Leadership_of_Change

word count 3432 “The only constant in this life is change” (McConnell 2000 p1).This also holds true for organisations, particularly within public sector services (Walshe & Smith 2007). Govier and Nash (2009) offer that constant change can adversely affect the provision of safe and effective patient care. Therefore the ability of managers to lead change effectively is vital (Jayne 2010). Keyzer and Wright (1998) propose that leading change can be unsuccessful when an unstructured approach is used. Anderson and Anderson (2009) identify the importance of considering organisational characteristics in effecting change. Guy and Gibbons (2003) consider the effect on change of the leader’s personal qualities, noting the importance of personal insight into leadership characteristics. George and Jones (1996) define change as movement from one state to another, from present to future. The introduction of bedside handover into a community hospital ward (referred to as Ward A in this text) will be used as a platform to explore leadership of change. As recommended by Karp (2006) a blended model of change will be used. Substantially a knowledge transfer model (Kitson et al 1998) blended with Boddy and Buchanans (1992, cited in Paton & McCalman 2008) work on the change agent. This approach will direct an examination of the evidence underpinning the proposed change, then an exploration of the context within which the change will take place, including consideration of the stakeholders involved. This then informs the facilitation stage. Using Boddy and Buchanan’s work provides the steps used to frame the presented action plan for change facilitation and also introduces consideration of key stakeholders the staff and patients ( Appendix One). Discussion of the facilitation stage identifies issues of leadership style and characteristics. This will be offered in the form of a personal analysis using work of Belbin (1981) and of Myers and Briggs (1995). This is presented in first person as required by the nature of the analysis. Finally, reflections on this change will be offered and recommendations for future practice. The proposed change from a traditional office based handover to a future state, (where a shorter office based handover is used based on the SBAR framework, followed by a bedside handover,) is essentially one of putting evidence into practice. Thus the knowledge transfer model and its implementation framework, Promoting Action on Research Implementation in Health Services (PARiHS) was selected (Kitson et al 1998, table 1). This proposes that effective change, “is a function of the relationship between the nature of the evidence, the context in which the proposed change is to be implemented and the mechanisms by which the change is facilitated” ( Kitson et al 1998, p 150). Table 1- Promoting Action on Research Implementation in Health Services (PARiHS). (Kitson et al 1998) Condition Low High Evidence Research Anecdotal evidence, descriptive information Clinical experience Expert opinion divided, Several camps Patient Preference Patients not involved Randomised controlled trials, Systematic reviews, evidenced based guidelines High levels of consensus, Consistency of view Partnerships Context Culture Task driven, Low regard for individuals, Low morale, Little or no continuing education Leadership Diffuse roles, lack of team roles, poor organisation or management of services, Poor leadership Measurement Absence of audit and feedback, peer review, external audit, performance review of junior staff Learning organisation, patient centered, valuing people, continuing education Clear roles, effective team work, effective organisational structure, clear leadership Internal measures used routinely, audit or feedback is used, peer review, external measures Facilitation Characteristics Respect, empathy, authenticity, credibility Role Lack of clarity around, access, authority, position in organisation, change agenda Style Inflexible, sporadic, infrequent, inappropriate Respect, empathy, authenticity, credibility Access, authority, change agenda successfully negotiated Range & flexibility of style, consistent & appropriate presence and support Change will be effective if all conditions are high. However if facilitation is high this can produce effective change even in low contextual conditions Another reason and an identified strength of this model, is that it is not only a conceptual framework but can also be used as a two stage change implementation process, of analysing evidence and context then facilitation (Kitson et al 2008). This model is not without limitations. Concept analysis of the terms, ‘context’ and ‘facilitation’, result in only limited acknowledgement of the human element of change (McCormack et al 2002, Harvey et al 2002). Kitson (2008) considers that there is a need to introduce social science theories into knowledge transfer; as change is most effective when involving key stakeholders. Jayne (2010) suggests that failing to get staff engaged with the change is a major reason for failure. Consideration of stakeholders, allows them a greater ownership of that change (Tornabeni & Miller 2008). Thus consideration is also given in this analysis to the stakeholders involved namely the patients and staff, and their openness to change. The knowledge transfer model describes the facilitation stage as aiming to, “help people understand what they have to change” (Kitson et al 1998, p152). With this comes the presumption that explanation and understanding of change is enough to affect a behavioural change, a view which is not supported in other change literature (Johnson et al 2005). Although referring to a flexibility and range of styles the model leads the facilitator towards a collaborative approach of leadership. Kenmore (2008) identifies the importance of a range of leadership styles to affect change. Certainly the change proposed here would seem to suit a more directive and interventionist approach rather than that of collaboration (Johnson et al 2005). Thompson et al (2006) explore the concept of facilitator and change agents and note that though they are often used interchangeably, they have distinct differences. The role of the facilitator being characterised by “helping and enabling rather than telling or persuading” (Harvey et al 2002, p 585). The role of change agent is seen as more directive, as in this case, often having already identified a specific change needed. They then proceed to present this to the team, continuing to work with them to develop an implementation plan. So unlike the facilitators’ role, it is goal specific and involves active intervention with the team, often taking the role of team leader (Thompson et al 2006). The work of Boddy and Buchanan (1992, cited in Paton & McCalman 2008) is used as the framework for the facilitation stage. It provides a simple step by step process, reflects the managers’ role of change agent and includes consideration of the human element, the stakeholders. In using the PARiHS model the first stage is to examine the evidence supporting the proposed change. In the ward environment communication of information between nurses is a fundamental component of patient care. As a co-ordinator of care the nurse will communicate this information to other health professionals, informing their approach to care delivery (Kinnaman & Bleich 2004). Traditionally, handover is the method used to transfer information from one shift to another (Hoban 2003). Evidence shows that the nature and structure of the handover, effects nurses recall and subsequent ability to plan care (Mascioli et al 2009). Curie (2002) adds that a poor quality of handover can compromise patient safety due omission or inaccuracy of important information being passed on. On Ward A, the handover method used is verbal and office based. This approach helps maintain patient confidentiality and increases the likelihood of recognition of psychosocial factors affecting patient care (Cahill 1998, Meisner at al 2007). Easily identified as a ritualistic part of ward culture, with it overt function of handover of information to inform the next shift; the handover also has covert functions (Payne et al 2000). It serves as a debriefing session, an opportunity for team building and a forum for socialisation for new staff into the ward culture (Lally1999, Hopkinson 2002, Evans et al 2008, McCloughlin et al 2008). However, this handover method can be lengthy and include discussion of irrelevant information (Sexton et al 2004). It can also take substantial amounts of nurses out of the clinical area, at any one time (McKenna 1987). McCloughlin et al (2008) reported that handovers which lacked structure, varied in content and quality. Scovell (2010) offers evidence that guidelines surrounding what should be included in handover would improve its outcome. Hohenhaus et al (2006), describe one form of standardised communication; the SBAR method. Already in use on ward A for nurse- doctor communication, this work utilises this approach for handovers; nurses offering information under the headings of situation, background, assessment and recommendation, facilitating structure and consistency of approach. The practice of beside handover has support within nursing literature , seen as supporting patient centred care and encouraging patient participation (MacMahon 1990). Limitations are also noted; dominance of physical aspects of care to the detriment of psychosocial care needs, fear of breaching confidentiality and lack of opportunity for nurses to access to collegial support (Cahill 2008, Seers 1986). But what of the patients perspective' Wiggens (2008) finds that patients consider the experience of care and being treated as an individual as vital; specifically noting involvement in decisions and continuity of care. Also reflecting some of the key attributes of partnership; shared responsibility, communication and decision making. Cahill (1998) further explores the patients’ perspective, finding that most expressed positive views, seeing handover as important to maintaining their safety. Patients also expressed concern over use of technical terms and jargon, nursing dominance over the process and only minimally over confidentiality. However, it is not clear from the results what environment the patients were nursed in. In Ward A the majority of patients are in shared rooms which may have an impact on confidentiality and practicality of bedside handover. These patient concerns reflect the power imbalance that exists between patients and nurses that can hamper the development of the patient as a partner in their care (Henderson 2003). Nurses have a strong clinical power base. This includes informational clinical power, as holder of and co-ordinator of information, legitimate power by virtue of their professional registration and charismatic power. This has the potential to put the patient at a disadvantage and to become the submissive partner. The traditional handover process serves to allow nurses to guard and maintain control over informational power. Nurses can be reluctant to give up their power, and perceive such attempts as threatening (Hakesley- Brown & Malone 2007). Although the partnership between patients and nurses is viewed as one of the closest relationships in healthcare, it is not equal. The expertise and experience of the patient often ignored (Kramer 2005). Partnership implies an equality in a relationship, with attributes of shared information and decision making (Wiggens 2008).To support this equality and move patient from passive user to valued customer in change, Maher and Baxter (2009) support an experienced based approach, enabling capturing of patients experience in order to understand and hopefully improve it. For Ward A methods of capturing patient experience were already present with patient surveys and patient diaries an established practice, embedded into the ward culture. The move to bedside handover should act as a further opportunity for nurses to capture that experience and begin to see their patients as no longer a passive recipient but an active partner in care. The second condition to be considered is context. Here consideration will be focused on organisational structure and culture. The organisation within which ward A sits has a flattened structure theoretically allowing communication to be more direct and an improved ability for adaptation and innovation (Rushmer 2000). Structurally the organisation is typical of a divisional structure with a board of directors, centralised support services and then a series of defined divisions, each division being locality defined with a manager at its apex. This divisional structure allows for ease and speed of decisions and improved communication, which allow for an openness to change (Maddern et al 2006). Ward A sits within one of the community hospitals divisions. There is a clear hierarchical chain of power from locality manager at the apex of the division, to matron level (this is the role of the author), then to ward managers and ward staff. Thus decisions taken by matron have the potential to be rapidly translated into action. The matrons role not only holds positional power (legitimate, reward and coercive) but also expert power and the potential for referent power. Thus, is in a strong position to influence and direct change (Porter at al 2003). Of equal importance is the organisational culture (Rashid et al 2004). Culture consisting of practices, values, beliefs and underlying assumption shared organisations members (Gordon & DiTomaso 1992). Considered to be not only, “historically determined and socially constructed” (Rashid at al 2004, p 4) but also “subjective and personal” ( Huber 2000, p439). Thus, there exists potential for organisational culture to be open to interpretation and translation at ward level. The organisation within which ward A sits has the following values; to provide patient centred services, always deliver results, value success, offer value for money and to have pride in the services it provides (HCHC 2010). These clearly support a culture of change within the organisation and the specific change proposed on Ward A. The organisation also demonstrates a no blame culture and clear evidence of rewards for innovation, with annual innovation rewards for clinical staff. Mickan and Boyce (2006) report that an organisation with a tolerance for mistakes, is one which is supportive of change. For the purposes of this analysis it is pertinent to consider the ward sub- culture, using some of the themes identified by Johnson et al (2005), in their cultural web analysis framework. Of relevance are the routines, rituals and stories of this culture. Ward A is geographically and professionally isolated being the only ward in a community hospital, some distance from the other hospitals. Many staff cannot drive and there are minimal public transport links. Ward practice is steeped in tradition and ritual, with a large percentage of the staff having worked there for over ten years. Predominantly, cultural stories concern threats of closure to the hospital and examples of being ignored by management. This is seen positively at times in allowing traditions to continue unhindered and any changes at organisational level historically have been viewed as having minimal relevance to the ward. Recently new staff have been moved into the ward from another hospital, due to ward closures. Thus, there exists a small group of staff who although are socialised into the organisational culture, are not socialised into ward sub-culture (Curnow & Timmons 2006). These staff could be viewed as potential ‘seed carriers’; people who move within an organisation taking with them organisational values and learning into their new environment (Kerfoot 2005). But; their presence can also be seen in supporting a key feature of this culture, that of uncertainty of future; representing the reality that wards can close. Chawla and Kelloway (2004) describe this uncertainty of future as leading to a lack of openness towards change; which needs to be managed by staff engagement. The final stage in PARiHS model is that of facilitation. Using Boddy and Buchanan’s (1992) framework a plan was developed as seen in Appendix One. The aim being to introduce a combination of a structured office based handover based on SBAR, followed by a bedside handover. The combined approach was chosen to offset concerns re confidentiality, due to the physical environment of the ward and maintain the benefits to nurses of office based handover. At the same time, introducing a bedside handover supporting a partnership based approach. Using this framework for facilitation allowed the factors identified in stage one of the PARiHS model to be addressed successfully. The final step that of planning offers only guidance as to content and as an experienced manager this was appropriate to the change agent involved. The main mechanism for change used is the formation of an implementation team. Tucker (1965, cited in Fletcher 2008) identifies stages of team formation, the first stage that of forming requiring a directive approach from the leader. The following stages of, storming, norming and performing require a more facilitative style. This development is supported by the leadership styles identified in the plan, in moving from directive to interventional. Fletcher (2008) considers that it is possible to shorten the time teams take to reach the level of performing; if the task is important with commitment from all team members to a shared goal. This is reflected in the membership of the team being selected from ‘seed carriers’ and also those who were open and seemed to support the planned change. Change leadership styles are identified within the plan, commencing with directive; a top down approach using authority to drive change, combined with educational. Then the use of intervention, here the change agent retains control, but may delegate parts of the change process to others. Johnson et al (2005) agree that it is appropriate to use a variety of styles in order to be an effective leader of change, but add that leaders may also have preferred styles depending on their personality types. The question for me, as I consider myself as a leader of change is; do I prefer roles based on direction and intervention and if so what can I learn from that. I sought the answer in the work of Belbin (2010) and Myers and Briggs, (1995) who considered team roles and team members’ personalities respectively. The model of facilitation selected, required me to act as a change agent. Belbin (2010) suggests that individuals not only have a functional role at work but also a preferred role within a team. To explore my role preference, I completed an online Belbin questionnaire. This was also sent to six others who were a mixture of staff I manage, my peers and managers. Other people are shown to be a more reliable source of information than oneself (Harris and Kuhnert 2008). The completed results of the questionnaire are shown in Appendix Two. My individual results showed clear top roles of co-ordinator, implementer and team worker. The role of completer finisher appeared towards the middle. The compiled results, showed the same top roles being preferred but significantly, the role of the completer finisher was the lowest. Belbin suggests the key characteristics of co-ordinator and implementer are organiser, efficiency, confidence and promotion of decision making. These are all traits that I see in myself and certainly ones that have been reflected within my work based performance appraisal. However the role of the implementer is also seen as one that has a tendency to be inflexible. The co-ordinator having a tendency to manipulate and delegate their personal work. My initial reaction, was to feel that was not me. However on reflection I do not enjoy the finer details of projects and I can become easily bored if the project stalls and will if possible, allow others to complete the task. As the results also showed that others saw me as a poor completer-finisher then maybe not only do I need to acknowledge this, but I need to actively manage it. Perhaps as with the change plan, I need to actively seek out completer- finishers who are keen to perform this role, rather than just allowing others to pick up this role. With regards to being a manipulator, yes I would agree with that. As team leader this can be a positive characteristic, selling the team vision both internally and externally (Fletcher 2008). However, I can see that the ability to sell could also contribute towards inflexibility. Certainly within the interventionist style of leadership, the role I have taken for a large part of this change, there is an associated risk of being perceived as manipulative (Johnson et al 2005). When I looked to the Myers –Briggs Indicator score to consider my personality within the team, my results showed that me as extrovert, sensing, judging and feeling. What could I learn from this' Allen (1994) identifies extroverts as those who can tend to act first and reflect afterwards. This I can relate to, as I do tend to be solution focused and make rapid decisions. I also can find it difficult to understand why some individuals do not react quickly to change, often finding them irritating. Opt and Loffredo (2003) see extroverts as having a more positive communicator image, with qualities of dominance, openness and relaxedness when working in a team. Norton (1983, cited in Opt & Loffredo 2003) offers that a dominant personality is assertive, confident and enthusiastic. I can see myself in these statements, once again also seeing the presence of the seller and manipulator. I would not previously have thought of myself as dominant, but upon reflection I can see that the directive and interventionist styles adopted in this change are underpinned by dominance. Loffredo and Opt (2001) found that those who were extrovert intuitive and thinking are more likely to be argumentative, when compared with those who are introvert sensing and feeling. I do not see myself as argumentative; in fact I know I actively avoid conflict when possible. My scores for sensing and feeling were very high and Knicely (1996) postulates that sensing and judging types tend to communicate in ways that tend to avoid and resolve conflict. I see this as a positive balance to my extrovert nature and perhaps the reason I and others see me as a team worker. It is also a good skill to have in terms of weathering the storming stage of team formation. Mani (1995) considers judging and describes this type as one who likes to plan work, likes to finish and reach closure on decisions. I scored highly on this and I can really see myself here, I dislike ambiguity and enjoy the sense of closure to a task. So in terms of my earlier question; I do believe that my preferred roles are directive and interventionist. I have always believed that I have been good at selling ideas to others and thus bringing about change. However this has made me aware that I could well have been more manipulative than I intended. A judging personality may bring with it many positive attributes, but is also likely to make me impatient with others who like to take their time and explore all possibilities. I am pleased that others saw me as a team worker but I feel that I need to work on developing a more collaborative approach to change with staff. I can take the opportunity after completion of this change to move to a collaborative approach, allowing the group formed to continue identifying and managing future change themselves. It should allow me to work on developing a less directive, manipulative approach. It would be interesting for me to repeat my Belbin questionnaire and analysis after six months and look for any changes in others perceptions. In using the change to bedside handover, this has demonstrated the importance of examining change models and using a model or models that reflects the type of change required. The identification of a need for a specific change in practice was well met by using the blended approach chosen. Allowing consideration of the organisational structure, culture and stakeholders involved. Using the cultural web of Johnson et al (2005), allowed for the possibility that organisational sub- cultures may exist, differing from the identified organisational culture. Leadership styles used to implement the planned change of direction and intervention were appropriate to the model of change and were also demonstrated to be the preferred styles of the change leader. However, the ability to use a variety of styles is important and future changes may require a less directional and more collaborative approach. “Change is inevitable” ( Mc Connell 2000, p1); and managed badly it can adversely affect the provision of safe and effective patient care. Therefore the ability of leaders to drive the change journey effectively is vital. However driving others is not enough, the leader also needs to take a journey into understanding themselves as leaders, in order to be successful. Appendix One - Strategy for change Step Discussion Approach Required Action Leadership Style Identify and manage stakeholders Staff- Patients Subculture identified Traditionally embedded practice Anxiety surrounding change Historically resistance to change- belief that organisational change does not include them Cultural stories - fear of closure agenda New staff- ‘seed carriers Matron as change agent has positional power and expert power Evidence shows patients see value of bedside handovers. Already using patient satisfaction surveys. Patient diaries already used Strengthen link between subculture and organisational culture Celebration of ward achievements across organisation Communication strategy. Identify supporters of change Communication strategy Acknowledgement of patient experience Engage with staff by ; Team exercises to review organisational values and development of team values. Share project across organisation, entries in organisation wide newsletter to celebrate practice. Set up open communication, regular face to face team meetings with matron. Ensure organisational developments regular part of agenda. Develop ward newsletter. Plan sessions to inform all staff of change required, to include research literature supporting change. Develop information sheet for patients to be given on arrival on ward re bedside handovers. Continue to use. Education & communication Intervention Directive Work on Objectives Evidence suggests improved partnership and patient outcomes with bedside handover. Office based approach had advantages of confidentiality, provision of forum for debriefing and staff support. Structured approach required. Anxiety concerning change. Resistance due to loss of power Combined approach with office based handover based on SBAR framework followed by bedside handover Work with learning and development to formulate training package to include, use of SBAR for handover, patient experience of bedside handover ( role play) awareness of jargon, principles of working in partnership. Prepare package for staff identifying evidence underpinning practice and rationale for change. Directive Set full agenda- highlight potential difficulties Potential difficulties Ward staff lack of openness to change Personal preferred team roles weakness in completer/ finisher role Do not need to gain support from all staff to affect change Identify supporters of change Awareness of team roles Work with small team to implement change. Team members picked from those who demonstrated openness and commitment to change. To include seed carrier. Ward staffing roster to reflect spread of supporters of change across shift pattern. Identification of completer finisher from ward team. Intervention Build appropriate control systems Importance of two way feedback Communication strategy with staff Utilisation of patient diaries and satisfaction surveys Plan for pilot study prior to implementation. Programme of team meetings set prior to commencement of change. Use ward newsletter to up date staff. Set up Change notice Board in staff room, allocate team member to update. Set up notice board for patients and visitors, allocate team member to update Allocate team member to monitor patient diaries and surveys to gauge patient experience. Monitor for any complaints re handover. Directive Intervention Plan process of change Action Plan Timeline Rationale Leadership Style Preparation Develop Communication Strategy to include team meetings, use of staff newsletter and specific notice board to inform staff and patients of change process Develop written package to give to staff Development of team values Month one Communication increase readiness to change. Develop link between ward subculture and organisational culture. Directive Education & communication Participation Initial team meeting- team is forming Team meetings to communicate planned change, objectives and presentation of evidence supporting change. Select ion of implementation group of six staff to plan implementation. Ensure mix of staff grades and established and new staff. Month One Communication to increase openness to change Identification of supporters of change. Nurture support amongst staff. Role of seed carriers Do not need to get support of all staff to affect change. Directive Education & communication Training All staff access preparatory training, held on ward Month Two Staff confidence in participating in handover. Ensuring time efficiency in handover Directive Education & communication Initial Implementation group meeting -team storming Plan implementation strategy with implementation team. Allocation of team tasks and responsibilities. Set time line for implementation. Develop patient handout Month Two Awareness of preferred team roles to ensure well functioning team Communication to patients / working in partnership Intervention Pilot study Team -norming Matron to participate in handovers for first 5 shifts. Members of implementation group lead in trial of new approach for cohort of 8 patients(2, 4 bed rooms) . Ensure member of implementation group are rostered to each shift. Identify one member of group to monitor patient surveys. Month Three Matron has positional and personal power. To lead by example. Nurture support amongst staff. Do not need to get support of all staff to affect change. Use of key staff to lead change in positive way to assuage staff anxiety. Pay attention to patient experience. Directive Intervention Review and communicate results of pilot study Team - performing Ongoing review of patient diaries and satisfaction surveys. Patient focus group to reflect on patient experience. Discussions of staff and patient experience at ward meetings Discussion of experience at implementation group Regular notice board updates. Month Three Access patient experience. Patient as partner in change. Communication to increase openness to change Identification of supporters of change. Allay anxieties around change Directive Intervention Participation Share experience across organisation Support team to produce article for organisation newsletter. Article put onto organisational intranet Month Three Increase sense of link between ward sub culture and organisational culture. Allay fears of ward closing. 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