Nursing Management: Chapter 17

As a new manager, you are shocked to learn that your unit is still using heparin in heparin locks. You are aware of evidence related to this practice and want to change this practice as quickly as possible on your unit. You are in which stage of Lewin's stages of change? a. Unfreezing b. Experiencing the change c. Moving d. Refreezing

ANS: A Although you may be at a higher level of change in relation to your individual practice and knowledge of the use of change, in this situation, you are recognizing the need for change in relation to practice on the unit that you are managing. This phase is the initial phase in first-order change and will involve listening to staff to see if they perceive a similar problem.

The nurse manager frequently interacts with staff and other hospice facility employees. Communication is purposeful because the manager assesses current issues, such as specific satisfactions and dissatisfactions with the newly implemented computerized documentation system. Informally, the manager gathers available staff members to address similar learning needs. Many times, staff members are found coaching other staff about improving use of the new system. According to Senge (1990), the activities demonstrated in this example are: a. Dialogue, team learning. b. Resilience, personal mastery. c. Shared vision, systems thinking. d. Mental models, teachable moments.

ANS: A Building shared vision occurs when leaders involve all members in moving personal visions of the future into a consolidated vision common to members and leaders.

To engage your staff in awareness of their current practice and how it is affirmed or not by evidence, you plan a short series of learning presentations on evidence and use of heparin and saline to maintain IV patency. You meet with the educator to plan out the goals for each session with the overall purpose of increasing knowledge and awareness of staff in readiness to consider questions related to the IV practice. This learning approach is an example of which change management approach? a. Linear b. First-order c. Facilitative d. Integrative

ANS: A In the second stage, the moving or changing stage of Lewin's first-order, planned change process, planned interventions and strategies are executed to support the implementation of the change. One commonly used method is educating staff about the need for the change.

Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that "what she has been doing all these years means that she is incompetent and doesn't care about her patients." After speaking with Elizabeth a few days later you discover that she is now fine with the change but is concerned that other areas of the organization might resist the change because of perceptions related to patient safety and cost. She suggests that it is important to bring pharmacy on board as they have had previous concerns about the use of heparin. In relation to change theory, this is indicative of: a. Systems level thinking. b. Linear thinking. c. Interprofessional collaboration. d. First-order change.

ANS: A Senge's complexity theory, Bevan's Seven Change Factors, and general systems theory all highlight connectivity and the idea that changes are not isolated events.

Complex change situations require that the change leader promote ongoing visioning among staff members. One strategy is to: a. Consciously evaluate invisible mental models. b. Allow for individual outcomes. c. Encourage cooperative activities. d. Operate between order and disorder.

ANS: A Senge's theory on change suggests that each individual or organization bases activities on a set of assumptions, or a set of beliefs, or mental pictures about the way that the world should work. When these invisible models are uncovered and consciously evaluated, it is possible to determine their influences on work accomplishment.

Which of the following are examples of application of the Leadership Rounding Tool? (Select all that apply.) a. "What is working well for you during bedside reporting?" b. "What has not worked for you today?" c. "Is there someone on your team who deserves special recognition for her efforts in the implementation?" d. "Did you have a good vacation?"

ANS: A, B, C, D The Leadership Rounding Tool suggests establishing and maintaining rapport and asking what is working well, what was a barrier, and who should be recognized, as well as answering tough questions.

Based on Elizabeth's insights and suggestions, you involve pharmacy, only to discover that the change in practice involves practice committees, a medical practice committee, and concerns from administration about potential costs and safety of the proposed change to the IV protocols. The change process at this point is: a. Linear. b. Nonlinear. c. Sabotaged. d. Neutralized.

ANS: B Complex change involves nonlinear processes and a variety of strategies to negotiate influences on change. Complexity theories alter the traditional systems thinking approach by asserting that system behavior is unpredictable. This theory views change as emergent, nonlinear, and highly influenced by all individuals and subsystems in an organization

An example of one strategy used to improve participation in the change process by staff fitting the behavioral description of innovators and early adopters is to: a. Repeat the benefits of the change. b. Share change experiences early in the process. c. Initiate frequent interactions among staff. d. Provide select information to the staff.

ANS: B Connecting innovators and early adopters to new ideas and with new peers keeps them at the cutting edge.

To engage your staff in awareness of their current practice and how it is affirmed or not by evidence, you plan a short series of learning presentations on evidence and use of heparin and saline to maintain IV patency. You meet with the educator to plan out the goals for each session with the overall purpose of increasing knowledge and awareness of staff in readiness to consider questions related to the IV practice. Staff nurses who gain information on current IV therapy practices are engaging in which phase of Rogers' decision-making process? a. Persuasion b. Knowledge c. Confirmation d. Decision

ANS: B Rogers' innovation-decision process involves five stages for change in individuals, the first of which is knowledge.

When goals/outcomes are somewhat unclear in early preparation for a complex change, the manager and the change management team develop several acceptable goals/outcomes. This change in management approach is termed: a. Unfreezing. b. Nonlinear. c. Cybernetic. d. Linear.

ANS: B While Lewin's theory was designed to describe planned or first-order changes, many scholars think the theory is too simplistic to address how unplanned or second-order change occurs. In complex situations with an uncertain change environment, a nonlinear approach that involves flexibility improves overall outcomes. Linear change is appropriate to stable, less complex, and more predictable situations

Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that "what she has been doing all these years means that she is incompetent and doesn't care about her patients." Which of the following would be the most effective response to Elizabeth? a. "I understand how you feel, but you are going to have to change." b. "It is unfortunate that you feel this way. Others seem quite excited about the new information." c. "It is difficult sometimes to change what we know very well. Sometimes it can be frightening." d. "Perhaps I can arrange some more information sessions for you, so you can see just how important this change is to patient safety."

ANS: C Dialogue can reveal areas where individuals feel inept or overwhelmed, providing the leader with an understanding of what programs need to be developed to increase personal ability to change and what educational initiatives need to be implemented to support change. To promote dialogue, leaders must serve as facilitators, promoting the sharing of ideas, fears, and honest reactions to the change proposal.

You anticipate that your region will soon move towards an e-health record system. You begin to discuss this with your staff and are disappointed that you receive little positive response from the staff about this possibility. One staff member, in particular, seems to sum it up by saying "e-health? Won't happen in my working life! There are too many problems with it, like privacy issues." This response is most likely motivated by: a. Lack of urgency regarding the need to change. b. Lack of evidence to support importance of technology. c. Deficits in education and experience. d. Lack of organizational support for change.

ANS: C For leaders to inspire change, they must have intimate knowledge of what matters to the people they manage. Kotter (2012) characterizes this as establishing a sense of urgency, and this involves overcoming complacency. This is especially hard when there doesn't seem to be any visible crisis, or the crisis seems irrelevant to the people being asked to change (Kotter, 2012).

The clinical coordinator expects the position description of the new wound care specialist to change nurses' responsibilities in caring for clients with skin integrity problems. The best approach to address this need for change, yet to have the best outcomes for clients, staff nurses, and the organization, is to: a. Select one of the change models. b. Use Lewin's model and principles of change. c. Apply both planned and complexity theory approaches. d. Form a task force of nursing staff and wound care specialists.

ANS: C In the second stage, the moving or changing stage of Lewin's theory, planned interventions and strategies, such as education, vision building, and incremental steps towards the change, are executed to support the implementation of the change. This situation potentially also involves complexity theories that recognize that change involves engagement of individuals and subsystems throughout the unit and organization.

As the unit manager on the unit that is leading changes to heparin locks, you find that Elizabeth is very valuable in terms of her observations about other units and her knowledge of organizational processes, and now in discussing the new procedure with others. Elizabeth might be considered an: a. Engager. b. Innovator. c. Informal change agent. d. Informant.

ANS: C Informal change agents are those who do not have formal, positional power but who have credibility through expertise and can model the new way of thinking, or who offer suggestions, ideas, and concerns

Elizabeth is an example of a(n): a. Early adopter. b. Late majority. c. Laggard. d. Resister.

ANS: C Laggards prefer keeping traditions alive ("We have always done it this way") and openly express their resistance to ideas (speaking out against the change). Late majority individuals are openly negative but will engage with new ideas when most others adopt the change.

Edith has been vocal about her negative concerns related to a new charting system and frequently expresses the view that keeping the "old system" would have been "just fine." In facilitating change, your best approach to Edith would be to: a. Put her in the pilot planning group for the change. b. Determine if she has considered retirement. c. Schedule her work assignment so that it coincides with those of two staff members who are confident with technology and the change. d. Avoid discussion of the change, and trust that with sufficient training and information, she will change.

ANS: C Laggards prefer keeping traditions and openly express their resistance to new ideas. Having a group of change agents and innovators on board to champion an idea builds what Patterson et al. call "social motivation" and "social ability." This group can help staff, such as laggards, who are less adept at change.

The oncology clinic manager and the educational coordinator asked nursing staff to complete a brief written survey to assess their attitudes and knowledge related to having used the new infusion equipment for 6 weeks. The stage of change in this situation is: a. Developing awareness. b. Experiencing the change. c. Integrating the change. d. Perceiving awareness.

ANS: C This particular initiative assesses the success with which the change has been integrated into everyday practice after it has been experienced, or the degree to which staff members have accepted using the new infusion equipment.

The home health agency hired an expert in financial management to evaluate and propose a plan for reversing growing expenses and decreasing revenues. The expert is well respected, both personally and professionally, by members living in this small community. To be effective, staff will need to perceive this change agent as: a. Trusted, quiet. b. Flexible, informal. c. Credible, enthusiastic d. Communicative, personable.

ANS: C To influence the decision, the expert must be seen as having knowledge of what matters to the people that they lead and of the change area itself. The expert also must be enthusiastic and communicative and have referent power.

An example of one strategy to improve participation in the change process by staff fitting the behavioral descriptions of laggards, early majority, late majority, and rejecters is to: a. Encourage teamwork. b. Transfer to a different unit. c. Require attendance at staff meetings. d. Delegate the roles and tasks of change.

ANS: D According to Rogers's work, the individual's decision-making actions pass through five sequential stages. The decision to not accept the new idea may occur at any stage. However, peer change agents and formal change managers can facilitate movement through these stages by encouraging the use of the idea and providing information about its benefits and disadvantages.

Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that "what she has been doing all these years means that she is incompetent and doesn't care about her patients." Your response to her indicates that: a. Elizabeth will never adopt the change. b. Elizabeth is insecure in her practice. c. Elizabeth requires more information about the practice. d. Change involves emotions.

ANS: D Change, whether proactively initiated at the point of change or imposed from external sources, affects people. Responses to all or part of the change process by individuals and groups may vary from full acceptance and willing participation to outright rejection or even rebellion. It is critical to be able to "read" people and to recognize that communication should involve people's emotions and feelings.

To effectively achieve a change goal/outcome in a change situation, the wound care specialist will: a. Preserve the status quo. b. Diminish facilitators and reinforce barriers. c. Weigh the strength of forces. d. Strengthen facilitating forces.

ANS: D For change to be effective, the facilitators must exceed the force of the barriers; thus, strengthening the facilitating forces would achieve this aim.

As the unit manager, you spend a day performing direct patient care and work with a new system that is designed to capture patient documentation at the bedside. During discussions with staff while giving care, you discover that the number of screens that need to be opened during documentation makes charting more complex and time-consuming than traditional manual charting approaches. On the basis of this feedback, you: a. Assume that the system is doing what it needs to do. b. Provide reassurance to staff that the unit has achieved its goals in implementation of the system. c. Ask some of the staff if they have had similar experiences with the system. d. Consult chart audit data and end user consultation reports to determine if errors and problems are occurring.

ANS: D In Kotter's eight-step change model, removing obstacles means keeping alert for barriers in structure and processes that limit the ability to change and then removing those barriers once they have been found.

Sarah, RN, is one of your most enthusiastic staff members and has been to a workshop on preparing educational materials for patients. On the basis of this workshop, she would like to develop an information Website for patients who are being admitted to the ward. An appropriate response to Sarah's suggestion would be: a. "That is a great suggestion, but we have no resources for such an expensive undertaking right now." b. "Perhaps you can keep that in mind as we redesign our charting system." c. "We have too many seniors as patients, and you know that they don't use technology." d. "There is a great group here that meets to look at technology pilots. Let's see if you can join them and discuss your idea further."

ANS: D Involving Sarah with others who enjoy new ideas and who are able to try out new ideas in pilot projects enables her to remain on the cutting edge and to try out innovative solutions with the least amount of disruption.

Resistance is most likely when change: a. Is not well understood. b. Involves many layers in an organization. c. Involves nonprofessional workers. d. Threatens personal security.

ANS: D Resistance and reluctance commonly occur when personal security is threatened and may involve loss of confidence in abilities or loss of job or financial security.

The wound care nurse decided to involve those to be affected by change early in the change management process. This can positively result in: a. Coordination. b. Resistance. c. Anticipation. d. Participation.

ANS: D Successful change means persistence and advancement of the change, which requires the undivided focus of all team members. Early involvement and participation are critical to capturing the undivided focus of team members.

Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." According to Havelock (1973), this comment may originate from failure in which phase of the six phases of planned change? a. Generating self-renewal b. Choosing the solution c. Diagnosing the problem d. Building a relationship

ANS: D The first phase of this model of planned change involves building a relationship as a basis for later phases, which include diagnosing the problem and choosing the solution. At this point, as a new manager, the relationship may not have yet developed sufficiently with Elizabeth.