|
TOWARD REFLECTIVE PRACTICEDon’t like change? Blame it on your strategic style
by Beatrice J. Kalisch One of the biggest challenges in nursing is how to achieve change and tap into the creativity of nursing staff. Nursing has a long tradition of acceptable behaviors (often called rituals), ways of looking at practice and organization of nursing care delivery. As a consultant, I am confronted repeatedly with the challenge of change. Staff nurses unhappy with current practice methods and sincerely interested in doing things in a new and improved way find it difficult, nonetheless, to embrace change. For example, many nurses on day shifts still feel uncomfortable if patients do not receive morning care, including baths, yet this practice is not based on any rationale other than tradition. Many patients would prefer to have their bath right before bedtime, so they can sleep better. The consistency of this behavior led me to ask what might be behind it. I was returning from a meeting with a client and serendipitously was seated on the plane next to a consultant who used in his work—not related to nursing—an information-processing tool called “I-Opt.” This survey tool, which has foundations in psychology-based, adult-learning theory developed by David Kolb (Kolb & Fry, 1975), was created by Gary Salton, a sociologist and founder of Professional Communications Inc., to study behavior of groups of people functioning in organized, goal-directed environments. As a result of my chance meeting with the consultant and subsequent interaction with Salton about the use of I-Opt for organizational engineering, I embarked upon a research project to assess receptivity to change by nursing staff—managers, registered nurses (RNs), licensed practical nurses (LPNs), nursing assistants (NAs) and clerical staff—in acute care hospitals (Kalisch & Begeny, 2006). The research was conducted at two geographically separate hospitals and involved a total of 578 nursing staff (RNs, LPNs, NAs and unit secretaries (US). The study utilized the I-Opt survey instrument, which measures people’s information-processing preferences. The reliability and validity of the tool have been established. The survey instrument is based on the idea that the kind of information sought and accepted from the environment limits or facilitates certain types of behavior. There are four basic profiles or “strategic styles” that emerge from the I-Opt survey: Reactive Stimulator (RS), Logical Processor (LP), Hypothetical Analyzer (HA) and Relational Innovator (RI). The RS style is characterized by fast execution, low rule/norm compliance, intensity and low tolerance for routine. The LP style is decisive and steady, needs clear goals, and has low tolerance for uncertainty and change. The HA style is capable of high conceptual planning, is thoughtful, will not be hurried and has low tolerance for forced action or decision making. Finally, the RI style is innovative, creative and enthusiastic and has low tolerance for confined decisions. Our study (Kalisch & Begeny, 2006) resulted in the following findings.
Finding 1: Nurses differ markedly from non-nurses We found that nurses most closely resemble customer-service personnel, who typically answer client questions by referring to pre-approved information sources. There was no significant difference between nurses and customer-service personnel across all four I-Opt strategic styles. Nurses differed significantly, however, from engineers, scientists and corporate managers in all four I-Opt strategic styles. The latter disciplines consistently scored higher in the nonpatterned input strategies associated with Relational Innovator (ideas) and Reactive Stimulator (decisive action) than their nursing counterparts. These are the adaptive styles that initiate and accommodate change with relative ease. In the middle zone, nurses were significantly less idea-oriented (RI) than teachers and plant operations managers, but significantly exceeded people in those roles in disciplined action (LP). This suggests that teachers and plant operations managers find change and innovation more palatable than do nurses. Hourly industrial workers significantly exceeded nurses in both disciplined action (LP) and analysis (HA), but equaled nurses in creative ideas (RI) and decisive action (RS). The picture painted by this analysis is that, among people in the jobs and professions studied, nurses are among the least able to initiate and accept change. Their favored information-processing strategy relies on certainty, precision and step-by-step operational knowledge. This posture forecloses information needed to initiate change associated with unproven possibilities or unexpected associations, or to accept change readily. For example, nurses are less willing to use tools that are not fully specified. Nurses can, of course, adapt to change. However, if the same methods used to initiate change for engineers, scientists and corporate managers are applied to nurses, the road will be difficult. Moreover, it will be difficult for everyone. Nurses are likely to feel a sense of discomfort if they are forced out of their preferred approach to processing information. The sponsors of change will feel pain as they meet reluctance and resistance. There was some variation in nonpatterned strategies (RS/RI). Nurses in intensive care and psychiatric units were found to be more idea-oriented (RI) than other survey respondents, and perioperative nurses were significantly lower in spontaneous, decisive action (RS). RNs were then compared to unit secretaries (n=40). Like the NAs, the USs were found to be significantly more committed to disciplined action (LP) than RNs. This means that there is another layer of potential resistance to change that regularly interacts with and influences RNs. Finally, RNs were compared to LPNs, who were found to be significantly more Logical Processor in strategic style than RNs. This is yet another layer of change resistance. This portion of the analysis indicates that accepting, adopting and sponsoring change are even more difficult than they first appear. Registered nurses rest on an organizational support system that is even more reluctant to change than they are. Since these support functions interact constantly with RNs and are positioned to magnify the basic disinclination of RNs to change, a difficult job becomes more difficult. To be successful, initiatives for change must be organizationally sensitive. Change initiators must understand that addressing RNs is not the end game; they must also address organizational levels below the RN level. Change initiators must also understand that RNs will face a challenge when they ultimately accept change, as they, in turn, must “sell” it to support staffs. This is likely to be as difficult as selling change to RNs in the first place. Nurse managers face a challenge in sponsoring and guiding change initiatives. They do not think like the people who report to them, which presents a challenge. In other industries, however, staffs are more diverse in terms of information-processing style. This diversity means that there are likely to be several staff members relatively close to the manager’s position who can interpret matters in a way others can understand and accept. These people can then function as “emissaries” to help managers sell their ideas and postures to the larger staff. Nurse managers do not have this luxury and, thus, their job is more difficult. The likelihood of facing a solid wall of resistance to change means that nurse managers need to be taught how to lead people who are very different from themselves. Non-manager nurses are tightly clustered. Figure 2 shows strategic-style distribution of nurses in one section of a major hospital, a distribution representative of that encountered in both of the hospitals we studied.
Each dot on the graphic represents the centroid—point of central tendency—of the information-processing profile of a particular nurse. There is a clear clustering in the lower right quadrant, which is the “conservator” pattern. Groups with this pattern seek to conserve or preserve things that are proven and known to work. People comprising this pattern strive for excellence and precise execution. The conservator is the information-processing posture with the most structural resistance to change. This condition magnifies even further the difficulty of achieving change. As I’ve already stated, nurses are personally disinclined toward change and have support staffs that are even more reluctant to change. In addition, there is now a coalition factor. Nurses are likely to magnify their reluctance to change through interaction with each other. This tight clustering pattern means that nurses tend to think alike and will see much merit in each other’s judgments. Once again, a difficult job has been made more difficult. The overall picture painted by this research is that change management in nursing will present a unique challenge to all involved. Thus, if success is to be enjoyed, internal hospital resources are likely to require external support. The first step is to present the theory behind the four strategic styles of information processing used in I-Opt. All staff members are then provided reports—about seven pages in length—about themselves and their entire team, including managers. The graphic presentation shown in Figure 2 illustrates what type of approach to processing information dominates their group. When I use this tool in my role as a consultant, I ask team members to identify their strengths as well as their vulnerabilities. For example, a team may observe, “We are short on this way of thinking, but have a large resource of people who think this (other) way.” Once they have completed this self-analysis, I ask them to divide into smaller groups to develop strategies to overcome their vulnerabilities and to maximize their strengths. The action plan that emerges is posted in the staff lounge, along with the diagram of their team, to reinforce the plan they have developed. Helping staff members realize, in a positive way, that they are resistant to change helps them adjust and listen to members of the team who have strategic styles that are less representative of the group. Nursing requires the styles associated with the LP and the HA. The problem is not that we have a large number of individuals with this style, but that we have so few nursing staff in the other categories. When so many team members have a similar way of taking in and responding to information, the few who have a different mindset tend to be ignored. There are many other strategies for managing the change process, but I have focused on one strategy that has had very positive results. RNL Beatrice J. Kalisch, RN, PhD, FAAN, is Titus Distinguished Professor of Nursing and director, Nursing Business and Health Systems, at University of Michigan School of Nursing in Ann Arbor, Michigan, USA. Continuing nursing education: The following course is offered by the Honor Society of Nursing, Sigma Theta Tau International: Transforming Organizations to Support Evidence-Based Decision-Making, by Gail Ingersoll, RN, EdD, FAAN, FNAP. References Kolb. D.A., & Fry, R. (1975). Toward an applied theory of experiential learning. In C. Cooper (Ed.), Theories of group process. London: John Wiley. |
