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- the act, process, or result of altering or modifying - inevitable in health care

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Change

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nourishes creativity in entire organization to facilitate change

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Leaders can create an environment that

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- structured approach to transitioning from current state to desired future state, to fulfill or implement a vision and strategy

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Change management

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- what is your usual response to: deliberate, planned change? unexpected change? sustained ambiguity in a change situation? - what types of expertise and values do you have that could facilitate change in a work setting?

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Questions to consider

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- chaos -------- stability - tension - change

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Change Process

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- a change in one part affects other parts and other systems - people affected by change should participate in making the change - people should be informed of the reasons for the change: evidenced based practice - concrete and specific feedback about the process of change will enhance its acceptance - people need assistance in dealing with the effects of change - people's suggestions and contributions about implementation of change should be sought and incorporated - a change must be reinforced, or the system will revert to its old practices - conflict may occur at any step during the change process - the more compatible the new ideas are with one's values and needs, the more easily a change will be adopted - the more trust one has in the initiator of change, the more likely one is to support the change - one's past experiences with change can profoundly affect one's willingness to support a new idea

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Principals of Change

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1. positive (2.5% of people are openly ready for change) 2. negative (16% of people will reactively resist change)

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Individual responses to change

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- level of trust - past experiences - ability to cope with change - predictability and capability

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resistance can be affected by:

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- Diffusion of innovations is a theory that seeks to explain how, why, and at what rate new ideas and technology spread through cultures - Everett Rogers, a professor of communication studies, popularized the theory in his book Diffusion of Innovations; the book was first published in 1962

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Diffusion of Innovations Theory

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1. the innovation itself 2. communication channels 3. time 4. a social system

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Rogers proposes that four main elements influence the spread of a new idea:

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- 2.5% - love change - risk taker

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Innovators

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- 13.5% - open and receptive to change - often respected by peers - opinion leaders

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Early adopters

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- 34% - enjoy status quo, but eventually accept change - not the first ones out though

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Early majority

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- 34% - skeptical, negative at first; accept when evidence that others have bought in - need encouragement

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Late majority

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- 16% - open resistance - like status quo, fear change - important to understand why

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Laggards

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- active opposition/sabotage

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Rejectors

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- help in the process of adaptation - create new models or patterns for care delivery - listen and collaborative with all the interdisciplinary team - embrace uncertainty - continuous quality improvement engagement

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Role of new leader

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- know the players in the work setting (innovators, early adopters, early majority, late majority and laggards) - your values are important - learn and use of new technology - renew yourself - learn to cope with unknown or uncertainty - expect emergence of many leaders - allow autonomy people will adapt and adjust in their own way - improve connections between colleagues - do not allow people to say that's not my job - assist peers to become skilled at handling ambiguous issues - assist organizations and people to discover goals themselves - work smarter, not necessarily harder - provide for the emergence of new visions

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Leadership in Chaos

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- learn - expect - allow - improve - assist - work - provide

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Key Words = leadership in chaos

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1. what is the problem? 2. Could we do more work in the same time (efficiency)? 3. Could we do our work better (effectiveness)? 4. Could we save money (economy)?

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Identifying change: what needs to be changed and why?

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often difficult to pinpoint what needs to change

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Often easy to identify problem, but

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- try to clarify what exact problem is - identify all problems and ask why each one is happening - keep asking why until real problem is determined

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Root-cause analysis

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i.e. Ishikawa diagrams (also called fishbone diagrams or cause-effect diagrams) are diagrams created by Kaoru Ishikawa (1968) that show the causes of a specific event

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Cause and Effect

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- product design - quality defect prevention - to identify potential factors causing an overall effect

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common uses of the Ishikawa (fishbone) diagram

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1. machine (technology) 2. method (process) 3. materials (info, consumables, raw material) 4. measurements (inspection) 5. man power(person) 6. milieu/mother nature (environment) 7. management/money (power) 8. maintenance

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The categories of the Ishikawa typically include (8):

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- identify everyone who is an interested party in the proposed change - analyze in terms of power, influence and impact

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Who will help you? Stakeholder analysis

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- human behaviour is caused by forces: beliefs, expectations, cultural norms etc.

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Understand driving and restraining forces

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- push individuals and organizations towards change

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Driving forces

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- push people to hold onto status quo (away from change)

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Restraining forces

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1. Unfreezing stage 2. Moving stage 3. Re-freezing stage

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Lewin's Stages of Change (3)

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- promote awareness of the need for change - show implication of the status quo (why isn't good)

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Unfreezing stage

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- clarify the need to change, explore alternatives, define goals and plan and implement change

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Moving stage

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- integrate the change into organization - ensure stable environment, provide positive feedback, data, etc.

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Re-freezing stage

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1. set the stage and create sense of urgency 2. pull together guiding team 3. creating a shared vision 4. communicate for understanding and buy-in 5. empower others to act 6. plan and create short term wins 7. don't let up 8. create a new culture to anchor the change

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Kotter's 8 Step Process for Leading Change

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- allowing for complacency - failing to create sufficiently powerful team - not truly integrating the vision - allowing for obstacles - not celebrating short term wins - declaring victory too soon - neglecting to anchor changes firmly into culture

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Errors Common to Change

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- build new habits and skills - provide opportunities for discussions and tools to reinforce skills: may assist staff in institutionalizing processes - reward incremental change - make all staff accountable - assign responsibilities for change actions - encourage mutual leadership

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Overcoming the errors common to change

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1. nurse to patient 2. family-small group - environment 3. larger groups - inter or intraprofessional activities 4. institutionalizing change = small setting 5. institutionalizing change = large setting 6. interprofessional health policy activities 7. political nursing, health policy activities

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Focus for leadership development

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- focus on one field of nursing practice or health care that encompasses a level of knowledge and skill in a particular aspect of nursing greater than the acquired during basic nurse education

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Specialization

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- the client's age (i.e. pediatrics, gerontology) - the client's health problem (i.e. pain management, bereavement) - the diagnostic grouping (i.e. orthopedics, vascular surgery) - the practice setting (i.e. hospital, research facility, school, ER etc.) - the type of care (i.e. primary, critical, palliative, public health etc.)

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Specialization practice within any of the domains (clinical, research, administration, policy, education) may relate to:

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- CNA certification is a voluntary, recognized credential for RNs who meet specific nursing practice criteria, continuous learning and exam based testing requirements - 2 years experience + written exam

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CNA Certification

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- confirms that an RN has demonstrated competence in nursing speciality/area of nursing practice by having met predetermined standards - 20 nursing specialities under CNA C

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The credential, which must be renewed every five years

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- assessing - visioning - planning - marketing - scanning

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The Donner Wheeler Career Planning and Development Model

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- ask yourself what you want from a mentor and the mentoring experience - reflect on your strengths and weaknesses - decide on what qualities you want in a mentor - consider the availability of a mentor - make a list of potential nurse leader mentors: identify one, invite them and follow through

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Choosing a mentor

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- tell us about yourself? - where do you see yourself in 5 years? - how would you describe yourself? - how do colleagues describe you? - change manager? - describe a work situation you have had to deal with, how did you handle it? (conflict management and leadership) - what are your strengths and areas of improvement? (self reflection) - why do you want to work at this organization? (mode of nursing care, mission/values/vision, number of staff they employ, number of patient beds) - what is your philosophy of nursing? (what is their philosophy) - what do you know about this organization?

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Potential Interview Questions

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- Type/ length of orientation: What kind of training will I get? - What resources will I have access to?Mentors, library, computer with evidence based information, nurse educators - What are the ongoing opportunities for professional development? Paid education days, workshops, conferences - What is the model of care, model of nursing care? Interprofessional, family centered etc.? - What is the type of nursing staff here? - How are the working hours scheduled? - What are the shifts? Mandatory overtime? On call? How far in advance will I know my schedule? - Do you have a preceptor or mentorship program? - What is your absenteeism rate: Average is 7% → want less (shows how happy the staff are) ? - What is your overtime rate?

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What to Ask During an Interview

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- you have received a solid education and you are ready - integrity = own your practice, resist temptation to simply blend in - be an agent of change - engage in personal, professional and shared reflection - find a mentor: harness the wisdom - diversity is one of nursing's greatest strengths - seek and seize opportunities - be engaged, influence the future

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Humble advice

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- Canada Health Act - Federal-Provincial transfers - Provincial/territorial health systems - public private expenditures - 13 + health systems - Federal government is the 5th largest employee of health care services

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The Canadian Health Care System

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21 % = increased concerns over sustainability

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Percentage of world population 60 years or older by 2050

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- more urban, multi-cultural - world traders, with a growing focus on services - older, more female - tolerant, opinionated, demanding and difficult - post-idealogical libertarian (neither left or right) - less engaged with traditional institutions - aggressively Canadian

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New Canada

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- navigation of healthcare - access and timeliness - patients as partners - primary care - system integration - e-Health privacy - accountability and incentives - community care - communication - eliminate language barriers - disease prevention and health promotion - pharmaceuticals - mental health and addiction

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What the public wants (13)

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- power through connection - shared purpose - making sense through emotional connection - viral (grass roots driven) creativity - open approaches, sharing ideas/data, co-creating change - relationships

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Change and Transformation (Emerging direction)

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- Current system is not working to capacity - Canadians expect a responsive system - Time for change and innovation

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Health Care Realities

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- national professional association - a powerful unified voice for Canada's RNs, promoting the role of RNs and NPs - advance the profession and promote best quality of care - over 135, 000 members - a federation representing 11 provincial and territorial nursing associations and colleges

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Canadian Nurses' Association

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Vision: Registered nurses are leaders and partners working to advance nursing and health Mission: CNA is the national professional voice for RNs, advancing the practice of nursing and the profession to improve health outcomes in a publicly funded, not-for profit health system

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CNA Vision and Mission

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- Add a nursing perspective to current policy issues - Professional practice: Code of Ethics, Position statements - Continuing Education: 140+ accredited courses - CNA's core leadership comes from its nursing-led division.

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CNA's vision, mission and goals are aimed at serving Canada's RNs and NPs:

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- Advancing evidence-informed policy - Demonstrating relevance - Deepening influence - Delivering results - Achieving impact

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CNA is:

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1. Building up our profession 2. Influenza immunization 3. Staff Mix 4. RN prescribing 5. Public Engagement 5. Strategic Planning

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CNA's policy Action Plan was developed in response our new strategic plan.

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- first ever competencies developed for the clinical nurse specialist role in Canada

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Building up our profession

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- Pan-Canadian Awareness Campaign - Position statement, webinar - Collaboration with CFNU, PHAC, Immunize Canada - Nurse One Knowledge Featurette

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Influenza Immunization

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- joint effort between CNA, the Canadian Council for Practical Nurse Regulators and the Registered Psychiatric Nurses of Canada - staff mix is a component of nursing care delivery models that currently includes a greater emphasis on teamwork and collaboration

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Staff Mix

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- expanding scope of practice - significant activities undertaken to support RN prescribing - the right provider, at the right time and place

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RN prescribing

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- new and emerging roles for RNs in the care of older adults - innovative solutions address care gaps in areas

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Gaps in Seniors Care

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- 96% of Canadians say it's important to be able to age at home with access to health care at home - 94% of Canadians want more financial aid from the federal government for family caregivers - 94% of Canadians think nurses should have an enhanced role in the delivery of home health care

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Public Engagement

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1. Establish nationwide standards for home health care 2. Increase support to Canadians who provide care for aging relatives 3. Expand community- and home-based services

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CNA recommends that the federal government:

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- five year strategic plan cycle - extensive internal and external consultation

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Strategic Planning

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- a philosophy and approach that embraces promotive, preventative, curative, rehabilitative and supportive care - elements: accessibility, public participation, technology, interprofessional collaboration, health promotion

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primary health care:

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- aging population - lack of access - Canada lags in terms of overall quality of care - health systems integration with workforce modernization is needed - more interprofessional teams - increase collaboration across sectors - address scope of practice

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Trends (Naylor's Report 2015)

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1. Build Capacity 2. Advance policy and advocacy 3. lead a system shift

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Primary Care

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- set a joint vision - develop competencies - offer educational programs

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Build Capacity

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- create meaningful partnerships - promote a knowledge clearing house - lobby the federal government

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Advance Policy and Advocacy

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- make a business case - develop standards, tests - report and recognize progress

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Lead a system shift

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- appropriate regulation and legislation - clarity of roles - positive adoption and support from health professions - cultural readiness within the workplace - interprofessional education and training before and after entry to practice

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Policy Development

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- Nurses have an important contribution to make in health services planning and decision-making, and in development of appropriate and effective health policy - They can and should contribute to public policy related to preparation of health workers, care delivery systems, health care financing, ethics in health care and determinants of health

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Nurses in Politics

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- establishing a sense of urgency - creating the guiding coalition - developing a change vision - communicating the vision for buy-in - empowering broad based action - generating short term wins - never letting up - incorporating changes into the culture

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Process for Change

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- know what you stand for - tell the truth - listen actively - work the hours needed - be a teacher - park your ego - value every member equally - keep assessing the environment - build/use your network - sense of humour

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Leadership reflections

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