Change seems to be an almost unrelenting feature of the health service industry (Essen and Lindblad 2013) and as West et al. (2017, p. 1) indicate, “only innovation can enable modern health care organisations and systems to meet the radically changing needs and expectations of the communities they serve.” However, this needs to be balanced because during our time working in the National Health Service (in the United Kingdom), and to a lesser extent in other health services, modifications to the structure of the service felt like almost biannual events. Healthcare organisations and hospital divisions were amalgamated or disbanded, rebranded or dissolved with little real impact on the frontline service offered by clinically based staff, apart from never‐ending disruptions and feelings of disempowerment. The after‐effects of the COVID‐19 pandemic seem only to have exacerbated the process and advent of change. The issue is that organisations, particularly those such as hospitals or those that deal with healthcare concerns, are not like factories. They are communities of people and therefore they behave just like other communities. People are the core resource of the health service and even with the advent and entrenchment of technology, people are still, and will always be, central to the health industry and the leadership of these people is pivotal to how the organisations will function. Nurses, although the largest healthcare group in most countries, have commonly failed to understand how change can be managed and may still fail to recognise that they can direct or influence change, rather than be passive respondents to the forces about them. In nursing and healthcare, as in the wider community, there are a number of potential reactions to change, and it is these very differences that provide the fuel to drive the life of the organisation or community. It is these very differences that are essential if a community is going to continue to adapt to the world about it, to change, or in other words to develop and react to new situations. Change is a necessary condition of survival whether for individuals, communities or organisations. Differences are a necessary ingredient for change and stimulate a never‐ending search for improvement. Improving quality in healthcare involves changing the way things are done, changing processes and the behaviour of people and teams of people. The challenge for any one of us is to harness the energy and thrust of differences so that the individual, community or organisation does not disintegrate during the process of change but develops and grows. Without change we will wither and die, so from this perspective change needs to be embraced and managed. By that we mean evaluating the effects of change, sustaining the change if it is effective and positive and recognising when change needs to meet resistance or redirection. There are ways we can help change come about without destruction, dispute, hostility and division. This chapter suggests a range of tools that can be used to successfully manage change. Babine et al. (2016, p. 40) support this view, indicating that it is a key part of the clinical nurse leader’s role to engage in “systems management” that supports the implementation of sustainable practice change. This chapter will focus on leading change and innovation in practice. It will enable nurse leaders to recognise the steps for identifying areas where change is needed, to plan, implement and evaluate the change. An overview of some models of change will be introduced, and the challenges and potential barriers, such as organisational cultures and the importance of developing networks of support and approaches to networking, are presented. It will draw on examples from clinical practice that demonstrate how leadership has positively impacted upon the quality of patient care and why it is important for the future of the nursing profession. A number of tools can be used to support change. Each will be explored in this section. However, before these are outlined it should be noted that even with effective tools, it does not mean that change, at least planned change, will result. The models will help, but in the end, it may depend on the circumstances and attitude with which they are used, as much as your skill with the tools and leading the change. Iles (2011a) makes it clear that to be beneficial, change needs to be approached with care, courage and enthusiasm. Therefore, tools are merely methods of supporting your approach to change, not the magic remedy for success. Iles (2011a, p. 22) sees “conversation” as central to this process and reminds change agents (leaders) that simple, empathetic, engaging conversations that bring people into the process of change are vital for the outcome to be positive. This process requires listening as much as talking. A SWOT analysis can be used as a personal reflection tool or as an organisational management and change management tool. By looking at an organisation’s strengths, weaknesses, opportunities and threats, you may be able to analyse the current direction of the organisation (ward/clinical area/workplace), formulate future goals and objectives, or analyse specific situations, ideas, groups or activities. Then, once the assessment is made, ask yourself, can you change or challenge the threats or consider how threats can be changed to opportunities or weaknesses to strengths? The process requires scrupulous honesty and the capacity to be open and look at the threats (Mind Tools 2023; https://www.mindtools.com/amtbj63/swot‐analysis). By looking at these you may be able to foresee the obstacles to change. The four parts to a SWOT analysis are: Stakeholder analysis is used to develop a profile of the people vital for the change to be achieved. These are the people central or peripheral to the proposed change. When using the model, ensure you avoid using real names (to avoid identifying actual individuals and causing potential offence) but do consider the characteristics of the individuals that you see as stakeholders, to assess their capacity to be helpful, ambivalent or obstructive. Think carefully about why you see people having certain attributes. In the model, people are likened to three animal types: sheep, donkeys or lions. Sheep will follow; donkeys will resist, be sceptical and even work against change; and lions will adopt to or champion the change. This analysis allows you to consider who has low tolerance to change. Who are likely to be the adventurous types, who look for a challenge, who the sceptics may be and who the adaptors and saboteurs are. Working these out will profit from the proposed change greatly as it may allow leaders to target known agitators or develop a more collaborative or inclusive strategy for change to diminish resistance and share ownership (Varvasovszky and Brugha 2000). The core of Andrew Pettigrew’s model emphasises the importance of a broad, contextual approach to change. Pettigrew felt that an analysis of change should not just look at the processes of change but also at the political features of an organisation, and the history and cultural context in which the change might take place (Pettigrew and Whipp 1998). The model offers a continuous interplay between the ideas about the context of change, the process of change and the content of change (Pettigrew et al. 2001). The usefulness of this model is that it reminds the leader to consider the complexities of an organisation, and that it is commonly influenced by characteristics in the internal and external environment. Pettigrew defined the context as the “why and when” of change, differentiating between the inner and outer aspects of the context (outer might be the prevailing economic circumstances and the social and political climate at the time. Inner might refer to the resources, structure, culture and local politics). Content is described as the “what” of change and is concerned with areas of transformation, that is “what” is to be changed. The process is described as the “how” of change and refers to how the change will be made to come about, what actions are needed, who will do what and how things will get done. Wilfried Kruger developed the change management iceberg as a process to deal with change and the barriers to change. Kruger’s view (Ackerman‐Anderson and Anderson 2001) is that many leaders consider the tip of the iceberg (cost, quality and time) as significant issues. However, the proposed change is also influenced by other issues – below the surface. These are the management of perceptions and beliefs about the proposed change and issues of power and politics. These issues imply that more needs to be understood about the proposed change for it to be implemented successfully. Dealing with the types of barriers that arise and how the change can be implemented is dependent on the kind or type of change and the strategy of change that is followed or applied. The kind of change may focus on information systems/processes/policies etc. which can be difficult to implement, but only scratch the surface in terms of their impact on the iceberg. They can also focus on wider issues such as values/mindsets/capabilities, which can result in more profound change and be even more difficult to initiate or suffer from more ingrained barriers. The iceberg model also offers insight into the types of people who might be involved in the change, and like the stakeholder analysis, Kruger involves people in the change assessment. The change management iceberg model recognises that change is a constant feature of a manager’s (leader’s) task, but that superficial (tip of the iceberg) issue management can only achieve results on a limited level (structural change). For greater impact and control of the change, wider issues such as the interpersonal and behavioural dimensions, cultural dimensions, power and politics, perceptions and beliefs need to be considered. The model supports the concept of a complete and thorough assessment of the barriers that may impact the change, so the change is likely to be implemented with a greater chance of success. The PEST (political, economic, social and technological) analysis (sometimes called STEP by changing the letters or words about) is useful as an overall environmental scan for an organisation and while included here is not generally as useful as some of the other change tools at a local or ward‐based level. It is very useful to gain an overview of the “health,” sustainability or resilience of an organisation. The factors assessed are: A PEST analysis may take some time and be undertaken by a range of individuals with specialist skills in the various areas suggested. It may also be used in conjunction with a range of other change management tools, for example, SWOT analysis (Mind Tools 2023; https://www.mindtools.com/aqa3q37/pest‐analysis). Kotter’s (1996) model is quite simple: it offers an eight‐stage process for progressing change, offering a pattern or map that can support and direct clinical leaders and others when initiating or planning change (Jones and Bennett 2018). The steps are: Nominal group technique is an excellent change tool for helping groups to solve problems or propose changes for themselves. It may not be as useful for driving change through, but it is very handy for identifying where scarce resources and personnel with limited time can focus their energies. It is also an excellent tool for helping to engage wide numbers of people in the change process. The tool is useful for establishing what problems exist and what priority is placed on various competing issues. Significantly, it employs the stakeholders who take part in the process of decision‐making so that the priority problems or change issues have been identified from within the stakeholder group. The process for nominal group technique is relatively simple, but it takes time to set up and requires the majority of the stakeholders to engage in it for it to be successful. Have all the stakeholders gather or meet in some way, then follow the steps below: In this way the whole group has considered all the issues and decided themselves what the primary three issues are. This can be very empowering for stakeholders. The process isn’t over though; the final step is to ask stakeholders to focus only on these three problems. In their small groups again, ask them to propose potential solutions. This process will identify where the good (this is important to retain a fair perspective on the issues being discussed) and bad things about an issue/problem are and what might be done about them. The problem will still need to be addressed, but using this approach means that implementing change (that is often suggested by the stakeholders) has a greater chance of success as they have had a significant hand in identifying the issues and the potential solution. In addition, they have had a public and detailed opportunity to express their feelings and issues with people often in a position to support or direct resources for change (Sample 1984). Process re‐engineering is all about sticky notes! (They are small, usually yellow, low‐adhesive notes that can be removed and repositioned easily.) The process involves deciding on an issue or process that you would like to change. Gather together all the key stakeholders in one place. Give out a stack of different coloured sticky notes for each participant. Depending on the process under review and number of participants, it may be wise to break the large group into smaller groups. But usually, the group needs to have representation from all areas involved in the process under review for it to be successfully assessed. The first step is to brainstorm what the issues/problems/current processes are. These are then written on separate sticky notes, breaking everything down into its component parts. Then with everyone’s input, put the issue/problem/process back together using the sticky notes to manipulate the process, make changes or suggest new ways to deliver the desired outcome. Discussion is vital, as is physically moving the sticky notes about to see if/how a new process evolves. It may require a great deal of creativity and may also need people to suspend established ideas about how processes are traditionally done. The process has the potential to offer a whole new solution to significant problems or issues. It may point to restructuring and can be used in conjunction with other change management tools. This process can also be an empowering tool and often brings all the stakeholders together by valuing everyone’s input, like a team building exercise. As such, a key to the process is skilful facilitation of the sticky note activity. Force Field Analysis (FFA) has a clear advantage over the other models in relation to its use in the health arena; that is, it allows the leader to place themselves clearly in the picture and see their part in the process of change. The other advantage of FFA is that it is very easy to follow and use. Brager and Holloway (1992) described it as a tool for assessing the prospects of organisational change and Egan (1990) summed this up by describing FFA as an analysis of the major obstacles to, and resources for, the implementation of strategies and plans for change. It was developed because it was clear that stability within a social system is dynamic, rather than static, and the result of opposing and constraining forces. Lewin (1951) speculated that these operated to produce what we see or sense as stability. Changes occur when the forces shift, thus causing a disruption in the system’s equilibrium. Lewin’s model is therefore a way of listing, discussing and dealing with the forces that make possible or obstruct change (Jones and Bennett 2018). An analysis of these forces helps generate options that can help achieve or work against the objectives: Analysing these forces can determine if a solution can get the support needed, identify obstacles to successful solutions, suggest actions to reduce the strength of the obstacles and determine where the leader’s part in the change process might be and will be useful for an individual or for an organisation. The way to identify either restraining or driving forces is to employ other change tools (such as a SWOT analysis) or to use mind maps, brainstorming, consider the advantages and disadvantages of the change, explore key issues, or to follow “check or think” steps where you stop, question and consider what you have done, and re‐plan as required. Also consider social support and challenges and seek advice from others (e.g. experts, people who may have more experience or insights than you). Seek feedback on performance or get confirmation that you are on the right track, undertake education and training as this may provide you with the information you are looking for or give you more information to place you in a stronger position and undertake research and development to discover if someone else has faced this issue before. In effect, an FFA is a judged look at the potential future, saving some grief as you become forewarned. This model offers a cyclical approach to change with four stages. It is concluded that the process never really stops as evaluation and initiation are ongoing, so that as new problems arise and new goals are set, the stages renew and develop (Edgehouse et al. 2007).
5
Leadership for Innovation and Change
5.1 Introduction
5.2 Tools for Change
5.2.1 SWOT Analysis
5.2.2 Stakeholder Analysis
5.2.3 Pettigrew’s Change Model
5.2.4 The Change Management Iceberg
5.2.5 PEST or STEP
5.2.6 Kotter’s Eight‐Stage Change Process
5.2.7 Nominal Group Technique
5.2.8 Process Re‐Engineering
5.2.9 Force Field Analysis (FFA)
5.2.10 Initiating, Envisioning, Playing, Sustaining: A Theoretical Synthesis for Change
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