We are going to look at the two types of change and how learning organizations can move ahead with changes that benefit nurses and patients alike.
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Planned change is a slow methodologic approach that is viewed as linear. Planned change typically deals with predictable changes such as determining how to educate all staff on the use of a new piece of equipment.
The second type of change is nonlinear or complex change. Nonlinear refers more to a web. In other words, everything is connected; pulling on one piece moves other pieces so that a new pattern appears. Most change in health care is complex because it involves many people and clinical and organizational changes.
A common way to view planned change is to use Lewin’s force field analysis. This analysis allows us to look at all elements in a situation to determine what barriers we must overcome and how quickly a change can occur.
Barriers and facilitators can refer to elements of the change, such as gaining information, securing funding, and having needed equipment (including technology). They can also refer to people or groups of people. In other words, we can use this approach to map by name who is against and who is for a change, or which groups of people (either internally or externally) will support the proposed change.
Although each situation has to be analyzed, some common barriers exist for almost every change.
The first is budget. If the change doesn’t save money, at least in the long run, it will be difficult to secure support from administrators, who have a key accountability for costs. Even the planning sessions have money associated with them because the people in those sessions are not providing care or performing their normal work.
Equipment may merely be focused on accessibility, but it also may involve purchases. If the equipment has a high degree of unreliability that then consumes important staff time, the chances for the change being adopted are diminished. On the other hand, if the equipment can save time or increase safety or reliability, it is not a barrier.
People who value status quo and are fairly averse to change are typically barriers to change. To convert them to being at least neutral takes effort on the part of group leaders. Often people who prefer the status quo see no benefit to themselves to take on the proposed change. How that insight is developed is the challenge for leaders and managers.
Finally, groups who see the change as a threat are not supportive, and if their numbers are sufficient, they become a powerful opponent. Sometimes the reason a group opposes a change is because they see the change as eroding their turf and power. These are difficult challenges to take on. Other times, they oppose change because it has not been described adequately, especially in terms of patient care benefits. For example, when health care took on the added task of specifically identifying the limb to be amputated, some groups thought this was an unnecessary task. However, the publicity surrounding mistakes was compelling.
Common facilitators include many elements. The most basic facilitator is data, but data alone do not convince all that change is needed.
A second facilitator exists when community support is available. For example, during a hospital expansion project, the surrounding areas are often disadvantaged, but if members of that community see that traffic issues will be fewer and access will be improved, they often are engaged in supporting the change.
One of the key elements of facilitation exists when buy-in is provided by physicians and nurses. These two groups are key to big changes that occur within a healthcare organization.
Most important, however, is the driver for any change: patient safety. If the benefit to patients is clear, it is easier to obtain buy-in from important groups, including physicians, nurses, and the community.
The second type of change is nonlinear or complex change. Think back to the figure of this change. The interchange between what is happening within the organization and what is happening external to the organization shapes both changes. For example, think back to the example I gave about a hospital expansion program. I said the community had bought into the change because community members saw the end results. Now think what would happen if some major delay happened or an explosion occurred on site, or publicity was focused on the way in which the building expansion was being funded. Suddenly, the community isn’t so supportive. Now the organizational representatives are spending more of their time managing external relationships than they are moving the project itself ahead.
The five critical disciplines we must engage in throughout an organization are these. First is systems thinking. Each of us must think of the organization as a living entity and know that what one of us does affects the organization. The organization has a set of values that are lived out and support personal mastery.
Two is personal mastery. Systems are in place that help all of us learn, so that we are well informed to provide the care patients seek.
Third are mental models. Each of us operates on certain values, beliefs, and assumptions. For example, I assume my car will start in the morning so I can get to work. Organizations have similar assumptions, for example, that people want to do their best and that employees value patients and the work that they do on their behalf. These are mental models.
Fourth is a shared vision. When the mental models of assumptions, values, and beliefs are examined and common ground is established, we have created a shared understanding. Moving that to the future in a unified manner is the way in which shared visions are established. This shared vision is designed to make the organization a better place to work, a better place to seek care, and a better corporate citizen of the community.
Finally, the fifth discipline is team learning. This refers to a cohesive group sharing learning experiences so that each individual benefits the other. This exchange results in more dramatic outcomes.
[Read slide] It may be useful to be an obstructionist if you cannot see the change as beneficial. Once you are clear, however, that the change is positive, you are either the agent or the follower, and these two roles may be fluid. For example, when the nurse manager is present, you may be the follower. When you are working with a preceptee, you may be an agent. Change requires a group of people working together to be effective.
