Motivating and engaging others: driving practice change
Saturday, March 2, 2019
Do changes introduced within your practice go no further; are they met with negativism, disinterest or even resistance? Are new ideas dismissed by a culture of complacency and inertia? Change can be a difficult and even uncomfortable process to go through and when poorly handled can lead to high levels of stress amongst the team. The ability to change is crucial, however, to the success of any organisation and has never been more important than it is in today's evolving healthcare environment. To manage change effectively requires time and dedication. This article aims to introduce novice/aspiring leaders to elements of change theory and make practical suggestions as to how to plan and implement a change in practice.
Snaith and Hardy (2014) suggested often-perceived small changes such as the recruitment of a new team member, or the move to a different equipment supplier, can be as disruptive and challenging as a move to a new premises.
According to Stobbs (2004) change is a strange phenomenon; it is an inevitable part of life, and is often a very positive experience. After change has occurred, employees often say that they prefer the new procedures or methods, however before the change is implemented, there is often a great deal of resistance and fear (Girotti, 2011).
Change is, however, inevitable within veterinary practice; it may come from within the profession, for example changes imposed by the regulatory body, or from external sources such as consumer feedback or increased demand for specialist services. Veterinary nurses are well placed to drive and support change in practice, however such change must be implemented carefully and supported by a solid evidence base in order to achieve desired outcomes for both patients and staff (Mount and Anderson, 2015; Ballantyne, 2018).
Types of change
Change is concerned with altering the way we do things or the way we behave. Girotti (2011) suggested that some change is only a matter of perception, while other change can have a dramatic and profound effect on the way we live and work. Change can be temporary or minor, permanent or major. There are two primary types of change: reactive, which is imposed; and proactive, which is initiated by the practice itself. Irrespective of the type of change, a number of elements must be in place in an organisation for change to occur: an agreement on direction for the practice; a functional and effective leadership structure; and a culture that promotes and rewards change (Gesme and Wiseman, 2010).
Sharing the vision of change
You may personally have identified an opportunity for change within your practice or had this thrust on you by the senior management team as part of your role. Whatever the source, it is essential that the process of staff engagement is structured and the vision for the service post-change is clear within your own mind — if you are not sure what the purpose and outcome of the change will be, it becomes difficult to effectively sell the concept to your team! The process of articulating a vision and strategic direction for the practice encourages input from all of the practice decision makers and enables divergent perspectives to be aired and addressed in order to reach consensus (Gesme and Wiseman, 2010). Effective communication of the vision can help gain trust and enthusiasm amongst team members who are prepared to not only go along with the plans, but be willing to engage in the implementation of change and hence positively influence the outcome (Snaith and Hardy, 2014).
In addition to a shared vision, effective leadership is vital for any change to be successful. A lack of clear leadership, including communication of the vision, can lead to alienation or distrust suggested Snaith and Hardy (2014), which can mean that changes are delayed or resisted.
According to Gesme and Wiseman (2010), the key to effective change is to have leadership that are able to understand, support and explain it, and move the organisation to commit to it. A good leader, however, is not sufficient and there is a requirement for followers: while such a term may suggest a certain weakness, it should not be viewed as such. The reality is that all staff members cannot and are not required to be leaders. The role of followers is actually a position of strength, involving elements of trust and letting go of a certain amount of control (Gesme and Wiseman, 2010).
It is essential to have a good knowledge of your team and what motivates them. As a leader, you need to think about how the proposed changes will affect individual team members, remembering that some may have more to lose than others during the process. It is often the people you least expect who may struggle the most with change, and those you thought would cope do not. Flight (2015) suggested it is therefore essential to make sure you know your team well and to try and anticipate how they might be affected, in order to support and motivate them through the process.
Creating a readiness to change
In shifting from a culture that is satisfied with the current working practices to one that is ready to embrace change, the ‘fire in the belly’ needed to bring about the change must start at the top. The practice team set the tone for the practice; the practice will not be ready to change until they are ready (Gesme and Wiseman, 2010). As veterinary nurses, evidenced-based care should be at the heart of everything we do — for team members that seem mired in inertia, providing factual information is one way to increase the team's desire to change. Ballantyne (2018) suggested undertaking a literature review on the relevant topic in order to gather evidence towards new ways of working. Gesme and Wiseman (2010) suggested that data are incredibly powerful, especially for clinicians, further suggesting that advocates for change should measure everything they can think of and use the data to help drive change. Another tactic is to initiate the change on a trial basis. Inform staff that after a set period of time, such as 3 months, the pros and cons of the change will be measured and its impact assessed.
Lead, delegate or collaborate?
- Lead — the nature of veterinary practice means that some change, especially high-impact and/or immediate, will require unilateral action on the manager's part, which he or she will need to manage and make decisions on by decree (Girotti, 2011).
- Delegate — there will of course also be relatively lowimpact changes that can be fully delegated to team members. Fully delegating the incorporation of changes to the practice can greatly aid acceptance from the staff, help overcome resistance, and demonstrate trust and the absence of micromanagement (Girotti, 2011). As a leader however, whenever you delegate a task, you must give responsibility while keeping accountability. Flight (2015) suggested that a leader must offer all the support required to enable other team members to complete the task successfully, further stating that the mnemonic
STEAM can be useful to keep in mind to help provide a supportive framework by ensuring the following:
- Skills — ensure all staff have had sufficient training for the task
- Tools — check that all equipment and materials required are available. Ackerman Anderson and Anderson (2010) suggested inadequate resources will hinder the implementation of change and may lead to the project failing altogether.
- Environment — ensure staff have adequate time and resources required to ensure success
- Approach — guarantee there is a clear pathway and time to enable staff to achieve their objective
- Mind-set — all participants involved with the proposed change need to have the right attitude towards it.
Flight (2015) suggested that as a leader, you are responsible for providing the first four elements of STEAM and doing so ensures that you have done your part to facilitate goals being achieved. The mind-set however is the team's contribution and is a must for the process to ultimately succeed. It is the author's opinion that this comes back to how effectively the vision for change is shared with the team in the first instance.
- Collaborate — Girotti (2011) suggested that most often, a collaborative style that involves taking account of staff views is most useful. This will enable the leader to gauge an idea of the types of resistance they may experience and identify where the resistance is coming from. Staff must understand, however, that while their views will be taken into account, ultimately, they may not be incorporated into the final plan or scheme.
Dealing with resisters
Gesme and Wiseman (2010) suggested that resistance to change is normal and usually comes from fear, on one of three levels — what will happen to me in my world, how will my relations to my colleagues change, or how will our practice and patients be affected. Such fear is to be expected when staff are good at their jobs; if you give them a situation where they do not know what to expect, they will become afraid, however instead of expressing it as fear, staff may simply dismiss the change as a poor idea, or not required. Gesme and Wiseman (2010) suggested that one way to address fears is to show individuals how the change will actually help them to do their job more efficiently or how it supports the direction of the practice.
It may also be beneficial to identify someone within the team who is committed to the proposed change from the outset (Gesme and Wiseman 2010; Girotti, 2011; Ballantyne, 2018). Within the NHS such team members are called ‘Nurse Champions’ and their role within the team is to help move the change along to the organisation's desired conclusion. Mount and Anderson (2015) suggested that Nurse Champions play a vital role in engaging team members in a shared vision by reinforcing goals and recognising positive performance, further stating that peer-to-peer accountability can empower the team to achieve the desired goal. This is because Nurse Champions belong to their individual nursing units; there is a history of trust between Nurse Champions and their peers before the project even begins.
The change cycle
Even when there is evidence to prove that the proposed change will be of benefit, for those who feel unsettled by change, it may take them some time to realise that the benefits will outweigh the negative impact they perceive. It is essential therefore for those involved in change management to ensure they carefully manage the change and are aware of the negative effects which could be caused by suboptimal management. Change can cause us to go through some of the stages more commonly associated with loss: denial, anger, depression with hopefully a gradual move toward acceptance. According to Stobbs (2004) getting to this last stage is crucial if people are to keep things in perspective and adapt to new circumstances. In order to get to this stage, a series of steps, or a ‘change model’ are likely to be required.
There are a number of proposed change models (Lippitt et al, 1958; Kotter, 2007; NHS England, 2012) however perhaps one of the simplest and practical models for understanding the process of change is that devised by Kurt Lewin in 1947. According to Lewin (1947), the process of change entails creating the perception that a change is required, then progressing toward the new, desired level of behaviour and finally, solidifying that new behaviour as the norm. Lewin's (1947) approach takes three steps, namely unfreezing, changing and refreezing, which are outlined in Table 1.
Table 1. Three step change cycle
Table 1. Three step change cycle
|Unfreezing||Prior to cooking a frozen meal, you need to defrost it or allow it to thaw — the same can be said for the introduction to change! Prior to implementing a change, leaders need to go through the initial stage of unfreezing. The goal of this stage is to highlight an awareness of how the status quo, or current level of acceptability, may be hindering the practice in some way. Old ways of thinking, behaviours, processes and organisational structures need to be examined carefully to demonstrate to employees the necessity of the proposed change in order for the practice to remain in line with or ahead of its competitors. Effective communication is essential during this stage — what is the logic behind it and how will the employees and the company benefit|
|Changing||The change can only begin once the staff are ‘unfrozen’. The changing step, sometimes referred to as ‘transitioning’ or ‘moving’ is marked by the implementation of the change. As the change becomes reality, people may begin to struggle due to uncertainty and fear; this is therefore the most difficult step to overcome. During this stage, people begin to learn new behaviours, processes and ways of thinking. Naturally, the more prepared they are prior to the initiation of the change the easier this step will be to complete. Leaders must ensure effective communication, education, support and time for their staff while they adapt to the new process. They must also remind employees throughout this process of the reasons for the change and how all will benefit once it is implemented.|
|Refreezing||Within the refreezing stage, the changes made to the organisational processes, goals, structure or people are accepted and refrozen as the new norm or status quo. During this stage it is crucial to ensure that people do not revert back to their old ways of thinking or doing prior to the implementation of the change. Every effort must be made to ensure the change is not lost and that it is cemented into the practice culture and embraced and maintained as the acceptable way of thinking or doing. It is important to note that refreezing does not mean that a practice will not need to change this way of working again — change is indeed constant within business and especially that of veterinary practice. Without implementation of the refreezing stage, however, there is a high chance that staff will revert back to the old way of doing things. This step cements the change until such a time that further change may be required.|
It is essential to set progress sessions to monitor how well things are going. Flight (2015) suggested these need not be formal meetings, rather a 10 minute catch-up each week to ensure things are still on track. It is essential for leaders to know exactly what they need to measure in order to accurately assess progress and to be flexible in their approach. Amendments to tasks or time lines may need to be made but Flight (2015) suggested that whatever change is implemented needs to have measurement criteria linked to it in order to provide an accurate assessment of its success. This is in congruence with Gesme and Wiseman (2010) who suggested that external data can provide credible feedback that can help to drive and sustain change, further suggesting that leaders should find out what clients and referring veterinary surgeons think about the changes being implemented, and give that information to the team.
Continuation of change
Even if change is successfully implemented, this does not guarantee that it will stay that way. People sometimes can slip back into old habits and ways of working. Once again, communication is crucial. If staff require evidence that the change has had a positive impact then this can be evidenced via an audit (NHS, 2009; Ballantyne, 2018). An audit is simply a process of examination of systems or ways of working (Ballantyne, 2018). It is essential to inform staff how they are doing and whether their efforts have made a difference. Gesme and Wiseman (2010) suggested that just as you used data initially to foster a change culture, you must continue to use it to document progress and reinforce new behaviours. It is essential to acknowledge people's efforts in the change process and to thank them for their contributions to the success of the practice. Milestones and successes should be celebrated in order to foster team cohesion and sustain change efforts.
Change is a part of life; whether we like it or not, it will happen, within both our personal and professional lives. To manage change effectively takes much planning, effective communication and commitment. Managing the implementation of change within a veterinary setting is challenging, however the suggestions discussed within this article, including effective sharing of the vision, the use of a Nurse Champion, the implementation of a change cycle along with regular review, can help contribute towards an effective and sustained change in practice (Ballantyne, 2018).
- Change is concerned with altering the way we do things or the way we behave.
- In order to effectively sell the concept to your team, you must be sure what the purpose and outcome of the change will be yourself.
- A good knowledge of your team and what motivates them is essential.
- Consider undertaking a literature review on the relevant topic in order to gather evidence towards proposed new ways of working.
- Resistance to change is normal and usually comes from fear.
- Audit can be used as a tool to evidence the impact post change.