Transcript The Future of Nursing LEADING CHANGE, ADVANCING HEALTH

The Future of Nursing
LEADING CHANGE,
ADVANCING HEALTH
The report from the Future of Nursing is ALL about change.
http://www.thefutureofnursing.org/IOM-Report
Empowering Nurses to Lead
Every Nurse in Every Setting
North Dakota Action Coalition
Leadership Program
Change and Innovation
2
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
• 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).
If you have not already reviewed the Future of Nursing, read it
at http://www.nap.edu/catalog/12956.html
Change
Leading Change …
Developed by the Change and Innovation Committee
Becky Graner MS, RN
Consultant
Innovation
Purpose
To explore how we
manage and
facilitate change
Objectives
1.
2.
3.
4.
Describe 2 change theory models frequently used in nursing.
Review how knowledge of systems impacts change proposals.
Review the definition of creative and innovative.
Describe responses to uninvited changes imposed by an outside
force.
5. Identify a situation where one could use a change model to lead
change at the workplace.
To successfully complete this learning activity
and be awarded contact hours:
• The learner must
• Complete the reading assignments.
• Complete any additional learning activities.
• You will be asked to use the skills you learned in the Communication module on
reflection.
• Complete course and self evaluations.
• To earn a certificate of Achievement in Leadership Development you will need
to complete the additional project as described at the end of this learning
activity.
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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 system
how to work in teams
how to collaborate effectively within and across disciplines
the basic tenets of ethical care
how to be an effective patient advocate
theories of change/innovation
the foundations for quality and safety improvement
One commonly known behavioral change model is
Prochaska and DiClemente’s Stages of Change
Nurses 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.
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 Approach
Action Learning
Workout
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
Inspiration
Infrastructure
Evidence
Education
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)
Appreciative Inquiry Resources
• http://appreciativeinquiry.case.edu/intro/whatisai.cfm
• http://www.mindtools.com/pages/article/newTMC_85.htm
You may want to explore the material
provided at the links if you are not
familiar with Appreciative Inquiry.
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/
Research Activities online
http://www.ahrq.gov/news/newsletters/research-activities/index.html
PDSA model
http://www.innovation
s.ahrq.gov/content.asp
x?id=2398
Click on the link for an
excellent overview on
how to use this model.
Act
Plan
Study
Do
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.
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.
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.
Do you have ideas for improvements
in your workplace?
You may be asking:
You may wonder 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?
Innovative and Creative
• Innovation – to begin or introduce something new (usually taking an
idea or way or technology and applying it in a different way).
• Creative – original, imaginative (usually introducing a new idea/ way
that has not been generated before).
• To be truly innovative you need to be creative.
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 thinking
As 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 artist
Mix 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 warrior
What 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
Click on the link and read the following article for an overview
of innovation in nursing.
Unlocking the Power of Innovation
Barbara A. Blakeney, RN, MS
Penny Ford Carleton, RN, MS, MPA, MSc
Chris McCarthy, MPH, MBA
Edward Coakley, RN, MSN, MA, Med
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/
ANAPeriodicals/OJIN/TableofContents/Vol142009/No2May09/Innovati
on.aspx
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 Michigan
Suzanne Begeny, MS, RN, Ph.D. Applicant, University of Michigan
http://garysalton.blogspot.com/2007/04/structural-barriers-to-changeand.html
Why is change so
hard?
“Habit is a cable; we weave a
thread of it each day, and at
last you cannot break it.”
Horace Mann
People tend to like
things just the way
they are… and we
are a creature of
habits.
Are you 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!
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.
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.changemanagementcoach.com/supportfiles/force-field-analysisapp.pdf
Learning exercise: Answer the following questions,
write your answers in your reflective journal (from
communication module).
• What motivates you to change?
• What keeps you from changing?
Reflective Exercise
• 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?
Gaining insight from your answers. . .
• First 2 questions seek to help you uncover your driving and your restraining
forces. (Kurt Lewin's Force Field Analysis ).
• The 3rd question seeks to help you uncover your patterned responses and
to consciously make those response choices rather than respond out of
habit.
• The last question seeks to help you pause in the face of change to reflect
on your style of response. Are you a late adopter or an early adopter of
new ideas? Are you impulsive or are you do you refuse to accept changes?
Take some time to
reflect on the
questions from this
learning exercise.
You may choose to
write your answers
in a journal.
Overcoming our reluctance to change. . .
The goal for
facilitating change is to
avoid building resistance.
To sell 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.changemanagement.com/tutorial-5-tips-resistance.htm
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 situations you have experienced that
are similar to this story. How do situations such
as this make you feel?
You may write your thoughts in your reflective
journal.
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. . .
Carol 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?”
#1 Develop a vision or
goal for the project that
will help guide actions.
Carol’s vision is to
Improve patient flow
while maintaining safety
and quality.
Inspiration helps others see the
proposed change is beneficial.
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
Carol 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 Carol 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. . .
Act
Plan
Study
Do
Leading change
Remember . . .
The new style of leadership that is needed flows in all directions at all levels.
Whether you are leading change or supporting change all nurses are
expected to lead.
Nurses are expected to participate in efforts to influence healthcare policy
involving healthcare consumers and the profession.
Communication, knowledge of how systems function, how to lead change
are all necessary skills to contribute to advocacy and policy development.
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.
Leadership Development
To continue to earn your certificate of achievement
in leadership development 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, implement, and
evaluated the change (the proposal).
 Implement the change project, evaluate the outcome.
 A goal you may have is to 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.