Leading During Change and Change Management The Future of Nursing: Leading Change,

Advancing Health (Institute of Medicine, 2011) has stimulated a lot of change for the nursing profession
and most likely will be doing so for some time. The recommendations from the report focus on change
in practice and education and the need for greater nursing leadership and expansion of the healthcare
workforce. The Robert Wood Johnson Foundation (RWJF) partnered with the Institute of Medicine
(IOM) and formed the Initiative for the Future of Nursing (Robert Wood Johnson Foundation, 2014). In
addition, the Center to Champion Nursing in America (CCNA) was established in partnership with the
American Association of Retired Persons (AARP) and RWJF. The goal is to mobilize stakeholders to
ensure that the Future of Nursing report recommendations are met and for nurses to assume more
leadership in the change process to address healthcare challenges of access, quality, and cost (Center to
Champion Nursing, 2014). The IOM report notes that the size of the nursing profession of more than 3
million registered nurses can make an important impact on the healthcare delivery system—there is
opportunity for the profession and for change to improve. The report and follow-up activities are
connected to the Affordable Care Act of 2010 (ACA). “The ACA represents the broadest changes in the
healthcare system since the 1965 creation of the Medicare and Medicaid programs and is expected to
provide insurance coverage for an additional 32 million previously uninsured Americans. Although the
passage of the ACA is historic, realizing the vision outlined above [in the report] will require
transformation of many aspects of the healthcare system” (Institute of Medicine, 2011, p. S-1). (See
Appendix B.) To participate actively nurses need to develop leadership competencies, and a key
competency is change management. To meet The Future of Nursing report’s recommendations requires
an understanding of change and the change process and the ability to effectively implement the change
process as a leader or as a team member. The Five “Rs”: Change and Decision Making in Action The
healthcare delivery system has been adjusting to changes in reimbursement, staff shortages, budget
cuts, technology, role changes, and much more, all of which have had a major impact on nursing.
Change has driven the need for the five “Rs,” which particularly affect HCOs, nursing education, and
nursing practice.

The five “Rs” are as follows:

1. Reengineering/redesigning/restructuring the healthcare organization

2. Redesigning the workforce

3. Reregulating professional practice

4. Rightsizing the workforce

5. Restructuring nursing education.

Each one of the five Rs is about change and requires decision making and change management
on the part of the HCO and its staff. Understanding the historical and in some cases current impact of
the five Rs provides an introduction to the importance of change, decision making, and change
management for nurses.
1.Reengineering/Redesigning/Restructuring g the Healthcare Organization Reengineering was used in
many HCOs for a number of years, and though not used currently, it had an influence on the current
status of many organizations. The IOM discusses the impact that reengineering has had on nursing in its
report on nursing that was published prior to The Future of Nursing report (Institute of Medicine, 2004,
2011). Other terms used to describe this process are restructuring and redesigning. This process
represents more than a minor organizational change; it was a reinvention or recreation of processes,
work, and systems. Often reengineering was not easy for nurses to accept as the process sometimes
resulted in radical changes in how nursing was practiced, and thus nurses were reluctant to participate.
To actively participate in reengineering, nurses needed to understand their own work and be willing to
explore improving their practice. Often reengineering focused mostly on reducing full-time equivalents
(FTEs), primarily nursing, developing or reducing services, or decreasing length-ofstay. This was usually
done with limited nursing input. Varied reengineering strategies were used. An important related issue
today is the growing emphasis on patient-centered care, which requires a combination of reengineering
and work redesign. The goals are to improve patient and customer satisfaction, quality of care, and cost
reduction. The use of the term “patient-centered care” is important in the IOM reports on healthcare
quality, and it is one of the five core competencies of healthcare professions. The idea of arranging work
around the patient rather than specialized departments has great potential for providing an opportunity
to deliver nursing care that meets patient needs; however, this has not been easy to accomplish. The
IOM reports (2003, 2004) now consistently emphasize patient-centered care. Although the reports
emphasize quality, the IOM reports also discuss the relevance of efficiency and design of work. It takes
time and commitment and requires significant change in the organization to provide patient-centered
care. Over many years, patient care has been delivered in hospitals with the number of departments
increasing and more and more staff interacting with the patient. Specialization has led to problems of
poor communication, complex processes, increased paperwork, poor collaboration, and error. How
would a hospital become more patient centered? What redesign would be necessary? What role would
nurses play? These are critical examples of decisions that must be made as planning is done to make
major changes in HCOs. Whenever HCOs undergo major redesign, retrospective evaluation needs to
occur to assess the outcomes, and nurses at all levels should be actively involved. The new initiative
Transforming Care at the Bedside (TCAB), which was influenced by the IOM report Keeping Patients Safe
(2004) and the Institute for Health Improvement (IHI), has had an impact on organizations in which TCAB
is used. This initiative is discussed further in Chapter 18. The focus is again on quality but also the design
of work to improve quality care. TCAB uses the change approach called Deep Dive, which is discussed
later in this chapter. This initiative focuses on small pilots in hospitals to make needed changes and
actively use nurses in the process (Robert Wood Johnson Foundation, 2009; Institute for Health
Improvement, 2015). TCAB is an example of current approaches to reengineering care, but it is
important to understand the history of the use of reengineering as it had a major impact on how nurses
practice today in hospitals.

2.Redesigning the Workforce Demands that managed care placed on clinical settings to increase
productivity and patient and customer satisfaction, and at the same time provide lower cost quality
care, pressured nurse executives and managers to institute work redesign, which is part of
reengineering. With the nursing shortage, the need for work redesign was even more important.
Improved efficiency that results in more effective practice with less staff is critical, and since a major
shortage is predicted for the future, this issue continues to be important. This has led to the
development of, and changes in, inpatient care delivery models, such as the use of patient-centered
care and changing staff mix, therefore, altering the number of RNs, unlicensed assistive personnel (UAP),
and licensed practical nurses (LPNs/LVNs) and changing of responsibilities. The effectiveness of these
changes varies. Traditional nursing roles and activities need to be assessed and may need to be rejected
to change to more effective roles that allow for more innovative approaches. Nurses need to provide
supportive data to demonstrate the impact that their own roles and activities have on efficiency,
improved care, and patient outcomes. The problem, however, is that there are many perspectives on
nursing work redesign. Determining the best way to design how staff work together to provide quality,
safe care that includes patients is the key issue. Some hospitals have introduced the new role of the
clinical nurse leader (CNL), which is discussed in Chapter 4; however, the introduction of a new role
needs to be planned by an HCO so staff understand the role and implications on other roles. New roles
impact current roles and cause problems if not thought through carefully. When HCOs confront the
need to make changes in responsibilities, functions, and tasks in the delivery system, the most common
reasons have been due to concerns about costs, productivity, and outcomes. Work redesign is used to
address these concerns; however, there are other factors that need to be considered. Nurses are
responsible for ensuring a baseline level of performance. If UAP are used, nurses need to ensure that
training and supervision are provided to UAP to ensure patient safety and quality care. (Content from
Chapter 15 on delegation applies to this issue.) The nursing profession must also be careful about new
delivery models or how staff are organized to provide care (for example, the use of teams), as discussed
in Chapter 4. There needs to be more research to validate the outcomes of these models so evidence-
based management (EBM) can be implemented more effectively. The bottom line is nursing needs data
to support these delivery changes. Are models effective? If not, why? What can be done to make them
more effective? Should the model be used? Under what circumstances is the model effective or
ineffective? Nurses should be asking these questions, not waiting for others to do so. Nurses should also
be directly responsible for finding the answers, analyzing the results, and making decisions about
needed changes.

3. Reregulating Professional Practice Why is reregulating professional practice an important change

issue today? Chapter 2 includes some information on regulation, for example the need for recognition of
scope of practice with advanced practice registered nurses (APRNs) (Institute of Medicine, 2011). Nurses
have discovered that many of the changes that are taking place in health care, such as the use of
telehealth, workforce mobility, and mergers (or several HCOs forming one organization, which may then
have parts of the organization in different states), are affecting licensure. Today many nurses are
providing care across state lines and in situations in which the patient is in a different state from the one
in which the nurse is licensed and located, particularly near state borders, which makes access easier.
The use of telenursing is also growing, which allows for greater opportunities to provide nursing care
over distances using telecommunication and other technologies. This type of care is considered to be
within the practice of nursing, even if it is not “hands-on care” or direct care. In addition, restructuring
of health care has led to an increase in multistate healthcare systems, which has affected how nurses
are employed and where they work. To understand the recent proposed changes in regulation, it is
important to recognize how regulation is applied. The purpose of practice regulation is to ensure public
safety. Boards of nursing regulate nursing practice. The right of states to regulate practice is based on
the Tenth Amendment to the U.S. Constitution, the states’ rights amendment. This amendment provides
each state with the right to regulate nursing practice within its own state but not within other states.
This is why nurses who move from one state to another to work must obtain licensure in the new state.
Reciprocity, or one state’s need to recognize a license issued by another state, is primarily based on
national board scores; however, the nurse must still apply for an RN licensure in the state, meet
individual state requirements such as continuing education, and pay state fees. Due to changes in health
care, boards of nursing and nursing organizations have been discussing changes that need to be made
nationwide in the regulation of nursing practice. The dilemma is that licensure remains state based yet
state borders may no longer bind nursing practice. Various options were considered by the National
Council of State Boards of Nursing (NCSBN) to resolve this dilemma, but thus far, the option selected to
address this licensure problem is mutual recognition. The implementation of this type of licensure
requires an interstate compact, which is an agreement between two or more states, entered into for the
purpose of addressing a problem that transcends state borders. Compacts are created when two or
more states enact identical statutes establishing and defining the compact and its role. The result is the
creation of both state law and an enforceable contract with other states that adopt the compact. Not all
states have made decisions to make this change and collaborate with adjacent states about RN
licensure, but there is a trend in this direction. Information about current states participating in mutual
recognition can be found on individual state boards of nursing websites and on the NCSBN website.

4. Rightsizing the Workforce “Rightsizing” and “downsizing” are terms that cause nurses to shudder, as
they suggest that the HCO might reduce staff. During times of downsizing, hospitals decrease their staff
and beds, but then they have to reverse those decisions as needs rise. The number of applications to
nursing programs has increased, but wait lists have grown at the same time. The economic crisis of
2009–2010 had a major impact on this problem, increasing the number applying. In addition, hospital
acuity remains high, requiring greater numbers of competent staff. Chapter 8 discusses staffing issues in
more detail. Rightsizing focuses on how much staff is required to do the job, though this has never been
easy to predict or accomplish. Budget plays a major role. Since education for healthcare professionals
takes time, it is important to try to predict future needs. The goal is to determine how many healthcare
professionals need to be educated to meet the future needs and ensure that there will be jobs for them
when they complete their education and training. It is clear that there are not enough nurses now, and
the predictions for the future indicate there will be greater need, particularly when the baby boomer
nurses retire. The economic problems did slow down retirements, and many nurses returned to nursing
or increased their hours. The shortage has undergone fluctuations: more nurses returned to practice
during the economic crisis of 2009–2010 and there was an increase in the number of applicants to
nursing programs. Some areas of the country found that they no longer had a severe shortage. As a
result, new graduates had a difficult time getting positions due to the return of nurses who had not been
in practice and the impact of nurses not taking early retirement because they needed more income.
However, this does not eliminate the concern about the number of nurses who will be retiring soon and
the need for replacement. Approaching the problem only from the point of view of getting the “right”
number of nurses is not helpful. Since it will probably not be possible to get the number of nurses
desired, other strategies will be needed to change how nursing care is provided to reduce the number of
nurses required.

5. Restructuring Nursing Education When restructuring nursing education is discussed, there are two
critical focus areas. The first is academic education, and the second is continuing education for nurses
who are practicing. Nursing education must make curriculum changes to prepare nurses to meet current
and future healthcare needs and work more collaboratively with practice partners (Finkelman & Kenner,
2007). Several recent reports emphasize the need for change and improvement such as the IOM report
Health Professions Education (2003) and the newest report on nursing education, Educating Nurses: A
Call for Radical Transformation (Benner, Sutphen, Leonard, & Day, 2010). Beverly Malone, chief
executive officer for the National League of Nursing, comments on this nursing report: “This book
represents a call to arms, a call for nursing educators and programs to step up in our preparation of
nurses. This book will incite controversy, wonderful debate, and dialogue among nurses and others”
(Benner et al., 2010, back cover). The report is all about change: change in the delivery of health care
and the practice of nursing that drives critical need for change in nursing education. The IOM report also
emphasizes need for change and five core competencies that all healthcare professions should meet.
These five core competencies are also emphasized in the newest edition of the Essentials of
Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing,
2008) and The Essentials of Masters in Nursing (2011). The importance of the consumer as a significant
player in the healthcare environment, emphasizing patient-centered care, must be part of this
preparation. However, this is not new to nursing education; nursing has always emphasized the
importance of the patient’s role. Understanding the interplay of values, motivations, and incentives of
the major players or stakeholders in health care, including insurers, providers, purchasers of health care,
and consumers, helps nurses understand the healthcare culture in which they practice. Stakeholders
sometimes have competing interests that affect decisions. Healthcare markets continue to change,
which means nurses at all levels need to be aware of these changes and know how to react positively to
change and, in many cases, even anticipate it. Understanding the reasons healthcare delivery has
become more business oriented and knowing its effect on nursing practice is also important. Today
there is a greater emphasis on service, innovation, cost effectiveness, and customer service. To be
successful in the increasingly business-oriented healthcare environment, nurses need to be flexible.
Nurses do need to have some understanding of the impact of costs on care and recognize that they have
a fiscal responsibility. They should be active in trying to reduce costs whenever possible and to better
explain the impact nursing care has on cost of care. Lack of understanding about this responsibility is no
longer an acceptable reason for not participating in reducing costs. All nurses need to be prepared to be
leaders as well as team members. In addition, education needs to provide more content and learning
experiences that assist students in developing leadership competencies. All of these needs require a
review of nursing curricula and nursing practice to better prepare nurses for practice. The second area of
concern about nursing education is the need for continuing education. All nurses need to be lifelong
learners. Practice should be based on current knowledge. Not only is current information needed, but
there also needs to be opportunities to understand and apply the knowledge. Staff education and
continuing education is discussed in more detail in Chapter 20.