The Future of NursingLEADING CHANGE, ADVANCING HEALTH

The report from the Future of Nursing is ALL about change.http://www.thefutureofnursing.org/IOM-Report

Leadership Program is divided into 4 main areas. Communication is foundational for learning and understanding about systems. Knowledge of how systems function is necessary to institute change. The ability to accept and engage in change is necessary to be an advocate for health policy.

All nurses are expected to lead!

Transforming leadership • Strong leadership is critical if the vision of a transformed health care

system is to be realized. Yet not all nurses begin their career with thoughts of becoming a leader. The nursing profession must produce leaders throughout the health care system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.

• FROM: Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine

If you have not already reviewed the Future of Nursing, read it at http://www.nap.edu/catalog/12956.html

• What is needed is a style of leadership that involves working with others as full partners in a context of mutual respect and collaboration.

• The new style of leadership that is needed flows in all directions at all levels. Everyone from the bedside to the boardroom must engage colleagues, subordinates, and executives so that together they can identify and achieve common goals (Bradford and Cohen, 1998).

Leading Change …

Objectives 1. Describe 2 change theory models frequently used in nursing. 2. Describe his/her response to uninvited changes imposed by an

outside force.3. Identify a situation where he/she could use a change model to lead

change at his/her workplace. 4. Write a proposal for change at his/her workplace.5. Implement proposal for change his/her workplace.6. Evaluate the results of his/her change project using criteria outlined

in proposal.

To earn contact hours you will need to submit the following: Identify the problem /change you would like to make using one of the

change models (you may use one of the models presented here or showcase another model you have used).

Share the steps you took to assess, plan for and implement a change. Share how you evaluated your project and the outcome of your

change project. Goal is to help you have a professional level presentation that can be shared

at conferences as a poster presentation, as an oral presentation, or as a written document that you could submit for publication.

You may also format the final work in a manner to include in a professional portfolio.

To be more effective leaders and full partners, nurses need to possess two critical sets of competencies: a common set that can serve as the foundation for any leadership opportunity and a more specific set tailored to a particular context, time, and place. The former set includes, among others: knowledge of the care delivery systemhow to work in teamshow to collaborate effectively within and across disciplinesthe basic tenets of ethical carehow to be an effective patient advocatetheories of change/innovationthe foundations for quality and safety improvement

Change Theories: There are many theories for change. Click on the link below to familiarize yourself with some of the many theories. http://changingminds.org/explanations/theories/a_alphabetic.htm

One commonly known behavioral change model is Prochaska and DiClemente’s Stages of ChangeNurses have long used this model when interacting with patients. It is often applied when trying to change patient behaviors.

• precontempation• contemplation• preparation• action, and • maintenance

Click on this link for a review of this model.http://currentnursing.com/nursing_theory/transtheoretical_model.html

When engaging in system changes we need a body of knowledge and skills that includes the individual and the system.

Changing a system requires knowledge of both individual and system wide theories. You will need to consider how the individual comes to making changes and you will need to consider how making a change within and between systems occurs.

Kurt Lewin's Force Field Analysis is a powerful strategic tool used to understand what's needed for change in both corporate and personal environments. It helps you understand the system in which you are attempting to initiate a change.

• http://www.change-management-coach.com/support-files/force-field-analysis-app.pdf

As you consider making changes in healthcare remember the concepts related to systems. You must assess your system when you are proposing and planning for changes.

There are many change theories used by nursing… this is a short list.. Appreciative Inquiry: A positive revolution in change (Cooperrider & Whitney)Open Space Technology (Harrison Owen)The whole systems approach: Using the entire system to change and run the business (Adams & Adams)Rapid Results (Murphy, Kriwan, & Ashkenas)Six Sigma ApproachAction LearningWorkout Holma, P, Devane, T., & Cady, S. (2007). The change handbook, (2nd ed.). San Francisco, CA: Berrett Koehler Publishing.

Specific change theories used by nursing I2E2

InspirationInfrastructureEvidenceEducation

Felgen, J. (2007). I2E2: Leading lasting change. Minneapolis, MN: Creative Health Care Management. Guanci, G. (2007). Feel the pull: Creating a culture of nursing excellence. Minneapolis, MN: Creative Health Care Management. http://chcm.com/the-i2e2-formula/

I2E2 guiding principles • Make every inquiry “Appreciative”… (refers to Appreciative Inquiry)• We have influence (R+A+A = responsibility, authority, accountability)• Experience exuberance (unleashing your creative self/ support creative

others)• Believe in your abundance (everyone has something to offer)• Be clear (clarity of purpose)• Embody the change (be the change you want to see in the world… Gandhi)• We get what we pay attention to (so be careful what you focus on)• Patients and families come first (ALL people’s feelings matter)

A word about “evidence”

Evidence-based-practice is• The integration of the best research evidence with clinical expertise and

patient needs and values.• Research is classified by levels ranging from weakest to strongest.

• Nurses use evidence based practice to promote quality, cost-effective outcomes for patients, families, healthcare providers, and the health care system.

• It is not “proof” to win an argument or get your way when seeking to make changes.

For further information about evidence based practice see• The North Dakota Center for Nursing website at

http://www.ndcenterfornursing.org/evidence-based-practice/

WILL NEED TO WATCH THIS AND UPDATE THE LINK AS THE WEBSITE WILL BE UPDATED OVER THE SUMMER

Plan

DoStudy

ActPDSA modelhttp://www.innovations.ahrq.gov/content.aspx?id=2398 Click on the link for an excellent overview on how to use this model.

PDSA model in a nutshell… • Plan- define the action/experiment. What will be done, who will do it,

and how will it be measured.• Do- implement the plan/experiment.• Study- was the intended improvement realized? Measure and discuss

the results with the team or workgroup.• Act- standardize the new process IF the action improved

performance. Act to put the process back to its original state if the plan did not improve the process. Determine why and how it did not work and begin again.

Click on the link below to read an overview of common barriers nurses encounter when managing change and innovation.

Structural Barriers to Change and Innovation in Nursing by:Beatrice J. Kalisch, Ph.D., RN, FAAN, Titus Professor of Nursing, University of MichiganSuzanne Begeny, MS, RN, Ph.D. Applicant, University of Michigan

http://garysalton.blogspot.com/2007/04/structural-barriers-to-change-and.html

You may be asking:

How do I become more innovative? How do I become more creative?How do I explore ideas or technology and come up with new ways to use them?

Are you creative?

Do you have ideas for improvements in your workplace?

Common patterns expressed by creative people • Curiosity• Testing and learning from “mistakes”• Highly developed skills at “noticing”• Ability and willingness to embrace ambiguity, the unknown, and irony.• Cultivate whole brain thinking (art and science)• Flexibility and balance• Systems thinking skills

Common ways we approach creative thinkingAs the explorer

Look outside your field, look for lots of ideas, see what is obvious, see a different route, look at ideas you tend to avoid. . .

As the artistMix up patterns, look for patterns, look at things from different angle, use of metaphor, how else

can you think about and or use things. . . As the judge

What is the idea trying to do, what can be salvaged, what assumptions, what is the chance of success, is the idea worth spending time on. . .

As the warriorWhat is your strategy to reach goal, what motivates you, what keeps you from starting, what

obstacles, how persistent are you, what are the sacrifices, consequences of failure. . .

From: A kick in the seat of the pants by Roger von Oech

Strategies to unlock your creativity• Define the problem or needed change (be specific)• Generate ideas (include the outlandish ones)• Select the idea and refine it• Put the idea into play • Evaluate the implementation and the outcome of the idea once it is in

play

Read the following article for an overview of innovation in nursing. Unlocking the Power of InnovationBarbara A. Blakeney, RN, MSPenny Ford Carleton, RN, MS, MPA, MScChris McCarthy, MPH, MBAEdward Coakley, RN, MSN, MA, Med

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No2May09/Innovation.aspx

What if you are the type of person who is resistant to change?

Most of us don’t wake up one day and say … heh, I am going to change!

Why is change so hard?People tend to like things just the way they are… and we are a creature of habits.

To change habits. . . .wouldn’t it be simple if this is all it took →

In fact many of us are excellent at tamping down change, holding off chaos, or flat out deflating any wild ideas….

Often we are the obstacle that prevents ourselves and others from changing even when outside motivation is positive.

There is usually some internal or external motivation for engaging in change. We need to discover those forces when leading change.

Learning exercise: Answer the following questions, write your answers in your reflective journal (communication module). • What motivates you to change?• What are your barriers to change?

• When you are reluctant to change, what is your pattern of response to change? Is your response a habit?

• Do you routinely find yourself stressed with proposed changes or do you enthusiastically engage in the process?

Overcoming our reluctance to changeEvents occur… (if we notice), and we make meaning of those events.Meaning making nearly always triggers an emotional response…feelings. At a fundamental level humans tend to ask “Is what just occurred safe?”(Communication with ourselves)Once we decide we may be threatened (real or imagined), our response to that threat is to maintain our safety. If we stay safe because of our response, we tend to repeat that behavior because we perceive it keeps us safe.The danger is this response could become a habit. Sometimes it becomes an addiction.

King, B. E. (2012). How the brain forms new habits: why willpower is not enough. Conference: Institute for Brain Potential.

Overcoming our reluctance to changeHabits tend to help us guard against any ‘perceived changes’ that may affect the present state one enjoys in the here and now. We tend to like things just way they are. We resist changing our behavior. Long term consequences are usually not factored into this way of thinking.If we think a change could impact our present state of well-being we may repeat past behaviors that we perceived kept us safe. Many of us simply resist change.

The goal for facilitating change is to avoid building resistance.

Pause and reflect on this story about perception and change. • Fable of the Roasted Pigs

• http://europepmc.org/articles/PMC2067655/pdf/jadsa00114-0027.pdf

Learning activity: Read the article Fable of Roasted Pigs

Consider what situations you have experienced that are similar to this story. Write your thoughts in your reflective journal. (You should have a reflective journal from the Communication Module).

Pulling it all together: think about this. . .• Nurses are especially prepared to lead change: Consider the nursing

process…. • We assess the situation • We diagnose the issue(s)• We make goals/ outcomes• We use best practices and can be very innovative when we plan for nursing

care• We implement the plan• We evaluate the outcomes

• We are pros at managing change…

A story of applying theory to practice. . .Judy is a staff nurse in the dialysis unit. She has noticed the patient flow on some days is especially congested. She wonders “is there a better way to move patients through the unit while preserving safety and quality?”

Now that she has formed a question what will she do next?Data gathering?More questions?Talk to other staff members? Investigate how other dialysis units structure their patient flow and assignments?

Develop a vision or goal for the project that will help guide actions.

Improve patient flow while maintaining safety and quality.

If Judy uses I2E2 after developing her vision she gathers evidence from multiple resources, she assesses then creates or modifies the infrastructure.These pieces include: defining roles, practices, standards, aligning with mission vision.For maximum success she engages all stakeholders in this process.

It is the action plan.

Next to provide necessary education Judy and her team must consider the various domains of clinical/technical, interpersonal relationships, critical/ creative thinking, and leadership. Because for the change to stick, one must include not just a change in one’s skill set but a change in behavior.

Again the overall success of the change is evaluated by collection of evidence.

The operational definition of success should align with the vision and be measureable.

Outcomes assist the team to refine and address any gaps in success.

If Judy decides to apply the PDSA framework. . . • Plan

• What will be done? Who will do it? • Gather evidence from multiple resources. • Conduct Force Field Assessment- forces for and against change• Develop the plan

• Do• Implement the plan• Provide support and education as necessary

• Study • Has the flow improved? (define and devise method to measure flow improvement).• Has patient safety and quality been maintained? (define safety and quality as it relates to these patients and

devise a method to measure maintenance).

• Act• Positive results?• Unexpected benefits? • No improvement?• Unexpected obstacles?

• Begin cycle again. . .

Plan

DoStudy

Act

Selling your idea…. avoid building resistance. • Engage those impacted by the change.• Expect some resistance.• Develop a plan to manage resistance.• 2 top reasons for resistance to change:• lack of awareness of why the change was being made• a lack of awareness about and involvement in the change

• Engage the leaders, managers, supervisors.

• For complete overview see http://www.change-management.com/tutorial-5-tips-resistance.htm

To earn contact hours you will need to submit the following: Identify the problem /change you would like to make using one of the

change models (you may use one of the models presented here or showcase another model you have used).

Share the steps you took to assess, plan for and implement a change. Share how you evaluated your project and the outcome of your

change project. Goal is to help you have a professional level presentation that can be shared

at conferences as a poster presentation, as an oral presentation, or as a written document that you could submit for publication.

You may also format the final work in a manner to include in a professional portfolio.

Project (how should we have the learner share their project)• Record and share your project by Portfolio format • Record and share your project by a PowerPoint presentation • Record and share your project by a poster presentation format• Record and share you project by writing a professional article

• If someone wants to learn how to do a PowerPoint electronic poster presentation I can insert directions here as well…. Then they can submit their poster electronically… and add a new skill set.

• Remember this module is prep for the advocacy and policy development level. It builds on communication and systems.

Creativity: Resources for further exploration. Csikszentmihalyi, M. (1996). Creativity: Flow and the psychology of discovery and invention. New York; Harper Collins Publishing. Von Oech, R. (1990). A whack on the side of the head: How you can be more creative. Stamford, CT: U.S. Games Systems, Inc. Gladwell, M. (2005). Blink: The power of thinking without thinking. New York: Little, Brown and Company. Gelb, M. (1998). How to think like Leonardo da Vinci: Seven steps to genius every day. New York: Bantam Dell. Thompson, C. (1992). What a great idea! New York: HarperPerennial.

For further information on Innovation (continuous improvements) consider the following resources.Healthcare Kaizen http://leanhealthcareperformance.com/lean/kaizen.php

Graban, M., & Swartz, J. E. (2012). Healthcare Kaizen: Engaging front line staff in sustainable continuous improvements. Boca Raton, FL: CRC Press.

How innovations catch and spread…Rogers, E.M. (1995). Diffusions of Innovations, (4th ed.). New York: The Free Press.

Resources for further reading… Marciano, P.L. (2010). Carrots and sticks don’t work: Build a culture of employee engagement with the principles of RESPECT. New York: McGraw Hill. (This resource is an excellent overview for both employers and employees).

Kegan, R. & Lahey, L. L. (2009). Immunity to change: How to overcome it and unlock the potential in yourself and your organization. Boston, MA: Harvard Business Press.