How can collective leadership in fluence the implementation of change in health care?

Chun-Mei Lv ,Li Zhng

aNursing Administration Department,The First People's Hospital of Foshan,Foshan,Guangdong 528000,China

bNursing Administration Department,Foshan Hospital Af f i liated to Sun Yat-sen University,Foshan,Guangdong 528000,China

1.Introduction

Implementation of change plays an important role in health care organizations and impacts the care of patients.For example,more than 500 years ago,the plague epidemic occurred and killed a third of the population of Europe.1Since then,better hygiene and antibiotic treatments have made this a rare disease.Today,with the rapid growth of the elderly population,chronic health problems have become a threat to our daily lives.2How to keep a healthy lifestyle and improve the effectiveness of long-term therapies has become a new challenge.The trends of diseases and the treatment methods are changing.Health care organizations also need to implement change to adapt to the trend and explore a variety of ways of implementing safe medical service for the patients.Shore3reported that there were 7.5 million unnecessary surgical treatments in the US,costing approximately$53.3 million annually.Additionally,some health care spending was wasteful,including overtreatment,medicine abuse and failure of care.Out-of-date clinical practice led to inefficient treatment,complications,disability,increased lengths of stay and medical costs.Only by continually learning and improving can health care providers deliver evidence-based care and utilize up-to-date practices for patients.4Such a change can narrow the gap between the current services and future needs.4A helpful and efficient medical service needs to keep up with the pace of change.However,lasting change requires fostering an organizational culture.A shared,positive,safety-oriented culture is shown to directly correlate with leadership fostering that culture.

2.Collective leadership

Eckert et al5reported that collective leadership is an ideal approach,combined with responsibility,accountability and acting at both the individual and collective levels.Eckert et al5noted that the capabilities of collective leadership unite leaders and staff and create a common vision.Through coaching and trust,collective leadership ensures the delivery of continual quality improvement.The desired collective leadership culture would motivate all staff,promote continuous learning,and adapt to change.Collective leadership builds up and provides a direction for organizations;they can share health information and give timely feedback on staff performance to promote constant development.Moreover,fostering collective leadership across health care organizations would highlight the continued growth of the whole team.5Ideally,collective leadership will adapt to change along with the team to bridge the gaps.

3.Barriers of implementation of change

Kouzes and Posner4argued that there is no single form of leadership that can implement change without any problems.Indeed,change is not easy.Implementation of change often meets many barriers in practice.Leaders should consider which barriers are in the organization and which may be relevant to a speci fic problem.6First,fear of change is the most common barrier.O'Connel found most staff did notwant to spend too much time and energy in pursuing an uncertain future because they found it difficult to adapt to new practices.For example,data from various studies indicated that chlorhexidine(CHG)administration is an effective way to reduce hospital-associated infection.Leaders want to implement the new change on the ward.However,front-line staff do not like to spend too much time and perform extra physical work.In addition,they need to learn more skills to adapt to the new intervention.A second barrier is when resistance is the attitude that some staff have when they face change.6Anxiety,anger and bargaining are the most common reactions fora new change.In the CHG bathing example,a senior nurse does not think it is a necessary change.During her 20 years of experience,she thinks that routine work is good enough.The intervention increases her workload,and she needs to learn new skills and practice them.Third,limited resources and a lack offinancial support are further barriers.6Implementation of change often requires more time,coaching,facilities and extra costs.New equipment might have to be supplied to ensure change happens.Without policy or financial support,it is difficult to achieve goals.Fourth,some senior leaders in the organization may not be ready to change;they just focus on a vision for the future and never plan the change in detail.3That is why change often needs continuous perseverance and passion to implement.

4.Models of implementation of change

Implementation can be considered a planned process or knowledge translation.1It represents an introduction of an innovation in routine work.According to a thorough study,7implementation includes diffusion;dissemination and adoption.The effective and efficient implementation of change needs a systematic,well-designed plan and strong leadership support.1Several models are widely used when implementation of change.First,Donnelly and Kirk8claimed that Edward Deming's plan,do,study and act(PDSA)cycle is an effective model to judge whether the change will work.The key components of the PDSA cycle are:plan,do,study and act.This process will help achieve continuous quality improvement.Second,Levasseur9described Lewin's change model,which many health care organizations have used to understand an individual's behavior during a change.Unfreezing,moving and freezing are three elements of this model.However,the most widely used model is Kotter's eight-stage process,and there are several fundamental ways to approach the implementation of change.10

4.1.The first stage in Kotter's change model is to create a sense of urgency10

Creating urgency involves helping staff understand why a change needs to occur.In a collective leadership culture,leaders often set a goal or build the vision in the organization before implementation of change.Without a sense of urgency,it is difficult to take action toward the goal.In the CHG bathing example,staff think that the change would take too much time and increase the physical workload and that it is unnecessary to change.In a collective leadership culture,coaching,mentoring,and feedback can be powerful ways to overcome the barrier.Information must also be shared in a timely manner across different levels of the organization.All evidence of why the change needs to happen should be presented,and staff should be educated on why they need to behave in a certain way.Visible crises can often catch staff's attention and increase the urgency level.However,not every change is possible with high levels of urgency.Likewise,not every staff member has sufficient autonomy to implement change voluntarily.Moreover,too much pressure may create stress and anxiety among staff.Continuous assessments and performing different strategies are necessary for the organizational leaders.4

4.2.The second stage in Kotter's change model is to create the guiding coalition

Finding the right people,creating trust,and developing a common goal are the key factors in building a coalition.5The collective leadership culture focuses on establishing a team and engaging all levels of staff in implementation of innovative change.However,in a rapidly moving world,everyone may think in different ways.An efficient team requires the right people and sufficient trust so that it can accelerate the process of decision-making.Position power,expertise,credibility and leadership are four crucial characteristics for guiding a coalition.Position power refers to having main line leaders;expertise indicates having people with various points of view;credibility refers to having enough people with good reputations;and leadership refers to including enough proven leaders to drive the change process.These are the right people to implement change.In contrast,Eckert et al5noted that implementation of change needs to be based on trust.If an organization creates an understanding,caring,respectful,and trusting culture,it is easier to perform activities.Without the right people,trust and a common goal,it is difficult to achieve change.

4.3.The third stage in Kotter's change model is to develop a vision and strategy

Vision is an imaginable picture of the future;it can arouse staff's interest and drive to create that future.A vision motivates staff to make an effort in the right direction.5In a collective leadership culture,all levels of staff have a common sense of vision that can identify the direction for change.However,in practice,there can be disagreements,confusion,and controversy when an organization implements change.The organization should prepare some backup strategies to help resolve these issues.It is vital to identify the gap between current practice and recommended policy.Ideally,baseline assessment will also help identify the potential and actual barriers to adjust ways of doing things.If a vision is unfeasible,staff will not be motivated.That is why effective strategy plays such an important role in implementation of change.Feasible strategies should be grounded in a clear understanding of organizational culture.

4.4.The fourth stage in Kotter's change model is to communicate the change vision

Mannion et al11found that the better performing organizations provided a common understanding of its goals and direction for collective leadership.In collective leadership cultures,there is intense communication and clear information flow across organizationalboundaries.They are responsible for communicating the change,sharing teamwork culture,and encouraging staff engagement.In addition,Eckert et al5demonstrated that communicating and encouraging staff to participate in decision-making can create a positive environment,which will lead to staffs'wellbeing.In practice,if leaders do not express the reasons for implementation of change honestly and directly,it is more difficult to get the buy-in of staff to make the desired changes.Effective communication is often clear and simple.Complicated communication will make staff feel confused,suspicious and alienated.However,not everyone may understand the policy or think in the same way.It may be difficult to communicate with the person,no matter how much effort you make,so additional strategies(e.g.,enforcement)may be needed.6

4.5.The f i fth stage in Kotter's change model is to empower broadbased change

Effective change always does a great deal to empower staff.In a collective leadership culture,Su12noted that when staff feel empowered,their autonomy develops and trust is established.Staff will develop their skill and work effectively to achieve their aims and objectives.This is a good way to achieve job satisfaction.Even when unexpected changes happen,staff can still handle the situation.Salmela et al13claimed there are four barriers or obstacles that need to be overcome:structural,skills,systems,and supervisors.The study also strongly suggested that training was an essential part in empowering staff to change.New behavior,skills and attitudes need to develop before change can happen.As a leader,it is necessary to evaluate the capability of staff;without the quali fied skills,staff would still feel disempowered.However,if all levels of staff are engaged in the decision-making processes,who will make the final decision?Occasionally,this can lead to dif f iculties when a quick decision is needed in a crisis situation.

4.6.The sixth stage in Kotter's change model is to generate shortterm wins

Achieving short-term wins is the basis for a long-term goal.1Staff can gain con fidence and find evidence that they are on the right track.The short-term wins provide the information on the viability of their ideas.In a collective leadership culture,Eckert et al5stated that feedback across different levels of an organization may be the most effective way to develop leadership.After a period of hard work,they need some positive feedback to strengthen their motivation.Some negative feedback can also correct the method and strategies involved.In the CHG bathing example,the vision of implementation was for a whole year or a long period,but the leader needs to acquire feedback on how it is going in the short term.If the intervention can decrease the hospital infection rate,staff have a clear idea that what they do matters.Clear improvements make people feel con fident in their work and encourage them to keep implementation of change.Inevitably,targeting short-termwins will increase the pressure among staff.At the same time,it is also an effective way to keep up with the rapid development of today's culture and to establish urgency.

4.7.The last stages in Kotter's change model are consolidating gains,producing more change and anchoring new approaches in the culture

The implementation of change may be a decades-long process.In practice,without sufficient leadership,some changes cannot run simultaneously.In collective leadership,all levels of staff clearly understand their joint mission and,with multi-directional communication,work with others to achieve the goal.These factors all make the organization more adaptable to change.Kotter's theory mentioned implementation of a long-standing change and the need for the practices to be grounded in the organization's culture.Additional people are promoted and developed to help further change.Senior leaders will keep maintaining urgency levels and sharing the vision in the organization.West et al14reported that organizational culture indicates shared values in the team.It can powerfully in fluence staff's behavior,even when the group membership changes.Further research placed the quality of patient safety above all other aims.Ideally,health care organizations need a strong leadership culture that consolidates gains and produces more change for future medical service.The King's Fund reported that collective leadership fosters a patient-safety culture in the organization.It is developed across all levels of the organization;staff are engaged and develop observation capabilities and communication skills.All of the factors focus on exploring a culture-sensitive,safety-focused service,and its responsiveness to the needs of the patient.Thus,the organization improves their capacity to work with complex challenges.

5.Feasibility of change

5.1.Change can be effective and helpful for the organization

However,change is not always necessary in organizations.4Some change will be negative and unnecessary.If staff spends a great deal of time and energy in implementation of unnecessary change,they will feel disinterested,tired and exhausted.6The leaders need to develop a well-designed plan and avoid such a process.Fostering the right culture in health organizations is vital to ensure that both staff and the whole team provide kind,respected,and high-quality medical service.1Recent research by Eckert et al5described collective leadership as a culture-sensitive leadership.It includes characteristics such as establishing vision and trust;engaging all levels of staff;evidence-based assessment;developing the individual and team;coaching;timely shared responsibility; accurate feedback; supporting investments;and modeling behaviors.In one case,Grol1reported that there was a change in reallocating working staff(e.g.,surgeons,nurses)that led to high post-surgery mortality rates and complication rates in the Cardiac Surgery department of Nijmegen Medical Center.Within a few years,staff did not follow the evidence-based protocols to collaborate with others.The leaders had lost the ability to control the situation.Finally,the inspectorate had to close the Cardiac Surgery department,and six months later,a new team was built and the department reopened.This was a new change,and the new medical team established patient safety as a vision;used an audit method to supervise the implementation;publicized the data;and built a sense of urgency.In this case,unnecessary change had occurred and led to poor outcomes for patients.The competencies of new surgeons were developed to the required standard.The mortality and complication rates decreased to far below the average because all levels of staff were engaged in the improvement and formed a patient safety culture.1

5.2.Although the ef f i cacy of collective leadership has been supported,its feasibility has been criticized

In practice,it is difficult to achieve all elements of collective leadership in the management processes.Thus,some leaders may not have the ability and power to enforce that.Moreover,if all levels of staff are engaged in the decision-making processes,it is difficult to make a decision.Allahverdyan and Galstyan15reported that leaders make decisions without reference to anyone else in an autocratic leadership culture;it may be valuable in speci fic situations(e.g.,natural disaster,emergency)where decisions can be made quickly and decisively.15However,in a collective leadership culture,the performance focuses not only on individual leaders but on the whole team;the latter are the most important elements in the patient safety culture for health care organizations.In particular,the spirit of learning from errors or failures creates a shared and positive safety culture.It is responsive to the demand of patients and helps the organization deliver high-quality care.

6.Conclusions

This study is focused on how a collective leadership style could in fluence the implementation of change in health care.Change is not easy,and it will meet a variety of barriers in the process.To evolve in response to increasing health care needs,change is inevitable and necessary.All health organizations will face change if they want to provide better patient outcomes.Kotter's 8-step process is an effective way to guide the implementation of change.Likewise,leadership plays a significant role in implementation of the change.Collective leadership can highlight all levels of staff engagement,establish an organizational culture of learning and trust,and create continuous improvement.At the same time,it can formulate a well-designed plan;develop efficient strategies;communicate and empower the staff;assess the performance;and integrate the improvement.This is a desired leadership culture to implement change and ensure service that is of high quality and safety-focused in health care organizations.However,there is no single form of leadership that can overcome all situations.Therefore,the organization needs to adjust their strategies during the process of implementation of change.

Conflicts of interest

All contributing authors declare no Conflicts of interest.

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