Leading Nurses through Hospital Change Few industries are confronted with more c
ID: 126500 • Letter: L
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Leading Nurses through Hospital Change
Few industries are confronted with more change and more turbulence than the health care industry. As the perusal of any newspaper or news website will indi- cate, there is constant pressure on health care organiza- tions to provide quality care in a cost-controlled environment that is characterized by ever-increasing regulation. This pressure can be seen most clearly in the advent of managed care during the 1980s and beyond. Managed care involves integrated and com- prehensive systems of health care providers, insurance companies, and government programs, coordinated around specific care plans and guidelines designed to simultaneously enhance the quality of care provided, control the cost of that care, and maintain access to care for as many people as possible. As you might guess, it’s pretty much impossible to succeed in all three of these important goals of cost, quality, and access, but hospitals and other health care organiza- tions keep on trying.
I’ve run into many such organizations in my research on communication in health care organiza- tions. One of these organizations—we’ll call it Uni- versity Hospital—is discussed in several of my publications (Miller, 1998; Miller et al., 2000). Uni- versity Hospital is a large teaching hospital that employs nearly 5,000 individuals and is responsible for half a million patient visits a year. University Hospital is acknowledged as a very high-quality medical center—for example, it typically scores extremely well on accreditation surveys. However, like all health care organizations, University Hospital needed to improve in a number of financial areas, including average length of stay and cost per discharge. My involvement with University Hospital began when I learned of changes that were occurring in the nursing department and was asked to be a part of understanding and instituting those changes. As part of a hospital-wide effort to improve financial and care performances, the nurses were beginning a pro- gram of “differentiated nursing practice” (Hoffart & Woods, 1996) in which nursing roles were defined on a variety of specific levels of responsibility. These roles would require new training, new responsibilities, and a new orientation toward the systematized provision of care. The centerpiece of this program was the “care coordinator” role.
Care coordinators were defined as registered nurses charged with coordinating care for patients “from admissions to discharge.” This coordination involved communication with relevant physicians, social work- ers, allied health personnel, insurance representatives, and families. The nurses selected for these roles were the best and the brightest that University Hospital had to offer.
Sounds like a good change, right? Coordinated care from admissions to discharge is certainly an admirable goal. However, remember that the nurses selected for these positions were trained in traditional, clinical nursing. They were then thrown into a role that required them to work with individuals from a variety of hospital disciplines (with different turf issues and different levels of power) within an incredibly complex organizational structure. And they were doing this with little or no training and with a job description that was purposefully ambiguous; nurses were asked to design the job in the best way possible. Indeed, the final line of the job description for care coordinators read “Role in development/work in progress”!
So, imagine you are me, asked to help the leaders of the nursing department take their nurses—and espe- cially the new care coordinators—down this path of organizational change. The department is directed by two nurses—we’ll call them Hannah and Jen—who have an incredible amount of energy. Both are well- liked by the nurses they supervise. Hannah has been with the hospital for many years and knows all the ins and outs of the system. She is the steady hand guid- ing the nursing department, and she feels a bit over- whelmed by all the change she is being asked to institute. Jen has been with University Hospital for only a few years but has made quite an impact as a charismatic leader who wants University Hospital— and especially the nursing department—to be on the cutting edge of managed care initiatives. Jen is a pro- ponent of all sorts of New Age things, and she is par- ticularly smitten with “chaos theory” as a way to manage organizational change. She figures that they have selected the best people they can for the care coor- dinator roles, and she trusts that they will use their own imagination and ingenuity to craft roles that will work for the new system. Indeed, when a care coordi- nator complained about the stress of the changes they were going through, Jen quoted her favorite chaos the- orist, saying, “Chaos is the rich soil from which crea- tivity is born” (Merry, 1995, p. 13). Oddly enough, the nurse did not feel comforted.
1. How does the nursing department at University Hospital exemplify ways that organizations often react to planned organizational change? Are there ways in which the nature of the change—or the way it is being instituted at University Hospital— differs from traditional patterns?
2. If you were taking on a “care coordinator” role at University Hospital, what kind of information would you want to have? Do you like the idea of an unstructured role that you can develop on your own? What are the advantages and disadvantages of this kind of organizational ambiguity?
3. How would you choose to lead this department through the change they are experiencing? Would you rather have Jen or Hannah as your leader in this process?
4. What are some ways that Jen and Hannah could work together to make the change process successful?
5.What are two things University Hospital should have done or could do moving forward to promote success in this change initiative? It's fine to integrate your two concepts into your answer here (but not required).
(please include analysis )
Explanation / Answer
Transformational leadership: It is an acontemperorary model which was used for relationship development and uses for communication with the followers. Generally a leader can frame his language during the interaction with a variety of constituencies. Un planned change can mostly explores the strategies of communication during a crisis
1. ANS: According to the case, the planned change goal was to improve the quality for patients by care coordinating from “admission to discharge” it is a good change; however, since the job description was ambiguous, member’s reaction to this good change in the nursing department was uncertainty about the organizational processes and stress of the change they were going through, as a result.
In addition, because of lack of management support, without any meeting or training programs, nurses thrown into a role they hadn’t before with lots of questions in their mind and feeling uncomforted. In the classical approaches, change demonstrated negatively if there is no careful controlled management through it.
However, here Jen who is one of the director of the nursing department used “chaos theory” and she trusted that they have chosen the best members to institute this change and when a core coordinator as a member engaged with the change, complained they say creativity is born in chaos although members feel uncomforted and stressed out.
2. ANS: If we were to take on the care coordinators role at the university hospital, first thing is to establish a structure to help the nurses working under the supervision to achieve their goals. We would set individual goals for all the nurses to track their performances and give them the guidance and feedback required, also set boundaries to make sure there is no misuse of the freedom allowed by the management.
The disadvantage of unstructured role is that there is no accountability if anything goes wrong, because we are trusting the nurses to do their jobs based on their creativity and then we as management cannot blame them for doing something which is wrong according to management. If it is wrong with managements prospective then it should be defiles and communicated across. And so proper training is required by any organization to make sure the person doing their jobs are aware of the consequences.
There are some advantages with unstructured role, most important of which is freedom. Nurses are given their space to be creative which is not entirely possible in a structured job role.
3. ANS: We would choose to lead this change someone with the transformational leadership capability. Jenis our choice because her style and skills demonstrate very appropriate in changing situations. Where we can observe that her leadership is based in building relationships through interaction with followers and modeling desired values. Also, her constitutive communication skill is key to support this complex changing situation.
4. ANS: Hannah and Jen can work together to make the change process successful by taking advantage of what they are good at. Hannah’s expertise with the hospital and her years of experience and Jen’s innovation and preference for managed care initiatives, will help the other nurses to use their ingenuity and imagination to construct roles that will work for the new system.
Hannah and Jen should, as leaders, should have constant communication with each other, with the other nurses and the management regarding the ongoing process of change; they should allow for suggestions and act on and solve problems as they happen; they should apply their knowledge and skills to create a job description for the role of care coordinators so that the nurses will be able to easily learn, manage and accept the change.
Hannah’s steady guidance of the nurses and Jen’s support for new ideas will help them keep up with the changes and make the process successful.
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