The topic of change management is pertinent as the veterinary nursing profession faces system-wide drivers for change. Section 1.7 of The Royal College of Veterinary Surgeons' (RCVS) Code of Professional Conduct for Veterinary Nurses states that clinical governance must form part of the professional activity of a veterinary nurse, emphasising the continual requirement for change in practice (RCVS, 2018). Further drivers for change for veterinary nurses in clinical practice include the implementation of patient, client and business improvement strategies such as those associated with clinical governance and clinical audit. In clinical practice, veterinary nurses are ideally placed to support and implement change; however, it is pertinent for veterinary nurses to be aware of potential challenges when implementing change (Ballantyne, 2018). As Ballantyne (2018) warns, trying to implement change is often accompanied by restraining forces, which include adopting an unstructured approach to change, ineffective communication, employee behaviour and inappropriate leadership. Ballantyne (2018) and many others highlight the importance of harnessing effective leadership strategies and the application of a model for change for more successful implementation. This review of the literature aims to identify effective leadership behaviours, traits and attitudes and consider the efficacy of Kotter's (1996) model of change as a change implementation tool. There is a limited but growing body of literature associated with implementing change in veterinary practice; therefore, the disciplines of human medicine and medical education leadership and change management have been included.
Leadership
Owen (2011) defines leadership as an individual's behaviour, rather than the position they hold. Historically, effecting change was identified as a key function of leaders (Kotter, 1996). More recently, effective leadership has been acknowledged as a prerequisite for change, with Alavi and Gill (2006) arguing that a leader's personality is an essential element of change implementation (Gill, 2002). Furthermore, Pearson et al (2018) acknowledge that effective leadership is crucial for the sustainability of the veterinary industry, highlighting its importance to the development of the profession.
The literature identifies that certain leadership qualities are essential for successful change; however, there are discrepancies regarding what these qualities are. Gill (2002) proposed that leadership has to communicate a vision to be successful and concludes that communication is an imperative quality. This is comparable to historical theories from the business sector, produced by Kotter (1996) and Bennis and Nanus (1997), who define communication as a key quality for effective leaders.
More applicable to the veterinary industry, Lorenzi and Riley (2000) conducted a study identifying the roles nurse leaders play in human healthcare. The results suggested that effective communication is necessary in effective leaders. Moreover, Goldberg (1990) identified and defined the ‘big five’ personality traits of a leader, represented in Table 1.
Table 1. The ‘big five’ leadership personality traits (Goldberg, 1990)
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Meta-analyses conducted by Judge et al (2002) and Ilies et al (2004) demonstrated that these traits were apparent in leaders and confirmed these as the personality traits demonstrated by successful leaders. Langford et al (2017) further emphasise the importance of knowledge about the variety of leadership theories and concepts, suggesting that in nursing, any leadership approach adopted must fundamentally correspond with the ethics of the profession. Sullivan's (2017) suggestion that nurses already demonstrate many leadership personality traits could be applied to veterinary nursing. Veterinary nurses may already have a predisposition towards leadership, and are well placed to lead change in practice. An example of this would be a veterinary nurse communicating the importance of post-operative care to an owner. The veterinary nurse in this situation is likely to demonstrate all of the big five leadership personality traits in their communication with the owner, adapting to each situation in order to portray the importance of appropriate aftercare and ensure client compliance.
The big five personality traits have been contested in more contemporary literature (Cavaness et al, 2020). Swapp (2018) compares the effectiveness of extroverted and introverted leaders, challenging the conception that leadership is a trait only extroverts can possess. Farrell (2017) identifies that if only certain traits are perceived to make a successful leader, then there becomes a disconnection between leaders and followers. Swapp (2018) highlights that introvert leaders are often more effective in unpredictable environments, such as veterinary practice, encouraging veterinary nurses who consider themselves to be introverted to not be alienated from the prospect of a leadership role.
Francis (2013) recognised that individuals displaying values of leadership were working at all levels of successful healthcare organisations. Whitby (2018) concurs that leadership is the responsibility of all staff, rather than being limited to senior roles. This concept is not limited to the medical field, as Badaracco (2002) identifies that effective leaders are present in all levels of successful businesses. More pertinent to the veterinary industry, Lloyd et al (2005) agree that leadership in the veterinary profession is required at every level for it to be effective. Literature supports the concept of shared leadership in an array of settings, suggesting that shared leadership is an effective approach to leading change in the veterinary practice. For shared leadership to be successful, the gathering and developing of followers and champions is essential. Hoch (2013) suggests team collaboration can be fostered by promoting team work, leadsharing within the team and shared goals. Applied to the veterinary scenario, an example of how veterinary nurses could successfully share leadership, would be when planning and conducting clinical audits, where various members of the practice team are required to be involved in different stages of the clinical audit process.
Change implementation
Implementing change successfully can be challenging, with Ballantyne (2018) warning that one in three improvement changes within the medical field fail after implementation. Similarly, but not limited to the medical field, Szabla (2007) estimated that two-thirds of organisational change fails, whilst Burnes (2004) states that the figure is higher. Literature in human nursing identifies change as often unsuccessful due to an unstructured approach (Wright, 1998). It is feasible to predict that the veterinary profession may suffer from similar barriers, emphasising the potential benefit of adopting an appropriate model for change (Pearson et al, 2005; Nilsen, 2015).
Implementing planned changes incorporating a recognised model of change is most common in human nursing (Roussel, 2006). There are numerous theoretical change models available. Kotter's model of change was originally developed for the corporate setting and incorporates eight steps (Figure 1). Haas et al (2020) applied Kotter's model of change to a change implementation in medical education, and a systematic review of models of change used more widely in healthcare, revealed Kotter's model of change as the most commonly adopted change model (Harrison et al, 2021).
Whilst adoption of Kotter's model of change in veterinary practice appears to remain understudied, various studies have investigated the success of the Kotter's model of change in a range of human healthcare settings and medical education, both in its entirety and as individual steps. A study conducted by Appelbaum et al (2012) ascertained that individual steps of the Kotter's model of change were successful in implementing change in the corporate field; however, Kotter's model of change in its entirety remained understudied. Baloh et al (2018) used Kotter's model of change in its entirety for the implementation of team huddles in eight human hospitals. They theorised that the successful implementation of the initial phases of the model would lead to the success of subsequent phases. However, the results revealed that change was successful without all the steps of Kotter's model of change being completed. Wijk et al (2021) saw similar results when implementing change in postgraduate medical education. They identified that greater importance was given to the initial stages of the model, neglecting the final stages responsible for maintaining the change. Wijk et al's (2021) study omitted to investigate the long-term success of the change implemented. It is possible that although successful in the short term, the implemented change may not have been sustained long-term. Concerns regarding the longevity of successful change management are echoed by Teixeira et al (2017) who suggest that the incomplete use of Kotter's model of change is associated with poor outcomes in practice. Kotter and Cohen (2002) found similar results, stating that each step of Kotter's model of change builds on the previous steps, and warning incomplete use of the model can negatively impact the long-term success of any change implementation. Therefore, to increase the likelihood of successful long-term change in veterinary practice, it is recommended that each step of Kotter's model of change should be completed in succession and evaluated.
Numerous studies have evaluated the use of Kotter's model of change in conjunction with other models of change. Participants of a study by Teixeira et al (2017) identified that a limitation of Kotter's model of change was the lack of practical implementation tactics, resulting in the participants feeling underprepared to conduct changes. Baloh et al (2018) agree that other models can complement the use of Kotter's model of change, providing leaders with a more comprehensive approach to change. A systematic meta-review conducted by Francke et al (2008) consolidates Baloh et al's (2018) findings, by concluding that the use of a single model is less effective, emphasising that the use of Kotter's model of change in conjunction with another more practical model may be more successful. Conversely, although the studies discussed above suggest improved outcomes with a multi-model approach, they provide no significant evidence that the success is greater when compared to the use of a single model. This highlights the requirement for future research in comparing the effectiveness of combined change implementation models to single models. Examples of other models used are Lewin's three-stage model of change and Silversin and Kornacki's model; however, there appears to be no consensus on which models work best (Harrison et al, 2021). The choice of model is therefore down to the individual implementer of change in practice.
The focus on a single aim of a change process highlights a drawback to Kotter's model of change. The model looks at change as a single outcome rather than an ongoing cyclical process. Kotter's model suggests that change is a linear process with a focus on a final result, rather than a repetitious process towards a goal. Cycles that support change are more recently being favoured in an increasingly complex world (Moradi Korejan and Shahbazi, 2016). Bleach (2014) suggests that the promotion of an ongoing reflective change process by leaders could result in more successful change implementation.
The time required for the application of Kotter's model of change has been identified as a limitation, with Applebaum et al (2012) describing each step as time consuming. Haas et al (2020) study reiterated the lengthy time commitment required by clinical staff to employ Kotter's model of change. If recognised as time consuming as a single model, it is possible to predict that a multi-model approach may be even more limiting; however, some reasons cited for their use was that they incorporated more steps and were therefore more time efficient in the long term. When considering its adaptability to the veterinary industry, where caseload is often high, the time requirement of the model must be considered. With change having been compared to the Kubler-Ross grief cycle (1969), the importance of a streamlined and efficient change process is imperative (Rivas and Jones, 2014). This, together with the lack of evidence surrounding the success of a multi-model approach, may further justify adopting a single change model to implement change in practice.
Conclusions
In conclusion, leading and implementing change in the veterinary practice can be challenging. The literature has identified that effective leadership, through the enhancement of certain personality traits, and a shared leadership approach, is a prerequisite for effecting change. For implementing change, the use of a change model has proved successful in the healthcare setting; however, there remains limited literature specific to the veterinary industry, highlighting the requirement for future studies.
KEY POINTS
- There is a limited but growing body of literature associated with implementing change in veterinary practice.
- The ‘Big Five’ leadership personality traits are extroversion, agreeableness, conscientiousness, emotional stability and intellectual imagination.
- Implementing change successfully can be challenging.
- A shared leadership is important for successful change implementation in practice.
- Kotter's model of change was originally developed for the corporate setting and incorporates eight steps. It is recommended that each step of Kotter's model of change should be completed in succession and evaluated.