The Future of Nursing
The report from the Future of Nursing is ALL about change.
Leadership Program is divided
into 4 main areas.
Communication is foundational
for learning and understanding
about systems. Knowledge of
how systems function is
necessary to institute change.
The ability to accept and engage
in change is necessary to be an
advocate for health policy.
All nurses are expected to lead!
Transforming leadership
• Strong leadership is critical if the vision of a transformed health care
system is to be realized. Yet not all nurses begin their career with
thoughts of becoming a leader. The nursing profession must produce
leaders throughout the health care system, from the bedside to the
boardroom, who can serve as full partners with other health
professionals and be accountable for their own contributions to
delivering high-quality care while working collaboratively with leaders
from other health professions.
• FROM: Committee on the Robert Wood Johnson Foundation Initiative on the Future of
Nursing, at the Institute of Medicine; Institute of Medicine
• What is needed is a style of leadership that involves working with
others as full partners in a context of mutual respect and
• The new style of leadership that is needed flows in all directions at all
levels. Everyone from the bedside to the boardroom must engage
colleagues, subordinates, and executives so that together they can
identify and achieve common goals (Bradford and Cohen, 1998).
If you have not already reviewed the Future of Nursing, read it
at http://www.nap.edu/catalog/12956.html
Leading Change …
1. Describe 2 change theory models frequently used in nursing.
2. Describe his/her response to uninvited changes imposed by an
outside force.
3. Identify a situation where he/she could use a change model to lead
change at his/her workplace.
4. Write a proposal for change at his/her workplace.
5. Implement proposal for change his/her workplace.
6. Evaluate the results of his/her change project using criteria outlined
in proposal.
To earn contact hours you will need to submit
the following:
 Identify the problem /change you would like to make using one of the
change models (you may use one of the models presented here or
showcase another model you have used).
 Share the steps you took to assess, plan for and implement a change.
 Share how you evaluated your project and the outcome of your
change project.
 Goal is to help you have a professional level presentation that can be shared
at conferences as a poster presentation, as an oral presentation, or as a
written document that you could submit for publication.
 You may also format the final work in a manner to include in a professional
To be more effective leaders and full partners, nurses need to possess
two critical sets of competencies: a common set that can serve as the
foundation for any leadership opportunity and a more specific set
tailored to a particular context, time, and place.
The former set includes, among others:
knowledge of the care delivery system
how to work in teams
how to collaborate effectively within and across disciplines
the basic tenets of ethical care
how to be an effective patient advocate
theories of change/innovation
the foundations for quality and safety improvement
Change Theories: There are many theories for change.
Click on the link below to familiarize yourself with some
of the many theories.
One commonly known behavioral change model is
Prochaska and DiClemente’s Stages of Change
Nurses have long used this model when interacting with patients. It is often applied
when trying to change patient behaviors.
action, and
Click on this link for a review of this model.
When engaging in system changes we need a body of knowledge and skills that
includes the individual and the system.
Changing a system requires knowledge of both individual and
system wide theories.
You will need to consider how the individual comes to making
changes and you will need to consider how making a change
within and between systems occurs.
Kurt Lewin's Force Field Analysis is a powerful strategic tool used to
understand what's needed for change in both corporate and personal
environments. It helps you understand the system in which you are
attempting to initiate a change.
• http://www.changemanagementcoach.com/supportfiles/force-field-analysisapp.pdf
As you consider making
changes in healthcare
remember the
concepts related to
You must assess your
system when you are
proposing and planning
for changes.
There are many change theories used by
nursing… this is a short list..
Appreciative Inquiry: A positive revolution in change (Cooperrider &
Open Space Technology (Harrison Owen)
The whole systems approach: Using the entire system to change and run the
business (Adams & Adams)
Rapid Results (Murphy, Kriwan, & Ashkenas)
Six Sigma Approach
Action Learning
Holma, P, Devane, T., & Cady, S. (2007). The change handbook, (2nd ed.). San Francisco, CA: Berrett
Koehler Publishing.
Specific change theories used by nursing
Felgen, J. (2007). I2E2: Leading lasting change. Minneapolis, MN: Creative Health Care
Guanci, G. (2007). Feel the pull: Creating a culture of nursing excellence. Minneapolis, MN:
Creative Health Care Management.
I2E2 guiding principles
• Make every inquiry “Appreciative”… (refers to Appreciative Inquiry)
• We have influence (R+A+A = responsibility, authority, accountability)
• Experience exuberance (unleashing your creative self/ support creative
• Believe in your abundance (everyone has something to offer)
• Be clear (clarity of purpose)
• Embody the change (be the change you want to see in the world… Gandhi)
• We get what we pay attention to (so be careful what you focus on)
• Patients and families come first (ALL people’s feelings matter)
A word
Evidence-based-practice is
• The integration of the best research evidence with clinical expertise
and patient needs and values.
• Research is classified by levels ranging from weakest to strongest.
• Nurses use evidence based practice to promote quality, cost-effective
outcomes for patients, families, healthcare providers, and the health
care system.
• It is not “proof” to win an argument or get your way when seeking to
make changes.
For further information about evidence based
practice see
• The North Dakota Center for Nursing website at
PDSA model
Click on the link for an
excellent overview on
how to use this model.
PDSA model in a nutshell…
• Plan- define the action/experiment. What will be done, who will do it,
and how will it be measured.
• Do- implement the plan/experiment.
• Study- was the intended improvement realized? Measure and discuss
the results with the team or workgroup.
• Act- standardize the new process IF the action improved
performance. Act to put the process back to its original state if the
plan did not improve the process. Determine why and how it did not
work and begin again.
Click on the link below to read an overview of common barriers nurses
encounter when managing change and innovation.
Structural Barriers to Change and Innovation in Nursing
Beatrice J. Kalisch, Ph.D., RN, FAAN, Titus Professor of Nursing, University of Michigan
Suzanne Begeny, MS, RN, Ph.D. Applicant, University of Michigan
You may be asking:
How do I become more
How do I become more creative?
How do I explore ideas or
technology and come up with
new ways to use them?
Are you creative?
Do you have ideas for improvements in your
Common patterns expressed by creative people
• Curiosity
• Testing and learning from “mistakes”
• Highly developed skills at “noticing”
• Ability and willingness to embrace ambiguity, the unknown, and irony.
• Cultivate whole brain thinking (art and science)
• Flexibility and balance
• Systems thinking skills
Common ways we approach creative thinking
As the explorer
Look outside your field, look for lots of ideas, see what is obvious, see a different
route, look at ideas you tend to avoid. . .
As the artist
Mix up patterns, look for patterns, look at things from different angle, use of
metaphor, how else can you think about and or use things. . .
As the judge
What is the idea trying to do, what can be salvaged, what assumptions, what is the
chance of success, is the idea worth spending time on. . .
As the warrior
What is your strategy to reach goal, what motivates you, what keeps you from
starting, what obstacles, how persistent are you, what are the sacrifices,
consequences of failure. . .
From: A kick in the seat of the pants by Roger von Oech
Strategies to unlock your creativity
• Define the problem or needed change (be specific)
• Generate ideas (include the outlandish ones)
• Select the idea and refine it
• Put the idea into play
• Evaluate the implementation and the outcome of the idea once it is in
Read the following article for an overview of innovation in
Unlocking the Power of Innovation
Barbara A. Blakeney, RN, MS
Penny Ford Carleton, RN, MS, MPA, MSc
Chris McCarthy, MPH, MBA
Edward Coakley, RN, MSN, MA, Med
What if you are the
type of person who is
resistant to change?
Most of us don’t wake
up one day and say …
heh, I am going to
Why is change so hard?
People tend to like things
just the way they are…
and we are a creature of
To change habits. . .
.wouldn’t it be simple if
this is all it took →
In fact many of us are excellent at
tamping down change, holding
off chaos, or flat out deflating any
wild ideas….
Often we are the obstacle that
prevents ourselves and others
from changing even when
outside motivation is positive.
There is usually some internal or external
motivation for engaging in change. We need to
discover those forces when leading change.
Learning exercise: Answer the following questions,
write your answers in your reflective journal
(communication module).
• What motivates you to change?
• What are your barriers to change?
• When you are reluctant to change, what is your pattern of response
to change? Is your response a habit?
• Do you routinely find yourself stressed with proposed changes or do
you enthusiastically engage in the process?
Overcoming our reluctance to change
Events occur… (if we notice), and we make meaning of those events.
Meaning making nearly always triggers an emotional response…feelings.
At a fundamental level humans tend to ask “Is what just occurred safe?”
(Communication with ourselves)
Once we decide we may be threatened (real or imagined), our response to that
threat is to maintain our safety.
If we stay safe because of our response, we tend to repeat that behavior
because we perceive it keeps us safe.
The danger is this response could become a habit.
Sometimes it becomes an addiction.
King, B. E. (2012). How the brain forms new habits: why willpower is not enough. Conference: Institute
for Brain Potential.
Overcoming our reluctance to change
Habits tend to help us guard against any ‘perceived changes’ that may
affect the present state one enjoys in the here and now.
We tend to like things just way they are. We resist changing our
behavior. Long term consequences are usually not factored into this
way of thinking.
If we think a change could impact our present state of well-being we
may repeat past behaviors that we perceived kept us safe.
Many of us simply resist change.
The goal for facilitating change is to avoid building resistance.
Pause and reflect on this story about
perception and change.
• Fable of the Roasted Pigs
• http://europepmc.org/articles/PMC2067655/pdf/jadsa00114-0027.pdf
Learning activity: Read the article Fable of Roasted Pigs
Consider what situations you have experienced that are similar
to this story.
Write your thoughts in your reflective journal. (You should have a
reflective journal from the Communication Module).
Pulling it all together: think about this. . .
• Nurses are especially prepared to lead change: Consider the nursing
We assess the situation
We diagnose the issue(s)
We make goals/ outcomes
We use best practices and can be very innovative when we plan for nursing
• We implement the plan
• We evaluate the outcomes
• We are pros at managing change…
A story of applying theory to practice. . .
Judy is a staff nurse in the dialysis unit. She has noticed the patient flow
on some days is especially congested. She wonders “is there a better
way to move patients through the unit while preserving safety and
Now that she has formed a question what will she do next?
Data gathering?
More questions?
Talk to other staff members? Investigate how other dialysis units
structure their patient flow and assignments?
Develop a vision or goal
for the project that will
help guide actions.
Improve patient flow
while maintaining safety
and quality.
If Judy uses I2E2 after developing her
vision she gathers evidence from
multiple resources, she assesses then
creates or modifies the infrastructure.
These pieces include: defining roles,
practices, standards, aligning with
mission vision.
For maximum success she engages all
stakeholders in this process.
It is the action plan.
Next to provide necessary
education Judy and her team
must consider the various
domains of clinical/technical,
interpersonal relationships,
critical/ creative thinking, and
Because for the change to
stick, one must include not
just a change in one’s skill set
but a change in behavior.
Again the overall success of
the change is evaluated by
collection of evidence.
The operational definition of
success should align with the
vision and be measureable.
Outcomes assist the team to
refine and address any gaps in
If Judy decides to apply the PDSA framework. . .
• Plan
What will be done? Who will do it?
Gather evidence from multiple resources.
Conduct Force Field Assessment- forces for and against change
Develop the plan
• Do
• Implement the plan
• Provide support and education as necessary
• Study
• Has the flow improved? (define and devise method to measure flow improvement).
• Has patient safety and quality been maintained? (define safety and quality as it relates to
these patients and devise a method to measure maintenance).
• Act
Positive results?
Unexpected benefits?
No improvement?
Unexpected obstacles?
• Begin cycle again. . .
Selling your idea…. avoid building resistance.
• Engage those impacted by the change.
• Expect some resistance.
• Develop a plan to manage resistance.
• 2 top reasons for resistance to change:
• lack of awareness of why the change was being made
• a lack of awareness about and involvement in the change
• Engage the leaders, managers, supervisors.
• For complete overview see http://www.changemanagement.com/tutorial-5-tips-resistance.htm
To earn contact hours you will need to submit
the following:
 Identify the problem /change you would like to make using one of the
change models (you may use one of the models presented here or
showcase another model you have used).
 Share the steps you took to assess, plan for and implement a change.
 Share how you evaluated your project and the outcome of your
change project.
 Goal is to help you have a professional level presentation that can be shared
at conferences as a poster presentation, as an oral presentation, or as a
written document that you could submit for publication.
 You may also format the final work in a manner to include in a professional
Project (how should we have the learner
share their project)
Record and share your project by Portfolio format
Record and share your project by a PowerPoint presentation
Record and share your project by a poster presentation format
Record and share you project by writing a professional article
• If someone wants to learn how to do a PowerPoint electronic poster presentation I can
insert directions here as well…. Then they can submit their poster electronically… and
add a new skill set.
• Remember this module is prep for the advocacy and policy development level. It builds
on communication and systems.
Creativity: Resources for further exploration.
Csikszentmihalyi, M. (1996). Creativity: Flow and the psychology of
discovery and invention. New York; Harper Collins Publishing.
Von Oech, R. (1990). A whack on the side of the head: How you can be
more creative. Stamford, CT: U.S. Games Systems, Inc.
Gladwell, M. (2005). Blink: The power of thinking without thinking. New
York: Little, Brown and Company.
Gelb, M. (1998). How to think like Leonardo da Vinci: Seven steps to
genius every day. New York: Bantam Dell.
Thompson, C. (1992). What a great idea! New York: HarperPerennial.
For further information on Innovation (continuous
improvements) consider the following resources.
Healthcare Kaizen
Graban, M., & Swartz, J. E. (2012). Healthcare Kaizen: Engaging front
line staff in sustainable continuous improvements. Boca Raton, FL: CRC
How innovations catch and spread…
Rogers, E.M. (1995). Diffusions of Innovations, (4th ed.). New York: The Free
Resources for further reading…
Marciano, P.L. (2010). Carrots and sticks don’t work: Build a culture of
employee engagement with the principles of RESPECT. New York:
McGraw Hill. (This resource is an excellent overview for both
employers and employees).
Kegan, R. & Lahey, L. L. (2009). Immunity to change: How to overcome
it and unlock the potential in yourself and your organization. Boston,
MA: Harvard Business Press.

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