Change Management in Nursing Essay
Leadership is defined as influencing people to achieve a purpose or set of goals, but differentiating it from management causes confusion in many instances (Tappen, Weiss and Whitehead, 2004; Senior and Fleming, 2006; Robbins, Judge and Sanghi, 2009). Leaders can be managers but not all managers can be effective leaders, making leadership an important aspect of effective management (Tappen, Weiss and Whitehead, 2004).
Several attempts have been made over the years to explain the characteristics of an effective leader. Trait, behavioural/style, situational-contingency and transformational theories are some of the theories that have been proposed to explain these characteristics (Yoder-Wise, 2003; Tappen, Weiss and Whitehead, 2004; Senior and Fleming, 2006). Goleman (2000) also used competencies of emotional intelligence (self-awareness, self-management, social awareness and social skills) to explain these characteristics. Nevertheless, none of these theories seem to adequately explain the characteristics that make an individual an effective leader. Yoder-Wise (2003) recognises followership as attitudes exhibited by individuals that the leader comes into contact with and explains that followers collaborate and act with the leader.
Mahoney (2001) states that all nurses must acquire leadership skills since nursing leadership ranges from the staff nurse caring for a patient to a nurse in charge of a hospital. Nurses in clinical leadership positions collaborate with other leaders in the healthcare system to promote positive change (Touati et al., 2006). However, Antrobus and Kitson (1999) criticise nursing leadership for its lack of external focus (socio-political impact on health policies). They recommend that, in addition to the knowledge on issues related to nursing practice, potential leaders of nursing should familiarise themselves with social and health policies, management and research. Sutherland and Dodd (2008) identify that a lot of changes are occurring within the healthcare system, driving the need for leadership development.
As a clinical leader in the making, a sound understanding of strategies for change management would prepare me as an effective leader. This is a reflective essay on how I set up a personal development plan to gain much insight on strategies for change management. The reflection is guided by Gibbs’s reflective cycle (1988 cited by Jasper, 2003). Although Cotton (2001) sees reflective practice in nursing as a problem, Durgahee (1996) identifies that nurses are able to perfect their actions when they examine their experiences through reflection and, consequently, become conscious of how different elements of care inform total professional nursing practice.
The essay begins with a brief introduction of my background, and a description of issues that led me to focus on change management strategies in my personal development plan. It, then, follows with a reflection on strengths, weaknesses, opportunities and threats that I have and how these would influence my career in the future.
The plan is presented, beginning with my learning objective and actions that I hope to take to meet my learning objective. The literature is then reviewed, followed by an appraisal of my organisation and how I plan to implement change. The last section describes my progress.
I graduated with a BSc. Nursing degree from the Kwame Nkrumah University of Science and Technology (KNUST) in Ghana in 2008. I practised at the Komfo Anokye Teaching Hospital (KATH), also in Ghana, as a general nurse for one year before enrolling at the University of Nottingham for MSc. Advanced Nursing. My responsibilities, as stated by the Ghana Health Service (2005), are to:
Assess care needs of patients, develop and implement plans of nursing care accordingly
Formulate, initiate and revise patient care as condition warrants
Participate in ward rounds
Allocate tasks based on skill of staff
Supervise staff and students in the ward
Evaluate nursing care and ensure continuity of care
In the third year of my undergraduate course, I was one of three students selected for a twelve-week exchange programme in the United States of America. The goal was for us to experience healthcare system and nursing practice in the USA and effect positive changes in nursing and healthcare at KATH. Generally, students who participate in such programs develop themselves, learn differences between cultures, and are able to compare healthcare systems and nursing in the respective countries (Scholes and Moore, 2000; Button, Green, Tengnah et al, 2005).
Judging from the exposure I had in the USA, I felt I could make a major impact on my colleagues upon my return. Exchange students, whether short-term (1 – 4 weeks) or long-term (more than 4 weeks), expect to have a positive influence upon their return to their home countries (Button et al, 2005; Carty et al, 2002). I developed myself, to an extent, as a result of participating in the exchange programme. This was confirmed by some of my colleagues. I, also, learnt some of the similarities and differences in culture, nursing practice and healthcare between the USA and Ghana. Notwithstanding, the overall purpose of having positive impact on my colleagues was not realised. I believe that lack of a strategy to effect the proposed changes as well as failure to collaborate with the other exchange students were the major reasons for the failure.
I expect to develop a teaching package to delay the progression of chronic kidney disease among patients with diabetes as my Advanced Nursing Practice module project and implement it at KATH. I, also, hope to gain new ideas on patient care while I am in the United Kingdom. Upon my return to Ghana, I aspire to assume a nurse-educator role. This job would give me some influence over the training of nurses at KNUST and KATH. All these have led me to focus on change management in my personal development plan so as to make positive changes in nursing at KATH.
I should be able to reflect on my strengths, weaknesses, any opportunities and threats that may influence my aspiration to effect some changes at KATH and Pearce (2007) suggests that using SWOT framework is a good way to do this. Therefore, using the SWOT analysis framework, I identified the following:
I am committed to what I do
I am good at motivating others
I have good interpersonal skills
I have good presentation skills
I attempt to please everybody
I am too lenient
I am studying with colleagues from different parts of the world
I have other experience from abroad
I am likely to become a nurse-educator at KNUST
Majority of the staff may see me as young and inexperienced to lead them
Pearce (2007) suggests that once threats have been identified, there should be a way to handle them. By confidently demonstrating the experience gained,
developing good interpersonal relationships and clearly presenting shared visions, majority of the staff are likely to collaborate with me (Martin, 2006).
Needs assessment assists individuals to set clear learning objectives for their personal development plan (Holloway, 2000). Reflection on the exchange program reveals that I lack ideas on strategies and skills required to lead change within an organisation. Therefore, it is my primary objective to use this personal development plan to learn and develop strategies to lead change in the institution that I work in.
Actions to Meet the Objective
The Management Standards Centre (2004a) suggests that leaders must possess three kinds of knowledge and understanding to be able to lead change successfully. These are general knowledge and understanding (example is knowledge on models and methods for leading organisational change, their strengths as well as their weaknesses), sector-specific knowledge and understanding (example is knowledge on emerging developments in the health sector) and context-specific knowledge and understanding (example is knowledge on areas within the organisation that need change, with reasons and priorities). To lead change successfully, leaders must, also, be able to describe the change process within the organisation and how it affects the people within (Mott, 1996). Considering these, actions that I consider as appropriate for me to meet my objective are as follows;
Review literature on change management within organisations;
Perform an appraisal of the organisation that I work in; and
Plan the implementation of the change.
Main resources that are needed to undertake these actions are time and literature on leadership and change management within organisations. I should be able to achieve my objective within seven months and the outcome measure for me would be my ability to identify change management strategies that would best fit my organisational context.
Change Management within Organisations
Change in organisations is inevitable (reactive) and desirable but, usually, complex and difficult to bring about (Sturdy and Grey, 2003; Bellman, 2003; Boshoff, 2005; Dzik-Jurasz, 2006). Yet, there are many a time when change is proactive (planned) – organisations make changes due to opportunities that they have to improve the workplace or their output (Dzik-Jurasz, 2006), and is also described as innovation. Change is very vital for healthcare institutions that seek to deliver quality and patient-centred care to its clientele, and nursing leadership is regarded as a linchpin for such changes to be successful (Dzik-Jurasz, 2006; Sutherland and Dodd, 2008). As a nurse aspiring to be a clinical leader, understanding the processes of change is, therefore, indispensable.
Pettigrew, McKee and Ferlie (1988) state that leaders of change should focus on the content, the process, the context of the change as well as the successful regulation of the relationship between the three. They explain content as the specific areas where the change is expected to occur, and processes as the activities, expected reactions and interactions between the groups that seek to bring about the change. Context, as they explain, refer to internal and external factors that have influence over activities within the organisation.
Lewin (1951 cited by Senior and Fleming, 2006) identifies three stages; unfreezing, moving and refreezing. At the stage of unfreezing, problems, needs or opportunities for change are identified, and the stage where new strategies or ideas are implemented causes individuals within the organisation to experience the change (moving). Finally, the stage of refreezing is reached when the change has been well integrated into the organisation (Yoder-Wise, 2003; Boshoff, 2005). Tappen, Weiss and Whitehead (2004), also, identify that change process is in four phases; description of the change, planning the implementation of the change, implementing the change, and integrating the change. Change starts when awareness of the need for it is created and ends when a complete evaluation of its expected effects has been done after the implementation (ibid).
Lewin (1951 cited by Baulcomb, 2003) states that change is associated with certain forces that either facilitate or resist it; success would result when the forces facilitating the change exceed those that are resisting it within the context. Personnel within the organisation may be one of such forces. People resist change on the grounds of their psychosocial needs, the appropriateness of the change and, also, how the change affects their position and power (Tappen, Weiss and Whitehead, 2004). Therefore, they should be taken into consideration and be actively involved in the change process (Boshoff, 2005).
Bennis et al. (1985 cited by Bellman, 2003) identify three strategies of change and these are rational-empirical, power-coercive and normative-re-educative strategies. Rational-empirical and power-coercive strategies both use top-down approaches while normative-re-educative approach employs a bottom-up approach. Top-down approach involves senior management generating the idea, planning and directly implementing the change while the bottom-up approach directly indulges the employees in the change process (Ryan, 2008).
However, Ryan (2008) adds that top-down strategy alone is not effective for managing change at all times although it is very common under transformational leadership. Other strategies are education and communication; participation and involvement; facilitation and support; negotiation and agreement; and manipulation, cooptation, and coercion; and, dependent on the situation, these strategies may be used alone or in combination (Kotter and Schlesinger, 1979 cited by Yoder-Wise, 2003). It appears that the kind of strategy used would influence how the content of the change would be communicated to the parties involved.
Action research is another change strategy and the process is said to begin when change is considered necessary (Bellman, 2003). Relevant data is collected systematically and reported to individuals who must act on it, after which plans are collaboratively formulated and the necessary actions undertaken – research and action combined (Senior and Fleming, 2006). The process is in five stages (diagnosis, analysis, feedback, action and evaluation) and is described as problem-focussed, and able to reduce staff resistance because of their active involvement in the process (Robbins, Judge and Sanghi, 2009).
Komfo Anokye Teaching Hospital (KATH) is the second largest teaching hospital in Ghana, training many doctors, nurses and other paramedics in the Ashanti Region of Ghana. It is an autonomous service delivery agent under the Ministry of Health of Ghana (MOH, 2009a). In addition to training many of the health personnel in the Ashanti Region, many people within and outside the Ashanti Region seek healthcare there. As a result, provision of quality healthcare has always been the focus.
An organisation that recognises the need for change, weighs costs and benefits, and plans for the change when the benefits outweigh the costs is ready for a change (Dalton and Gottlieb, 2003). KATH is, therefore, ready for change because some of its employees are sent overseas or to other parts of the country, whenever there is the need for a new skill or knowledge to be gained, to bring about a positive change within the hospital. This may be a factor that would facilitate my agenda to implement lead change within the institution upon my return.
However, Ghana, as a country is underdeveloped (CIA, 2008). Therefore, financial support, many a time, becomes a difficulty. Another challenge may be the fewer nursing staff. The Ministry of Health (2009b) estimates that there was a nurse-to-population ratio of 1:2024 in Ashanti Region and 1:1451 for the entire country in year 2007.
Planning the Implementation of the Change
This is the second stage of the change process, as was identified by Tappen, Weiss and Whitehead (2004), and it involves identifying possible resistant forces to the proposed change and identifying strategies to prevent or overcome them. The change strategies to adopt as well as how to communicate the need for change are considered at this stage (Management Standards Centre, 2004b). Bellman (2003) suggests that the normative-re-educative (bottom-up) strategy is suitable for changing practice within nursing.
As it appears in my case, the need for change would be driven from bottom (an employee) to top (management) and is likely to be supported by the nurses since it is coming from their colleague. Nevertheless, others may resist the change because they might not see the need for it (Baulcomb, 2003). But Martin (2006) suggests that a clear presentation of the vision and need for change may cause a majority of the staff to support it.
Flower and Guillaume (2002) suggest that unfreezing stakeholders of healthcare is a necessity to unfreezing the institution. Stakeholders at KATH for my project include the Director of Nursing Services (DNS), the Deputy Director of Nursing Services (DDNS) for the medical directorate, and the head of the diabetic clinic. When these key people are made to recognise the need for a change, then hospital management is likely to support the proposed change.
In times like these when evidence-based practice is being advocated for (McEwen, 2007), I should be able to use evidence to justify the need for a change. I, therefore, plan to undertake a study that would compare the teaching package that I hope to introduce with the current approach used at KATH. If the new teaching package proves to be relatively successful, then majority of the staff are likely to appreciate the need for it.
Reflecting on the exchange program, I realise that the idea of bringing about change in practice was not clearly communicated. None of the processes of change, as has been identified now, were known at that time neither was there a strategy or a plan for the change. Some changes are unsuccessful because they are not clearly defined (Tappen, Weiss and Whitehead, 2004) and that is exactly what happened. Although I am still working on developing the teaching package that may be different from what is already present at KATH, I now realise that its purpose and effectiveness should be well communicated to other colleagues and management before the idea would be supported. I have discussed my ideas with the Director of Nursing Service of KATH and the Deputy Director of Nursing Services for the medical directorate and both of them seem excited about my idea.
However, I have come to understand that all kinds of change are likely to face some form of resistance from the people (Baulcomb, 2003; Tappen, Weiss and Whitehead, 2004). I therefore, hope to apply the normative-re-educative (bottom-up) strategy because it has been identified as suitable for changing practice within nursing (Bellman2003). I also believe that such a strategy would let my colleagues feel actively involved in the change process and, hence, support it.
Moreover, I hope to gain new insights from my visits to some hospitals and my interactions with some specialist nurses while developing the project. I, therefore, hope to modify my plans and strategies, when the need arises, in order to become an effective change agent within my organisation.
Personal development plans assist individuals to focus on specific needs and steps to take to achieve their objectives (Floodgate and Nixon, 1994). This essay has assisted me to reflect on my practice and roles as a leader. Whenever there is reflection, there must be a change in perspective (Atkins and Murphy, 1993). Development of change management strategies was identified as my learning objective. Actions to meet this objective were identified and pursued. Gibbs’s reflective cycle (1988) was used as a guide. Consequently, I have become familiar with different strategies that could be employed to effect and lead change successfully, and plans to implement these in my institution have been proposed, although they are subject to change when new insights are gained.