CHAPTER ELEVEN Leading and managing change in nursing
INTRODUCTION
Change may be defined as making or becoming different; substitution of one for another variety (Concise Oxford Dictionary 1982, p.154). Change has become a constant part of our lives, and of our professional lives in particular. Porter-O’Grady & Malloch (2002) suggest that we should anticipate change and view it as a journey. While change is always occurring in the health field, it is occurring at a rapidly increasing rate and is becoming increasingly complex (Manion 1994; Menix 2000). This is due to a range of factors such as changing technological, political, economic and social forces, increased consumer participation in evaluation of health services, demographic changes, use of evolving financial and management tools, a shift from centralized bureaucracies to decentralised management systems (Henderson 2000), changing legislative requirements and processes, an emphasis on cost containment and cost efficiency changes in models of care, evidence-based practice, and a focus on health outcomes which have had a substantial impact on the management and delivery of health care (Duffield & Franks 2001; Heath 2002; Henderson 2000; Tappen 2001). These are issues of concern in nursing and health care internationally. Porter-O’Grady and Malloch see the system changes we are confronting in health care and nursing as being related to the fact that we are living in the midst of a major social transformation—‘a transition to a new way of living and acting’ (2002, p.9).
The lack of stability in the health care environment has an impact on the practice of nursing. It means that nurses need to be able to adapt to their changing role and manage both predictable and unpredictable changes. Although nurses may be regarded as ‘natural managers’ (Mintzberg 1994), they tend to lack a clear identity as leaders considered as a professional body (Commonwealth of Australia 2001; Duffield & Franks 2001). Despite the fact that nurses are the largest group of employees in the health care system, they tend to be excluded from decision and policy-making forums in health care (Borman & Biordi 1992; Duffield & Franks 2001). Nursing lacks senior positions in the wider health care arena where policy and funding decisions are made, which ultimately shapes the practice of the nursing profession (Duffield & Franks 2001). For example, the lack of leadership is evidenced in Australia by a large range of disparate nursing bodies rather than a coherent group that has a voice in developing policy, responding to policy proposals or advising on policy. Lett (1999) describes a similar situation in Britain, where there is a lack of clinical leadership. Grossman and Valiga (2000) argue that nurses need to develop a more positive self-regard, as they have allowed themselves to be exploited and controlled by others with greater prestige. Change can be accomplished by more active involvement on the part of nurses in professional associations and increasing awareness of government policies (Lusky et al. 2002).
The need for health services to move from centralised bureaucracies to devolved management structures has been internationally recognised in the last two decades (Henderson 2000). Tilley & Tilley (1999) found that this is occurring in the United Kingdom in middle-management nursing. They describe how the earlier mode of the classic bureaucratic role (with managerial authority, information and decision-making highly centralised) was increasingly problematic in a rapidly changing environment. Devolving management structures requires adequately skilled managers at all levels, yet there has been a failure to develop managers to meet the new requirements (Henderson 2000). Duffield and Franks (2001) report that in Australia there is little formal preparation for the transition and development of clinical nurses into management positions, with many first-line managers appointed on the basis of their clinical experience rather than managerial potential or educational qualifications. Furthermore, Mackenzie (1993) found that most nursing unit managers surveyed in the United Kingdom believed that their management responsibilities had increased since the start of the National Health Service, but 66 per cent felt inadequately prepared for their managerial role. The United States has also debated about the most appropriate way in which to educate and prepare nurses for leadership and management roles in health care (Cebulski-Alexander 1997).
Professional registered nurses manage change as an inherent and primary responsibility, regardless of the levels of their positions (Boynton & Rothman 1996). That is, all qualified nurses are managers of care (Mulholland 1994) and utilise management skills in the delivery of care. Poggenpoel (1992) suggests that nurses need to understand change as a phenomenon, identify emotional reactions to change and understand change management strategies in order to view change as a challenge that can be effectively managed. This chapter provides an introduction to key ideas regarding leadership of change, change management in the nursing environment, frameworks for analysing and understanding change, planning for change, strategies for leading change, resistance to change and implementation and evaluation of change strategies.
LEADING CHANGE
Leadership of change requires vision, courage, creativity, effective communication and a clear plan. The literature is replete with definitions of leadership. On analysis, the majority of definitions regard leadership as a ‘dynamic, interactive process’(Farley 1999, p.458). Three constituents must be considered in any leadership context: the leader, the followers and the situation or environment (Farley 1999). According to Trevelyan (2001, pp.41–2), leaders facilitate change ‘by serving as … symbols of change … creators of cultures of transformation … as rewarders and reinforcers of innovation … as role models who embody transformation and as givers of meaning to transformation’. She identifies two critical functions in leaders:
Leadership styles vary and may be classified as collaborative, consultative, directive or coercive (Stace & Dunphy 1996). Contemporary leadership and management theory emphasises collaboration and consultation over direction and coercion. However, change leadership and management is complex and different change imperatives require the use of specific strategies in particular circumstances. For example, if a rapid change in policy is required, and it is one which the leader determines is critical for an organisation, then directive change may be appropriate (Stace & Dunphy 1996). Leaders and managers of change may use a range of strategies, depending on the context in which they are working to achieve their objectives. It is clear, however, that successful, large-scale change in organisations requires the commitment of the majority of staff. This is best achieved through use of incremental cultural change (Gagliardi 1986), where the leaders and managers seek to win the hearts, minds and commitment of all employees in the organisation (Porter-O’Grady & Malloch 2002).
Leaders of change may be classified as transformational or transactional. The concept of transformation is used in theoretical discussions of change to mean ‘organisational change, learning and innovation’ (Trevelyan 2001, p.2). A transformational leader ‘is one who commits people to action, who coverts followers into leaders, and who may convert leaders into agents of change’ (Bennis & Nanus 1985, p.3). They ‘do not use power to control and repress but instead empower constituents to have a vision about the organisation and trust the leaders so that they work for goals that benefit the organisation and themselves’ (Farley 1999, p.469). Such leaders must live change by example. Porter-O’Grady & Malloch argue that
Transactional leaders are more focused on achieving short-term results, ‘typically by promoting teamwork and working in a practical manner’ (Crookes & Knight 2001, p.98). They are able to work within the vision or framework for change provided by transformational leaders. Zaleznik (1981), who has written widely about the differences between leadership and management, believes that leaders and managers are very different kinds of people. He believes that they differ in their own personal goals and their beliefs about the world and in their own personal motivation and their sense of self. Leaders formulate their goals from their passion and beliefs about what needs to be achieved. Managers, by comparison, adopt goals from the organisation. They differ in their orientation toward goals and in their working relationships with others and their view about the world. Managers hold appointee positions in the organisation. They are often appointed for both their technical and leadership experience. Managers have delegated authority, including the power of punishment and reward. A manager is expected to perform functions of directing, planning, organising and controlling. By contrast, leaders may not be part of an organisation or tied to a position of authority. They are not threatened by changes or the views of others.
Grossman & Valiga (2000) provide a number of principles to be considered in leading change, including the following:
People’s suggestions and contributions about the implementation of change should be sought and incorporated (Grossman & Valiga 2000, p.143).Grossman and Valiga (2000) stress that leaders do not need to be in positions of authority in order to create change. For example, nurses can develop a new patient care form and test it out if they are dissatisfied with the one currently in use.
MODELS OF CHANGE
Carney (2000) argues that because nurses utilise management skills in their delivery of care, it is essential that they have insight and knowledge into change models or theories. Models of change in nursing are usually categorised as either linear or nonlinear. While linear planning is appropriate when change is predictable or slowmoving, nonlinear models of change management are necessary in today’s health care system (Menix 2001). Nonlinear models are based on the premise that change occurs naturally from self-organising patterns. Begun and White (1995) suggest that nursing is a nonlinear dynamic system, where changes in one aspect of the system affect other parts of the system disproportionately.
Chaos theory was developed by Coppa (1993) as a new model for nursing. Grossman and Valiga define chaos theory as a ‘belief that hidden within the seemingly total disorganisation of a situation are patterns of order’ (Grossman & Valiga 2000: p.228). This theory encompasses the notion that change environments vary from being stable to being extremely tense, to being chaotic. Manion (1994) states that although unpredictability is a characteristic of change, applying a logical process to managing change can help reduce the chaos.
Menix (2000) conducted a literature review on change management in nursing. She found that undergraduate programs typically teach planned, linear approaches to change. The appropriateness of such a focus is questionable, given that the health care system is so unpredictable and that leaders need to be fluid and flexible in planning and implementing change. Some examples of linear models for planning change that are applied to nursing include Lewin’s (1951) three-stage change process, Roger’s (1983; 1995) five-step innovation adoption process, Lippitt et al’s (1958) seven-phase change process, and Havelock’s (1973) six-stage change process. Although it is beyond the scope of this chapter to discuss each theory in detail, one theory that helps understand the process of change is that of Lewin (1951). He identified three phases of change for use to deliberately disturb the equilibrium that exists before change is implemented, following which innovation is supported:
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