Hardwiring Nursing Practice Changes - Emerging Nurse Leader

By Rose O. Sherman, EdD, RN, FAAN

“For changes to be of any value, they have to be lasting and consistent.” Tony Robbins

One question that I ask every nurse leader in our conversations involves the challenges that they have in their leadership practice. This week, a nursing director told me that she felt her biggest challenge is hardwiring the many practice changes that she introduces each year. “It seems that just when I think everyone knows the new process or practice, I am circling about around because staff soon forget, and we seem to drift into noncompliance”. I am sure that this leader is not alone with this problem. Making practice changes “stick” can be very challenging.

The Evidence on Change

In most situations where we are asked to change, we are substituting new and unfamiliar behaviors or practices for old comfortable ones. This can make us feel insecure about our work and is often personally exhausting. That is why the reaction to change can be quite emotional and why staff often drift back into familiar patterns of working. Leaders play a key role in framing the context of change for their staff. This is especially true in uncertain environments.

You must help to manage change in a way that employees can cope with it. John P. Kotter, a Harvard Business Professor, is a highly regarded expert in the field of change management. He proposes the following 8 step model that leaders can use to understand and manage change. The first step in the process may be the most important – Create a sense of urgency about the need for change. We often forget to explain to staff the why of the need for change.

Hardwiring Change

The authors of the Influencer: The Power to Change Anything make the point that there are no silver bullets in the change process. Through their research, they have found that you will be more effective if you can identify 2-3 key behaviors that will have the most impact on the change. It is helpful to view nursing practice as a collection of habits. Charles Duhigg, an investigative reporter for the New York Times, has written an
interesting evidence-based book about how habits are formed and what we can do to change them.

Duhigg contends that habits make up 40% of our daily routines, whether at work or at home. What you see in your work environments is in a sense a collection of habits that develop over time. Habits are the brain’s way of saving energy. Yet, not all of our work or personal habits are good habits. If we want to replace bad habits with good habits, we need to be intentional whether it involves changing a practice to make it more evidence-based or getting staff to wash their hands before they enter a room. A mistake that leaders make is that they forget how ingrained habits really are. Hardwiring a new habit can take more than the 30 days that we often devote to implementing new initiatives.

McFadden and Ellington of Zero Point Leadership offer the following 5 step model to embed new practices:

Leadership is critical at every stage of the process. One of Kotter’s steps in the change process is Don’t let up – build and encourage determination and persistence – report on the progress. We need to implement tools to measure our progress. Nurse leaders sometimes complain about lack of staff compliance yet the problem with many performance appraisal tools today is that they are too general and don’t include specific behavioral expectations.

Leaders must build a culture that reinforces the new habit to make it stick and this includes changing rewards and recognition to influence the development of new behaviors. It is only through the intentional evaluation of our habits that we are able to change. Understanding habits is an important leadership skill. Duhigg suggests “once you see everything as a bunch of habits….it’s like someone gave you a flashlight and a crowbar and you can get to work.”

Read to Lead

Duhigg, C. (2012). The Power of Habit: Why We do What We do in Life and Business. New York: Random House.

Kotter, J. (1996). Leading Change. Boston, MA: Harvard Press.

Kotter International. The Eight Step Process for Leading Change

Patterson, K., Grenny, J., Maxfield, D., McMillan, R. & Switzler, A. ( 2008). Influencer: The power to change anything. New York: McGraw-Hill.