will advance the ethos of nursing and who will connect change to what matters to frontline nurses (Nghe et al., 2020).

FIG. 15.3 Change happens quickly in healthcare. (Copyright © Ikunl/iStock/Thinkstock.)

Box 15.2

Classic Principles Characterizing Effective Change Implementation

• Change agents within healthcare organizations use personal, professional, and managerial knowledge and skills to lead change.

• The recipients of change believe they own the change.

• Administrators and other key personnel support the proposed change.

• The recipients of change anticipate benefit from the change.

• The recipients of change participate in identifying the problem warranting a change.

• The change holds interest for the change recipients and other participants.

• Agreement exists within the work group about the benefit of the change.

• The change agents and recipients of change perceive a compatibility of values.

• Trust and empathy exist among the participants of the change process.

• Revision of the change goal and process is negotiable.

• The change process is designed to provide regular feedback to its participants.

Adapted from Harper, C. L. (2007). Exploring social change (5th ed.). Englewood Cliffs, NJ: Prentice Hall.

Conclusion

Nurse leaders have business skill competencies that empower them to facilitate the strategic planning process, giving them the credibility to be strategic leaders and change leaders. Nurses in direct care need to be engaged in the strategic planning and change process to be effective in implementing the plan and goals of the organization. A strategic plan is deemed successful when demonstrated intentional improvement in outcomes is evident.

Whether delivering direct care, serving as a nurse leader, or providing clinical education, embracing change is the new imperative for nurses. Contemporary nursing requires that we celebrate more innovation and risk taking, decide to “break the rules” whenever possible to promote improvement, and embrace a spirit of curiosity as we explore the benefits of change.

The solution

Teresa Di Elmo

The frontline nurses received didactic education on the guiding priniciples of a High Reliability Organization (HRO). The concept of power distance was introduced. The frontline nurses shared examples of their lived experience of various power distance situations they encountered and discussed retrospectively the impact of that situation. The frontline nurses were instructed on the methodologies utilized in an HRO. To best address the power distance concerns, the team did role-playing exercises. I wanted the frontline staff to know that I was here to support them and they did not have to be fearful when having a questioning attitude even when the power distance presented itself to the situation. The bottom line was, if there is a concern for safety, the frontline nurse is empowered to ask a clarifying question because that is how we can ensure the safety of our patients and entire staff. We also created a safety hero award, which has been well received. The nurse leaders were also part of the education and training. The leadership in the organization also conducted leadership rounds to reinforce the HRO practices and rounded with intent to validate, celebrate, reward and recognize the frontline nurses for great catches and utilization of the tool to keep everyone safe. Seeing the enthusiasm, I was able to tap into the frontline nurses to be safety coaches. This allowed for another level of engagement and commitment from the frontline nurses, who are just incredible change agents. The culture has embraced this new paradigm and the entire team and the physicians are on this journey. The power distance concern was eradicated and the cross checks/clarifying questions have become the new norm.

Would this be a suitable approach for you? Why?

Reflections

Think back on your experiences thus far. In what way have you been involved with strategic planning? What can you do to convey to others the importance of nurses being engaged in the strategic planning process? What are you willing to commit to in terms of involvement in the future?

Throughout your career, you will face many changes and challenges as you work to become highly competent in a given role or field. How can the content in this chapter help you prepare for those changes? What change support strategies are you going to use? How can you approach this as a planned change to promote your success?

BEST PRACTICES

As busy as we are in our practice areas, we all need to connect with the strategic planning process and the resultant plan. The process allows us to shape the direction of the organization from our perspective and the plan itself serves as the roadmap to the future. Being able to adapt quickly to unplanned change is increasingly an important skill in any nursing position because change continues to happen quickly.

Tips for leading change

• As the nurse leader, be clear about the vision for change.

• As the nurse manager, when managing change, ensure that you are connected to frontline nurses and that you are present in the moment for them by listening to their thoughts, ideas, and concerns about the change.

• As the nurse leader, recognize and mentor their change agents.

• As frontline nurses, be aware of their potential to resist change and be supportive when they are attempting to embrace it.

• As frontline nurses, recognize that your lived experience prepares you to share your views when a planned or unplanned change occurs. Your expertise can assist in the successful execution of the change.

Case study 15.1

NEXT-GENERATION NCLEX® case study

Next-Generation NCLEX® case studies are included in select chapters to familiarize you with these new testing items for the NGN exam.

Learning Outcome:

Analyze results of an initial assessment to determine which findings supports a potential action or hinder the action; or when additional information is needed.

Cognitive Skill:

Evaluating Outcome

A direct-care nurse who is actively involved in the governance of their assigned surgical unit has been asked by their nurse manager to participate in a strategic planning committee to explore the addition of a bariatric surgical service at the hospital. The nurse is excited and delves into the strategic planning literature to be prepared for this opportunity. She realizes that she must be able to participate in developing strategies that reflect the environmental scan recently competed. The Strategic Planning Committee is to review the Environmental Scan done by the Administration. The findings were as follows:

• Determining the need for more bariatric surgeries in the area has been difficult.

• The hospital has a positive cash flow, limited debt, and sufficient reserves for expansion.

• A competing hospital across town has a robust bariatric service, led by a well-regarded chief of service.

• A new surgeon has moved to town and would like to increase his bariatric practice.

• Members of the medical staff of the hospital have strong negative feelings regarding starting such a service.

• The operating room (OR) facilities are currently providing services at peak capacity Monday through Friday.

• Additional space could be converted into more OR rooms.

• The Director of Surgical Services is an experienced nurse who is responsible for the preoperative areas, the operating rooms, and the postanesthesia recovery room. She plans to retire in 6 months.

• The nurse managers of the preoperative areas, the OR, and postanesthesia recovery unit all have 5 years or less experience and have been at the hospital for less than a year.

• The hospital is experiencing a shortage of nurses overall, particularly on the medical-surgical units.

For each of the findings of the environmental analysis, indicate whether the finding supports moving forward with the planning process, reduces the likelihood that the bariatric service would be successful, or more information is needed.

Findings Supports moving forward Reduces likelihood of success Needs more information

Determining the need for more bariatric surgeries in the area has been difficult.

The hospital has a positive cash flow, limited debt, and sufficient reserves for expansion.

A competing hospital across town has a robust bariatric service, led by a well-regarded chief of service.

A new surgeon has moved to town and would like to increase his bariatric practice in this area.

Members of the medical staff of the hospital have strong negative feelings regarding starting such a service.

The OR facilities are providing services at peak capacity Monday through Friday.

Additional space could be converted into more OR rooms.

The Director of Surgical Services is an experienced nurse who is responsible for the preoperative areas, the operating rooms, and the postanesthesia recovery room. She plans to retire in 6 months.

The nurse managers of the preoperative areas, the OR, and postanesthesia recovery room all have 5 years or less experience and have been at the hospital for less than a year.

The hospital is experiencing a shortage of nurses overall, particularly on the medical-surgical units.