Change is never-ending. Unfortunately, that hasn’t made us, as individuals, any more comfortable with it.
John Kotter, an internationally known speaker on topics of leadership and change, describes an “emotionally charged change behavior” that helps employees overcome negative feelings toward change and adopt feelings that promote change.1
Fueled by emotion, a change in behavior is more likely to last longer than if fueled by analysis. This is simply because there can be a skewed interpretation of the facts. Kotter has developed a model that includes 8 guiding principles used to accomplish subsequent steps.1
#1 – Develop a sense of urgency
Why change? Visual examples are profound. For example, your healthcare system is implementing an enteral feeding system that would improve patient safety, improve patient care, and improve nurse efficiency. A video showing a mother telling the story of how easily a medical intervention meant to help her infant quickly took the life of her child really communicates how easily mistakes are made and the importance of the need to increase patient safety.
As Jeanne Ehmann, director of performance evaluation and improvement at Newport Hospital said, “We need to become more aware of ways to improve patient safety.”3 Medical errors are made by expert practitioners that very possibly could have been prevented by a simple change in product or equipment. There is nothing more alarming for a nurse than the thought of putting a patient in potential danger because of an action that could have easily been prevented, but was made possible by the fact that we are humans and humans make errors.
#2 – Build a guiding team
Now that we’ve established urgency, it’s time for a team (i.e. nurse educators, charge nurses, etc.) to be formed. When forming teams, select those nurses who have knowledge about the product and why the change is important, nurses who hold credibility with their peers, and nurses who have the ability to collaboratively work with individuals outside the department.1 This ensures that if any issues or obstacles arise they can help overcome those obstacles because of a collaborative relationship that is required amongst another department(s).
#3 – Get the vision right
Healthcare is constantly evolving. When changes are made, it is important to have a vision attached to that change. Kotter suggests that a good vision statement could be explained in a “sixty second elevator ride”. 2 To develop a vision statement, he suggests having six or seven broad statements that relate to what the organization envisions for the future (i.e. How can we help the medical staff prevent errors, how can we improve workflow, how can we increase patient safety).
#4 – Communicate for buy-in
Now it’s time for the guiding team to help communicate the buy-in. With change comes fear, anxiety, and thoughts such as “how much will this affect me?” and “what is in it for me?” It’s imperative that this team help broaden communication that addresses these feelings. Kotter uses a communication buy-in layered approach. At the core of the model is the “vision”. Each additional layer works to promote the “vision,” recognize and overcome any opposition, and build commitment towards the potential change(s). 1
The second layer “communicates the vision,” which helps to maintain urgency and a sense of how the proposed change will positively impact the institution (i.e. portray an engaging story relevant to how this change will improve practice and nurse efficiency). If the change involved a safety feeding system, GEDSA has several EXCELLENT highlight videos about how a misconnection affected a patient’s family.
The third layer involves “engaging in continuous dialogue with the employees.” Talk to employees. Ask them how they feel about the change (i.e. If tension is building, communicate/re-iterate why the change is necessary. This helps build trust amongst the staff).
The outermost layer is to “enroll the organization in the change effort.” Simple, straightforward posters, including who the change affects, what is changing, why the change, and when this change will take place are important. Another great way to communicate the change is to have screen savers on work computers highlighting the change. 1
#5 – Empower Action
Healthcare change is inevitable. We need to remember that, although this can be frustrating and obstacles can prevent change, change is necessary and vital to improving healthcare. 3
Obstacles preventing change include mental barriers, lack of information, supervisors, and a hospital system in general. When these barriers exist, individuals and/or teams become disempowered and lack the ability to move forward with change. 1,2
There are opportunities to overcome these barriers. For example, an institution is wanting to adopt a new warming method for human milk (HM). Nurses complain that the way of current warming is sufficient and an added piece of equipment is unnecessary. Presenting to nurses not only the benefits to the patient, but also the nursing efficiency this helps provide the nurse, can show individuals how the proposed change can be used to their benefit. Follow up after the change is implemented is essential to ensure the change is taking place as intended and questions do not go unanswered. Unanswered questions can lead to a mental roadblock(s) that inhibits the positive change and buy-in.
#6 – Create Short-Term Wins
As change takes place, it is important to show that the change taking place is creating a win. For example, the new warming system has resulted in a cost savings to the overall institution. This is evident by product cost analysis reports within the last quarter. Now we have identified improved patient care, improved nursing efficiency, AND an overall cost savings to the institution.
#7 – Don’t let up
As short-term successes start to accumulate, it is easy to lose the sense of urgency identified in the first step. Follow-up after change is important. It’s important to not only provide an improvement in healthcare, but to ensure continued success with the change(s).
One way to ensure a change is successful is to communicate feedback. An example would be an institution that has implemented new enteral feeding supplies. Follow up is done several months later and a nurse says she likes the feeding system, but “I sure wish we had a secondary port on the extension sets for meds.” As the guiding team, you are able to communicate that as an option.
Now you have proactively satisfied a need that may not have been identified if the sense of urgency had been lost.1 This keeps the change energized. This type of feedback communicates that you care about how the change has been tolerated. This empowers the action and the trust discussed earlier.
#8 – Make change stick
According to Kotter, “culture change comes last, not first…Culture changes when a new way of operating has been shown to succeed over some minimum period of time.” 1
This means that to get a nurse to “buy-in” to implementing a new warming system, he/she needs to see a positive effect from the change(s). For example, it is not uncommon for a premature infant to have difficulty growing and tolerating feedings. After a period of time it will be important for the guiding team (physicians, NNPs, QI teams, etc.) to communicate the improved weight gain and tolerance in feedings, which supports the change in warming methods. This “Post Live” analysis of an infant with improved weight gain and better tolerance for feedings will support the continued use of the new warming system and reinforce the urgency of implementing change. 1 The evidence shows that although change comes with many obstacles, frustrations, and resistance, change can be significantly positive to all those involved.
We all know change is difficult. Even positive changes can have negative connotations associated with them. As we discussed in the above principals, it is important to stay focused, keep communication flowing, and not take personally how some employees will perceive the change. I know that in management change was inevitable and very difficult. I encourage you to evaluate the steps above, and stay focused on your ultimate goal. As Charles Kettering stated, “the world hates change, yet it is the only thing that has brought progress.”
- Campbell, R.J. (2008). Change Management in Health Care. The Health Care Manager Volume 27 (Issue 1), pp. 23-39.
- Kotter, John P. Leading Change. Boston: Harvard Business School Press, 1996.
- Martinsons, Jame. “Seven ways to foster positive change in healthcare.” Quality Magazine. 27, January 2010, https://www.qualitydigest.com/inside/twitter-ed/seven-ways-foster-positive-change-health-care.html#. Accessed June 30, 2017.