The nursing profession is in dire need of renovations and has been for decades. Despite being the largest healthcare workforce in the U.S., nurses can be hesitant to think outside the box. Let’s discuss common barriers to change and how nurses can overcome such barriers.
By Dan Weberg, PhD, MHI, BSN, RN, FAAN
Change is hard, especially in healthcare. The combination of risk to people’s health, entrenched professional boundaries, and slow-to-move organizational structures have made the transformation and evolution of care models and technology significantly difficult over time. In my experience, new solutions can take over 18 months to get adopted, new care research takes over 10 years to enter practice, and even simple moves like new staffing models are met with significant resistance from nurses and other care providers. We even had to remove the paper from the nursing units to facilitate the adoption of electronic medical records. However, change doesn’t have to be hard or stressful.
Did you know there is a significant body of research and case literature about how change occurs in groups? Decades of scientific research on the Diffusion of Innovations, complex systems, and high-performing teams have yielded valuable insights for nurses and nurse leaders to use as they try to initiate and support change. Let’s explore a few of the concepts that impact nurses the most when leading change or experiencing a change in their work setting.
The Blame Game
In a study of over 1,000 nurses looking at the adoption of new care practices in nursing, one distressing finding emerged: Nurse managers were perceived to be the number-one barrier to change in health systems. Not the CEO or CNO. Not the finance team or IT. Nurse managers. Our nurses stopped change from happening. But before we go blaming our nurse managers for the slow healthcare change cycle, we should explore why this is occurring. The job of the nurse manager is to keep staffing levels safe, round on patients, develop schedules, manage budgets, and so on. Very few nurse manager job descriptions are filled with innovation, changing processes, or transforming teams. The nurse manager’s job itself is disincentivized from rocking the boat. Their literal job is to maintain the normal operating conditions of the unit.
So how can we overcome this barrier to healthcare change? The first step is to learn about the reasons why these barriers exist. Too many Instagram feeds create a divide between direct care nurses and management without actually addressing the issues. Now that you know managers need to be equipped or supported in change efforts, begin to help them. Know the ideas you have may need to be pitched to others besides your direct managers and begin to include your managers and charge nurse leaders in the ideation and change pitch process. The key is that nurse managers are not stopping change intentionally; there are structural issues that make their support for large changes hard and sometimes impossible
Noodles and Post-it Parties
As we mentioned, there is significant evidence of how successful change occurs in teams and organizations, but in healthcare, we tend to not focus on this evidence. Instead, in my experience, change occurs in the following ways. About 25% of change is led by a LEAN Six Sigma process improvement mindset. Fishbone diagrams, A3s, and process maps flood Post-it Notes and butcher paper while a Performance Improvement specialist tries to understand workflows and create change. Sometimes this works. Many times it’s not the right tool.
The next way change is led in healthcare is with Post-it Note parties. These are usually offsite sessions with a paid facilitator that gets the participants to write lots of ideas. Those ideas are photographed and sent to some magical inbox in which the executives decide what will be prioritized (FYI, this is not innovation).
Finally, the most significant tool that leaders in healthcare use to lead change is… Throwing things at the wall and seeing what sticks. That means no actual change process is used, no evidence of how change occurs was studied, and the personal whim of the change leaders was pulled from the depths of some Google search or experience.
If your unit or nursing team is struggling with change projects, it might be good to reflect on what process the team is using to create the change. If the problem being solved is a known issue, well defined, and has a known solution, then Performance Improvement is a great tool. If the problem is not defined well, requires new ways of thinking or working, and there is not a well-known solution, then innovation work is needed. Many times, very complex problems require both skills to be solved. Help your team reflect on the problem and what tools are needed to solve it. And maybe we can save trees and noodles and stop throwing things at the wall.
Failure is Success
Our nursing professional culture is also sometimes part of the issue when it comes to change. Because of our rigid training, ethical code, and fear of the unknown, nurses can default to rejecting new ideas, technology, and care models by suggesting they will harm patients. While we need to advocate for our patients, it’s not a blanket excuse to stop new ways of providing care or new technology to support our work. As nurses, how can we infuse innovation with best practices for patient care?
One excuse I have experienced over and over in my career is the phrase, “I’ve been practicing for (x number) years and it still works for me.” The underpinning idea is that because you have been successful in the past, you will be successful in the future. This is also not always true but is commonly used to stop new concepts.
For our profession to stay relevant, evolve our practice, and meet the changing needs of the patient population, we must accept new things and sometimes fail at them. Acceptance of failure in our change efforts is not a sign of weakness nor a negative mark against our nursing work—it’s a way for us to learn and grow, which is ultimately success. As nurses, we can reflect on our risk tolerance and propensity for accepting change and keep our minds open.
Finally, we need to know the only way nursing will survive as a profession and continue to help our patients is to evolve our practice continually. In 2019, almost every other healthcare profession had a bill in the California State Legislature to expand the scope of practice except for nursing. We are not invincible, and unless we get more astute about the way change occurs, the future of our profession, and the processes to improve our work as nurses, could eventually go away. So, if you have a great idea for nursing, staffing, technology, innovation, and other improvements, then brush up on your change science, tap an expert on the shoulder, and get your ideas out to the profession. We need them.