400846 Building Organisational Capacity in Health Care School of Nursing and Midwifery | Autumn 2017 LEARNING MODULE 2 Postgraduate ⦁ ⦁ Table of Contents Table of Contents 2 Table of Essential Readings 3 Additional Readings Module 2 4 Table of Activities 5 Module 2. Organisational capacity building, workforce development and change management 6 2.1. Introduction 6 2.2. Objectives 6 2.3. Leadership, adaptive organisational cultures and change 6 Leadership or management? 8 Leadership Theories 9 Leadership and Change 10 Clinical Leadership 11 Types of change, forces for change and resistance to organisational change 11 Change Management 13 2.4. Organisational capacity building and workforce development 15 Organisational development 16 Capacity building 17 This reading discusses the links between organizational performance and Schein’s (1997) theory which identifies culture as the beliefs and values of the group as a whole, providing the framework for the functioning of the group. 25 References for Module 2 26 ⦁ Table of Essential Readings MODULE 1 Introductory reading McGovern, G. (2014). Lead from the heart. Harvard Business Review. March………………………..7 Reading 2.1 10 Sarros, J.C., Cooper, B.K., & Santora, J.C. (2008). Building a climate for Innovation through transformational leadership and organisational culture. Journal of Leadership & Organisational Studies, 15, (2), 145-158. 10 Reading 2.2 14 Foltin, A. (2012). Leading change with emotional intelligence. Nursing Management. November 14 Reading 2.3 15 Yukl, G. L. (2013). Leadership in organizations (8th ed.).Boston: Pearson 15 Reading 2.4 18 Crisp, B.R., Swerissen, H. & Duckett, S.J. (2000). Four approaches to capacity building in health: consequences for measurement and accountability. Health Promotion International, 15, (2), 99-107. 18 Reading 2.5 19 Heward, S. Hutchins, C. & Kelleher, H. (2007). Organizational change- Key to capacity building and effective health promotion. Health Promotion International. 22(2). 19 Stanley, D. (2011). Clinical Leadership. South Yarra: Palgrave McMillan, pp 118-145 24 Reading 2.7 24 Kotter, J.P. & Schlesinger, L.A. (2008). Choosing strategies for change. Harvard Business Review, 86, (7/8), 130-139. 24 Reading 2.8 25 Jacobs, R., Mannion, R. Davies, H.T.O., Harrison, S. Konteh, F. & Walshe, K. (2012). The relationship between organizational culture and performance in acute care hospitals. Social Science & Medicine, 76, 115-125. 25 ⦁ ⦁ Additional Readings Module 2 Casali, G.L. & Day, G.E. (2010). Treating an unhealthy organisational culture: the implications of the Bundaberg hospital inquiry for managerial ethical decision making. Australian Health Care Review, 34, 73-79 Dignam, D., Duffield, C., Stasa, H., Gray, J., Jackson, D. & Daly, J. (2012). Management and leadership in nursing: an Australian educational perspective. Journal of Nursing Management. 20. 65-71. Downey, L., Roberts, J. & Stough, C. (2011). Workplace culture, emotional intelligence and trust in prediction of workplace outcomes. International Journal of Business Science and Applied Management, 6(1), 30-40. Duffield, C., Kearin, M. & Leonard, J. (2007). The impact of hospital structure and restructuring on the nursing workforce. Australian Journal of Advanced Nursing, 24, (3), 42-46 Gill, R. (2003). Change management or change Leadership? Journal of Change Management, 3(4), 307-18. Kim, J.H., Kim, C.S., & Kim, J.M. (2011). Analysis of the effect of leadership and organizational culture on the organizational effectiveness of radiological technologists’ working environment. Radiology, 17, 201-206. Kotter, J.P. (1995). Leading change: Why transformation efforts fail. Harvard Business Review. March. ⦁ Table of Activities Activity 2.1 15 Activity 2.2 15 Activity 2.3 18 Activity 2.4 23 Activity 2.5 25 Activity 2.6 25 ⦁ Organisational capacity building, workforce development and change management ⦁ Introduction Change is one thing that is constant in our lives. It impacts on our personal, professional and social lives and brings with it a need for us to make many critical decisions. In the past, change often occurred incrementally but in our modern world, it is just as likely to be radical, with new organisational missions and strategies, structures and pressures on workplace cultures to change and adapt more quickly. To successfully lead and manage change requires vision, courage, innovation, effective communication and a clear plan (Kotter, 1995; Kotter & Schlesinger, 2008; Stanley, 2011). Organisations today require excellent managers who also have the qualities of a transformation leader who can work through influence to achieve organisational goals. Change is not something to be entered into without thought and planning and it is useful to have an understanding of the different theories and models of change that can provide a framework for action. A major part of change management is organisational development and the building of organisational capacity for change by providing the structures, resources, leadership and workforce development to enable the organisation, teams and individuals to learn and plan and implement improvements. This module covers aspects of leadership and change in organisations; types of change, forces for change and resistance to change; change management, organisational development, capacity building and workforce development. A brief overview of concepts related to the learning organisation and managing conflict, power and politics in health care organisations is provided. It is not possible to cover all of these topics in great depth however supplementary readings and additional readings are provided in many areas for those who wish to read to more depth in specific areas of interest. ⦁ Objectives On completion of this module students will be able to: ⦁ Discuss models and strategies used in effective change leadership and their application to the health care environment. ⦁ Examine models of workforce development used in organisational capacity building in the health care sector. ⦁ Leadership, adaptive organisational cultures and change Reading: Introductory McGovern, G. (2014). Lead from the heart. Harvard Business Review. March. Read Gail McGovern’s Lead from the heart article which demonstrates the way in which teams and individuals adapted to serious internal and external pressures for change and the process used by McGovern to achieve that change. As leaders and managers in health care organisations, it is important to understand how people react to change and what leadership skills are required to successfully implement change – be it incremental change of policy at ward level or organisational change on a grand scale. Many people become ‘change weary’ when they cannot see the purpose or the benefits of proposed change programs either for themselves or for the organisation. It is important to remember that: ‘Real change... is intensely personal and enormously political’. (Nadler & Nadler, 1998 as cited in Johnstone, Dwyer & Lloyd, 2006, p. 163) Whenever change is contemplated it is important to consider the purpose of the change, who will be affected by it and what the likely response will be from those involved. The following quote shows the general reaction to the mention of the need for change: I can’t make the effort that’s needed to bring about effective change if I am not convinced it is necessary. The same is true of all staff in the organisation. What framework can help me share an understanding of why change is needed? (NHS, 2001, p.11) In a document called ‘Managing change in the NHS’ (NHS, 2001) it is recommended that the following questions be asked before any change is contemplated: ⦁ What is the purpose of the change? ⦁ Who benefits from the change? ⦁ Who has identified the need for the change? Following on from these questions about the change in question are a number of questions that leaders and change agents need to ask themselves. Those questions according to the NHS (2001) are: ⦁ What do I know about effective change management? ⦁ What don’t I know? ⦁ What do I need to know in order to initiate and sustain effective change? ⦁ Where can I look for evidence, further information and help? For example, should I be thinking about people, published resources, learning networks? (Managing change in the NHS, 2001) That document also provides a number of frameworks for change and provides references to a number of resources. The document is not provided in the Study Guide but a link is provided in the Additional Readings for Module 2 at the end of this Module. According to Hohne (2006, p.122) ‘The largest obstacle that a leader faces in moving others to achieve greater results is an inability to understand and improve their own leadership style’. Undertaking an assessment of our own leadership and management abilities gives us a starting point for understanding where we need to grow and develop in order to successfully lead change. Rapid change is often seen as a threat, but Porter-O’Grady and Malloch (2002, as cited in Daly, Hill & Jackson ,2014) suggest that, as leaders, we need to be proactive, anticipate the need for change and see it as the next part of our professional journey. ⦁ Leadership or Management? What knowledge, skills and attributes do we, as leaders, require in this constantly changing world? The concept of leadership in health care is not a new one but in recent times, health care systems across the world have felt the impact of change and reform and organisations have begun to look for ‘leaders’ who can help refocus the organisation, lead change, build teams and deliver evidence-based, patient-centred care. While it is true that we have many very good managers in health care today, increasingly their roles are taking them away from the bedside into the demanding domains of operational, financial and human resource management and to counter this, the concept of clinical leadership is being addressed to provide much needed leadership at the point of care. Many senior clinicians undertake management courses to help them prepare for operational, financial and human resource management roles within the health system but those courses often do not do so well at preparing people to lead other people in very complex organisations and systems. According to Antrobus and Kitson (1999) we provide Health care managers and senior clinicians with development programs, however, those programs often emphasise the corporate and political skills required in the current environment to the detriment of practice knowledge and leadership. These development programs often completely ignore the manager/clinical leaders’ need for the development of critical skills related to practice development and change – leadership, self-management and personal reflection, appraising evidence, clinical decision-making, and understanding the impact of context and culture on outcomes (Kitson, 2002). In other words, we have effectively turned out very good managers, but have not necessarily included the development of skills that ensure successful ‘leadership’ in its broadest context. There continues to be debates about whether leadership and management are the same thing or different, although there is broad agreement that both are required for organisations to thrive and prosper. Is leadership one of management’s broad functions or is management one of the roles of a leader? According to Marquis and Huston (2015, p. 31) ‘...if a manager guides, directs and motivates and a leader empowers others then it could be said that every manager should be a leader’. A number of authors have tried to differentiate the roles and functions of leaders and managers. The following lists are compiled from the work of Kotter (1990): Table 2.1 Summary - Leadership and Management Leadership: ⦁ Vision, goals, change ⦁ Aligning people ⦁ Motivating & Inspiring ⦁ Produces positive & sometimes dramatic change Management: ⦁ Plans and budgets ⦁ Organising & staffing ⦁ Controlling, problem solving ⦁ Produces order, consistency, predictability If you compare these two lists you can see that if good management is in place the organisation (or ward or department) would run smoothly, there would be order, consistency and life would be predictable – which of course is the way many people like to work. Unfortunately such an organisation may not be very flexible or adaptable in response to the need for change and consequently may not be a very satisfying place to work for people who like change and challenge. If you look at the leadership list, you can see that leadership without management may result in chaos and failure of the organisation to achieve its goals and objectives because of a lack of planning and control (Marquis & Huston, 2015). Clearly, organisations need good managers who also have strong leadership attributes and skills. Clinical leaders at the bedside also require strong management skills to provide efficient services. The Manager/leader needs to have a vision of what the organisation (the health service, the hospital, the ward or unit) and what the services will need to look like in the future - what needs to change and improve to meet the challenges of the changing health care environment - and then we need those leaders to provide the conditions, expertise and support necessary to motivate the team to achieve those goals. The real leadership issues are related to developing, motivating and leading teams to bring about change and achieve goals for the patients, the individuals themselves and the organisation. According to Rear-Admiral Peter Sinclair a naval leader and former Governor of NSW these concepts can be brought together: Management is about methods and procedures…cost effectiveness and the optimum use of resources. Leadership…is an art acquired through observation, practice and experience. It is the art of influence and is about human relationships, motivation, encouragement, inspiration and vision…. (cited in Hirsch, 2000). ⦁ Leadership Theories The following section briefly explores some of the leadership theories and how they have evolved over time. Research into leadership continues to expand and many different theories and types of leadership are postulated in the literature including the ‘Great Man’ theory, trait theory, behavioural theories, situational and contingency leadership theories and the interactional leadership theories including transactional and transformational leadership. More recent literature talks about different types of leadership such as servant leadership, authentic leadership, breakthrough leadership and of course the health literature talks about ‘clinical leadership’. Early leadership theorists attempted to explain leadership on the basis of inherited characteristics, or personality types that resulted in particular leadership behaviours. We have all heard of those who are ‘born to lead’ and can name a number of world leaders that might fit this bill. Proponents of these theories have developed lots of psychological tests of personality traits and lists of behaviours that are said to identify people who have the ‘leadership traits’ although the research is equivocal. The studies have identified a large number of traits associated with successful leaders, but there doesn’t appear to be any consensus on what the essential traits that make a good leader. There is not a lot of evidence that supports the notion that someone who has particular traits will make a good leader. The behavioural theorist movement moved away from traits and placed an emphasis on leadership behaviours and styles (Marquis & Huston, 2015) and moved away from describing the personality traits. Contingency and situational leadership theories began to identify the complexity of the workplace and the relationship between the leader, the team and the situation at hand, rather than just concentrating on the leader’s traits and behaviours (Maquis & Huston, 2015). According to these theories there is not one leadership style is suitable for every work situation or work group and a good leader will have the ability to adopt a different leadership style depending upon the type of work, the relationship with, and the skill level of the people in the work situation. In these theories you can see a shift from an emphasis on characteristics or traits of the leader, to recognition of the role that leader/follower relationships play and the importance of the commitment and maturity of the followers in this relationship. In an emergency a leader might act in an autocratic manner and become quite directive in relation to what needs to be done. The same leader may well employ a very inclusive and participative style when working with a team to implement a new policy. In the late 1980s and the 1990s attention turned to interactional theories of leadership. In these theories there is a movement from the notion that leaders are born to lead (that they have particular traits) towards theories that support leadership as a group interaction process. Interactional leadership is about relationships – the relationship between the leader’s … personality, perceptions and abilities, the follower’s with their personalities, perceptions and abilities …and … the situation within which the leader and the followers function… (Maquis & Huston, 2015, p. 53). Within the interactional leadership theories Burns (2003, cited in Marquis & Huston, 2015) identified two types of leader within the ‘management role’. The transactional leader role reflects the management functions related to the day to day operations of setting goals, giving directions and maintaining control in the work environment. The transformational leader role relates to the ‘manager’ who is committed, has a vision about how practice and services can be improved and then is able to motivate and empower people to bring about that change (Marquis & Huston, 2015). You can see that in an efficient, effective and adaptable organisation – you would need both transformational and transactional leadership attributes in the managers. ⦁ Leadership and Change In much of the literature transformational leadership has been seen to be the appropriate type of leadership where change is required, particularly when the strategy requires a change in organisational culture so that it can become a more flexible, adaptable and innovative culture with a focus on continuous improvement to meet customer need. The following reading provides an overview of the linkages between transformational leadership, organisational culture and change and performance improvement. It reports on a survey of managers about leadership, culture and change in the competitive, performance-oriented private sector in Australia. Although it is not a health related reading it brings together many of the concepts discussed above. Reading 2.1 Sarros, J.C., Cooper, B.K., & Santora, J.C. (2008). Building a climate for innovation through transformational leadership and organisational Culture. Journal of Leadership & Organisational Studies, 15 (2), 145-158. This reading introduces the concept that articulating a vision is a major feature of transformational leadership and it is strongly related to organisational culture and innovation. The major finding is: ...that transformational leadership is associated with organizational culture, primarily through the processes of articulating a vision, and to a lesser extent through the setting of high performance expectations and providing individual support to workers. (Sarros et al., 2008, p.155) People need to be able to see the ‘vision’, be able to contrast the present with the future, understand and embrace the new direction. Strong transformational leadership is the key to successful change management. ⦁ Clinical Leadership We need managers who are good leaders and leaders who can manage resources but overwhelmingly need clinical leaders who have a vision for person-centred care, who can motivate and encourage others to change and improve their practice are what are required. Managers usually have a formally appointed position within the organisational structure. They have the power and authority to mandate change but of course, that does not guarantee successful change. Leadership can be more informal and much of the health care improvement literature now refers to the need for ‘clinical leadership’ to come from anyone who has direct responsibility or influence on patient care at ward, unit or team level (RCN of the United Kingdom, 2004). A great deal has been written about clinical leadership in health care. According to Ham (2003) it is the front line clinicians who have the greatest power to drive change or, on the other hand, to subvert a change management process. They have credibility with their peers and are able to educate, influence, persuade and motivate people to make change – or to resist change. Expert clinicians are in the perfect place to lead change and the improvement process in clinical care. According to Siriwardena (2006) clinical teams led by clinicians who are close to the patient and point of care, and supported by the organisation, are critical to any organisational change and improvement process. Many health services and organisations now offer leadership development programs to senior clinicians in all discipline areas, to help them develop the leadership skills and strategies needed to lead change and service improvement. Further references to readings on leadership and clinical leadership are provided in Additional Readings for Module 2. ⦁ Types of change, forces for change and resistance to organisational change In health care organisations, there are many forces for change and many factors which restrain or resist change. Change may be driven by: ⦁ Political forces such as changes in government, the health authority, health insurance companies ⦁ Economic forces with changes in funding formulae, sources of funding or overall fiscal policy or circumstances ⦁ competition, particularly in relation to private health service providers ⦁ global forces such as international disasters, trade agreements impacting on the availability and cost of technology and drugs, migration ⦁ demographic and social changes within the population serviced by a particular organisation and changes in workforce demographics and available ⦁ technological advances that change the way services are provided or the setting in which they are delivered Restraining forces can also include many of those mentioned above including political, economic, global, demographic and social changes. Resistance to change can be felt at the level of the organisation, the ward or department, the team or at the individual level (Jones, 2007; Johnstone, Dwyer & Lloyd, 2006). Change may be incremental (also referred to as evolutionary or transitional) where processes are continually adjusted in order to try to improve the performance at department or division level without impacting on the equilibrium of the organisation as a whole. According to Lewis (2008) few people are satisfied with the status quo. The difficulty is that change in health care is usually done in small, incremental steps where a system or a process might be changed at ward or department level but performance is not necessarily improved. This type of change often addresses a symptom of the problem but not the problem itself. To be effective, these changes must integrate with other changes across the organisation. One example might be the improvement in technology in one department that will then flow on to other departments in order to achieve greater levels of productivity across the organisation (Johnson, 2009; Daft, 2007). Transformational change (also known as revolutionary or radical change) is associated with organisation-wide change and transformation. It may result from a change of government or a change of ownership and could be in the form of mergers (for example the merger of Area Health Services to form fewer, larger health services), a radical change to the organisational structure (from vertical to horizontal) and the management processes that go with that new structure, or a change in the type of services provided (Johnstone, Dwyer & Lloyd, 2006). For example a facility might change from a small district, acute hospital to a rehabilitation centre because of changes in population and funding. Lewis (2008) says that small change is just as disruptive as large scale, transformative change but that the time is right now for transformative change in the health sector. Health care workers have never been more highly educated and specialised in their roles, technology and information systems are highly developed and there is strong evidence of the need for change in many areas of health care provision. The issue is that the transformation needs to ‘occur first in the mind’ (Lewis, 2008) and it has to be central to everyone’s agenda (the frontline staff through to the Executive and consumers) for it to be successful. Some organisational cultures can be resistant to change and create difficulty for the leader when they want to implement change and/or practice improvement. Prior to contemplating any organisational change it is important for leaders to think about the organisational culture and make an assessment of how likely it is that the culture will be supportive of the change and be able to adapt to the new circumstances. Strong adaptive cultures, according to Daft (2007, p. 373) display the following values; ⦁ The whole is more important than the parts and boundaries between parts are minimized. ⦁ Equality and trust are primary values. ⦁ The culture encourages risk taking, change and improvement. Kee and Newcomer (2008, p.69) recommend that leaders ask the following questions to assess the readiness for organisational change: To what extent: ⦁ Does the culture support a systems view of issues and problems and encourage different ways of thinking about those issues and problems? ⦁ Does the culture reinforce team learning and cross team collaboration? ⦁ Is the culture supportive of risk taking and innovation? ⦁ Does the culture promote creativity and change through supportive feedback, recognition and rewards? ⦁ Are power and influence in the organisation determined by personal attributes and skills rather than position? ⦁ Are employees personally committed to the organisation’s mission? ⦁ Are employee’s comfortable challenging existing traditions, norms and values? ⦁ Do employees share ideas for improving the quality of their work? ⦁ Do organisational norms and processes support a learning culture? ⦁ Does the culture support a democratic approach to decision-making? If you answered ‘yes’ to most questions the culture is more likely to be one that is supportive of change efforts (Kee & Newcomer, 2008). However, if most of your answers are in the negative, then maybe as leader, you need to pay more attention to the workplace culture prior to thinking about the change initiative. Remember that culture change occurs over time and so the leader may need to address the aspects of the culture that are related to promoting the status quo and resisting change (Kee & Newcomer, 2008). As Johnson (2009) suggests the goal should be that change is not seen as an initiative or a project but as a continuous cycle of improvement that has no actual beginning, middle or end. To quote Johnson (2009, p. 295) ‘the objective being to create a learning organisation, that continually reinvents itself, based on external and internal forces’. This of course requires an adaptive organisational culture – one that welcomes and thrives on change; one that values people and processes that constantly create useful change. ⦁ Change Management Health care organisations still experience difficulties in designing and implementing successful change strategies (Johnson et al., 2006). Most successful change strategies are based on proven theoretical frameworks or models for change. These theories and models help leaders and change agents anticipate resistance and choose from a number of techniques to address the concerns that have led to the resistance and bring about sustainable change. According to Johnson (2009) one of the most common approaches applied to a model of change is “the rational model, which focuses on planning, problem solving and execution’ (p.295). One change theory that is commonly cited in the health care literature is Lewin’s three-stage change process. While there are a number of criticisms of this theory because it is linear in nature (and the health care is complex and unstable and managers need to be flexible and adaptable if change is to succeed) it still provides a clear outline of stages of change that need to be considered, including unfreezing, moving and refreezing (Cummings, Bridgman & Brown, 2016). Lewin’s model provides a ‘picture’ of the change process. It suggests that in some way the organisation (or the people) need to have the current reality challenged or threatened by external forces in order for people to become aware of the need for change and begin to ‘unfreeze’. In the ‘movement’ phase change is planned and communicated and people are engaged in the change process. In the third stage the change is consolidated, integrated into the system and underpinned by resources and support. This is said to be the ‘refreezing’ stage (Marquis & Huston, 2015). Lewin is also credited with the force-field analysis model that can be used to analyse the forces for and resistance to change prior to initiating a change process (Johnson, 2009). Reflection Think of a change that you have recently been through in your work environment. ⦁ What was the impetus (or driving force) for the change? ⦁ How was that change communicated? ⦁ Was there a clear plan for the change and could people see the benefits? ⦁ Do you have any suggestions for how the change process might have been improved? There are many different theoretical approaches to, and model for change in the literature and different authors use different theories to explain their world view. Johnson (2009, p.295) provides the following activities that are commonly associated with effective change management, whatever the theory. The activities include: ⦁ Motivating change ⦁ Creating readiness for change ⦁ Overcoming resistance for change ⦁ Creating vision ⦁ Mission ⦁ Vision ⦁ Valued conditions ⦁ Midpoint goals ⦁ Developing political support ⦁ Assessing change agent power ⦁ Identifying key stakeholders ⦁ Influencing stakeholders ⦁ Managing transition ⦁ Activity planning ⦁ Commitment planning ⦁ Management structures ⦁ Sustaining Momentum ⦁ Providing resources for change ⦁ Building a support system for change agents ⦁ Developing new competencies and skills ⦁ Reinforcing new behaviours Remember while this looks like a linear process, change rarely occurs in a straight line as originally planned. As a leader planning change you may have a good plan, you motivate your staff and get them engaged, agree on the mission, vision and strategies and then become aware that politically there are one or more stakeholders who will not support the plan. It may be that you can work through influence to get those people on board to support the change or you might have to go back to the beginning, revise your plan and start working with staff again. It is always a good strategy to get the key stakeholders involved in any change proposals early so you know that you have support. Johnson (2009) sounds a note of caution – just because the change management process is followed through in detail, there is no guarantee that behavioural change will occur, or if it does – that it will be maintained over time. Consistent leadership communication, support and adequate resources will help in the process to transform the organisation and sustain the change over time. Reading 2.2 Foltin, A & Keller, R. (2012). Leading change with emotional intelligence. Nursing Management, 43 (11), 20-25.r Consider the domains of emotional intelligence and why it might be an advantage for a leader to possess these attributes when working with health industry groups to develop a flexible and change-ready workplace. Activity 2.1 ⦁ Consider your level of emotional intelligence. Do you have any of the identified attributes? ⦁ Can you think of leaders in your workplace who have any of these characteristics? Activity 2.2 Think of a clinical practice issue that may need to be changed in your own sphere of practice. Think about the following questions: ⦁ Why is change required? What has prompted you to think about this issue? ⦁ Who are the important stakeholders that will need consulting? ⦁ What barriers to change do you anticipate? ⦁ How would you get people involved in the decision-making and the change process? ⦁ What steps are required to ensure success with this change management process? ⦁ How will you embed the new practice to ensure that the change is sustained? Reading 2.3 Yukl, G. L. (2013). Leadership in Organizations (8th ed.).Boston: Pearson This chapter describes leadership types and attributes. The leadership types and their behaviours are discussed and you are asked to consider the types of leadership styles and behaviours you have experienced and how these differing leaders affected the workplace. ⦁ What style of leader would you prefer to have? ⦁ If there were workplace changes to be planned and implemented, what type of leader do you think might be better able to achieve sustainable outcomes? ⦁ Explain why this type of leadership may be preferable and why others might not be as suitable. ⦁ Organisational capacity building and workforce development The health care industry is subject to continuous change in response to many internal and external factors and the speed of that change appears to be accelerating. Economic and political conditions, consumer demands, technological advances, difficulties in recruiting and retaining health care professionals and many other factors continue to put pressure on health systems across the world. Consistent with this continuous state of change is the need for health care to transform, restructure and find new ways of meeting the demands of the key stakeholders (Johnson, 2009). In organisations like health care and community services planning for any reform, change or performance improvement strategy needs to include a number of important strategies and conditions. According to Ham (2003) these include: ⦁ engagement of the clinicians who will be the key to bringing about the changes ⦁ development and strengthening of clinical leadership ⦁ the development of the capacity of the workforce including resources, time, information and skills training ⦁ the provision of policies, systems, processes and resources to support the change In most health authority strategic planning documents the strategic statements and goals include priorities related to both improving performance and capacity building. For example: ⦁ NSW Health State Health Plan (2007) ⦁ Make prevention everybody's business ⦁ Create better experiences for people using health services ⦁ Strengthen primary health and continuing care in the community ⦁ Build regional and other partnerships for health ⦁ Make smart choices about the costs and benefits of health services ⦁ Build a sustainable workforce ⦁ Be ready for new risks and opportunities. The ability of organisations and individuals within those organisations to initiate, lead and sustain change into the future must be underpinned by a management focus on approaches to organisational development and capacity building that are closely tied to ‘the mission, vision, culture and strategy’ of the organisation (Johnson, 2009, p.296). ⦁ Organisational development Organisational development is defined and operationalised in a number of ways by different authors in different fields. Garside (1998, p. S8) defines organisational development as: ... a field of applied behavioural science focused on understanding and managing organisational change”. Organisational development usually refers to an organisation-wide change process which is sponsored, planned and managed from the top down to increase organisational effectiveness and efficiency (Garside, 1998). A more detailed definition of what this process entails is provided by Impact Alliance which defines organisational development (OD) as: The term used to capture the variety of processes and systems used to understand and change the beliefs, attitudes, values, structures, and relationships of organisations. Through these processes, organisations become better placed to adapt to changes in their environment, and respond to new opportunities. In Module 1 organisational development (by this definition) is almost exclusively about understanding the workplace culture and the structures, systems and processes that underpin that culture, and through working with those structures, systems and processes helping the organisation become more adaptable to change. Another way of defining organisational development is to say what is included in the process. According to Dawson et al. (1995, as cited in Garside, 1998, p. 58): Organisational development includes making changes in: job descriptions; decision making processes and arenas; shape, size, and nature of groups and departments; managerial style; work organisation; quality programmes; mechanisms for reporting and exercising accountability; human resource management practices. Essentially this explains organisational development as ‘reorganisation’, making major changes to structures, systems, processes, ways of working, measurement systems, lines of reporting and accountability and management practices throughout the entire organisation. According to Huntington, Gillam and Rosen (2000) there are four aspects of organisational development that are particularly important and they are culture change, skill development, structural change and the development of effective leadership. Johnson (2009) recommends that the organisational development process begins with an assessment of aspects of the organisation that impact on its performance and ability to change. This includes an assessment of the organisational structure and culture, the learning and development needs of the staff and the human dynamics and relationships across the organisation. The data from this assessment forms a starting point for the development of the organisation in relation to where it is at present, and where change and improvement is required to reach its vision, mission and strategic goals for the future. While organisational development is generally said to be a top-down approach to change and improvement it relies on gaining trust and commitment from the staff, consulting widely, planning and empowering people to make the changes and improvements required. Generally it is felt that a both a top-down and a bottom-up approach is necessary to bring about sustainable change and development. It requires leadership, structures, processes, resources and learning and development – the building of capacity for the changing health care environment. ⦁ Capacity building Reference to ‘capacity building’ began appearing in literature related to international aid, community development and building capacity in developing countries (Crisp, Swerissen & Duckett, 2000) however it has now become more broadly associated with organisational development and the building of capacity for change and improvement in general. Eade (1997) writing for Oxfam, provided the following definition: ‘Capacity building is an approach to development. It is a response to a multidimensional process of change, not a set of discrete or pre-packaged technical interventions intended to bring about predetermined outcomes. In supporting organisations working for social justice, it is also necessary to support the various capacities they require to do this: intellectual, organisational, social, political, material, practical or financial (Eade, 1997, p.24) In Australia Penny Hawe and colleagues wrote about capacity building, particularly in relation to health promotion. They address the issues of how to develop organisations and infrastructure to underpin health promotion; how to develop individuals so that they have the knowledge and skills to deliver the interventions aimed at promoting health, and how to develop communities to ensure that the health promotion strategies are sustainable and health outcomes are improved. They define capacity building as: Developing sustainable skills, organisational structures, resources and commitment to health improvement in health and other sectors... [to] prolong and multiply health gains many times over. Capacity building not only can occur within programs, but also more broadly occurs within systems and leads to greater capacity of people, organisations and communities to promote health. This means that capacity building activity may be developed with individuals, groups, teams, organisations, inter-organisational coalitions, or communities (Hawe, King, Noort, Jordens & Lloyd, 2000). This definition explains capacity building as much more than just training and development of staff. It includes three main aspects: ⦁ the development of staff through on the job training, technical skills training, access to information, leadership and management development, clinical supervision, mentoring and support, formal education and courses and other areas of personal and professional development. ⦁ Organisational development or redevelopment, as discussed above and including networking and the building of relationships within and across different sectors (for example between the acute hospital setting and aged care organisations or non-government organisations providing services to the same client groups). ⦁ Improved institutional governance and legal and financial framework development to enable organisations to enhance their ability to change and improve. (Urban Capacity Building Network; Alliance for Non-profit Management) Activity 2.3 Think of a clinical practice issue that may need to be changed in your own sphere of practice. Think about the following questions: ⦁ Why is change required? What has prompted you to think about this issue? ⦁ Who are the important stakeholders that will need consulting? ⦁ What barriers to change do you anticipate? ⦁ How would you get people involved in the decision-making and the change process? ⦁ What steps are required to ensure success with this change management process? ⦁ How will you embed the new practice to ensure that the change is sustained? Reading 2.4 Crisp, B.R., Swerissen, H. & Duckett, S.J. (2000). Four approaches to capacity building in health: consequences for measurement and accountability. Health Promotion International, 15, (2), 99-107. This reading defines capacity building and provides an overview of four different approaches to capacity building. Those approaches include the top-down approach, the bottom-up approach, the partnership approach and the community organising approach. Approaches to measuring capacity building are discussed and questions asked about how short-term funding for capacity building ‘projects’ can bring about systematic change. In the health care system, Hawe et al. (2000) contend that capacity building refers to at least two things: ⦁ Building capacity to deliver specific services or address specific problems within the usual or familiar organisational situation. For example reference is made to developing the capacity to set up a Pap smear service where specific skills and accreditation is required as well as new procedures, supporting management structures and infrastructure such as equipment and premises are required. ⦁ Building capacity of a more general nature (including aspects of service and team development, leadership development and workforce development) and preparing the health care systems to be able to solve new problems and respond to unfamiliar and complex situations. With outbreaks of infectious diseases such as SARS and natural disasters such as the tsunami, cyclones and fires, much work has gone into capacity building at local, national and international level to deal with these very new and complex situations. As discussed above, capacity building is commonly seen at a number of levels including at the level of: ⦁ the individual (to learn specific skills required in the workplace e.g. health promotion) ⦁ the ward, department or team level (to improve teamwork, communication and project management skills to change and develop practice) ⦁ the organisational (to respond to changes in the environment, and ⦁ health partnerships, coalition or communities This is not a simple task and it will need consideration of the context in which the capacity building is taking place as well as strategic actions such as organisational development, workforce development, resource allocation, leadership and partnerships. Reading 2.5 Heward, S. Hutchins, C. & Kelleher, H. (2007). Organizational change- Key to capacity building and effective health promotion. Health Promotion International. 22(2). This reading links a community health promotion change process tightly to capacity building within the sector. The focus here is that capacity building is essential to ensuring that any workplace is able to work its way through the hurdles of change strategies. The three case studies may help you to apply these principles in your own workplaces. Capability development, according to Tertiary and further education (TAFE) NSW, is the development of individuals or teams so that they have the knowledge, skill, attributes and confidence to achieve current organisational goals, but they also know how to learn to meet future organisational challenges and to build capacity for change (TAFE NSW Training and Education Support, Capability Development). In general the terms ‘capacity’ and capability’ appear to be used interchangeably in many contexts. This section has covered capacity building in general. Capacity building is a term that is often used in relation to areas like health promotion, public health, indigenous health, alcohol and other drugs or in relation to new services or contexts of care. Traditionally is it difficult to get staff with the right skill sets in many of these areas plus they need additional skills such as health promotion and community development skills to ensure sustainable change within the communities in which they work. Within the acute health sector capacity building is seen as a way to deal with the constant change that is occurring. According to Leggat, Harris and Legge (2006) the rapid change and unpredictable nature of health care today can be addressed to an extent, by capacity building and organisational learning. Sometimes the term ‘capacity building’ is used interchangeably with ‘workforce development’ although according to NCOSS (2007) while there is an interdependence of all these systems within organisations; ‘workforce development’ is really a component of capacity building. ⦁ Workforce Development The human resources (HR) or the ‘people management’ aspects of the leadership role have always been recognised as crucial to the ability of an organisation to deliver its services in an effective and efficient manner. Health care is of course a very labour-dependent service with workforce costs making up a large proportion of the total health budget (Isouard, Stanton, Bartram, Thiessen & Hanson, 2006). The workforce is also unusual in that it is ‘highly professionalised, specialised, largely tertiary educated and strongly unionised’ (Isouard et al., 2006, p. 115). With a major focus of most reforms in health care concentrating on cost containment the health workforce often comes under scrutiny as an area for savings (Buchan, 2000). There is recognition that a motivated and appropriately skilled workforce is crucial to the success any organisation and ‘that getting HR policy and management "right" has to be at the core of any sustainable solution to health system performance’ (p.2). The many changes in the health care environment and the subsequent reform and restructure of health care organisations that has been spoken about above increasingly puts pressure on health care leaders and managers to think more strategically in terms of how human resources are organised and developed for these changing circumstances. Roche (2000, p.6) makes the point that many things within the organisation impact on the effectiveness of work practices and they include: ⦁ education, training and workforce development strategies which address knowledge, attitudes and skills ⦁ support strategies for skills and knowledge (e.g. information systems, mentoring, discussion opportunities, research ⦁ strategies to effect workplace structure and policy (e.g. incentives, performance monitoring systems, job specifications, resource allocation, management priorities). These are the areas that need to be targeted if workforce development in its broadest sense is to be effective. In order to be effective, workforce development must focus on: ⦁ the needs of the consumer of the services ⦁ the organisation itself and the environment it is operating in ⦁ the vision, mission and strategies of that organisation and how they impact on the individuals and teams providing care, and ⦁ the broader industrial and community environments influencing the system (Staron, 2008; NCOSS, 2007). Until recently ‘workforce development’ (which may also be called human resource development or HRD) was often equated to education and training with a focus on the development needs of individual workers (NCOSS, 2007). Increasingly research has shown that there is a need for organisations to have a much higher level, strategic focus on the human resources aspects of the business. This strategic focus brings together concepts such as workforce planning, human resource management and workforce capability or capacity development at a systems level (the systems may be national, state or territory level, or at the level of one organisation). Increasingly workforce development is being seen as ‘a broad, comprehensive and multifaceted focus on the entire system’ (Staron, 2008), rather than just a focus on HR. Workforce development as a term is used to describe a wide range of ‘activities, policies and programs’ that includes legislation, policy, funding, recruitment and retention, resources, support mechanisms and incentives’ (NCOSS, 2007, p.2). A definition of workforce development offered by Staron (2008) is as follows: Workforce development is a holistic concept that integrates workforce analysis and planning, human resource management and capability development to strengthen organisational success by aligning the workforce to both current and future service demands. In Australia the National Centre for Education and Training on Addiction (NCETA) has published a number of useful discussion papers, models and tool kits related to workforce development in that field. Many of the principles of that work can be transferred across the health and social care sectors. Roche (2000) contends that workforce development is about ‘systems, settings and people’ (p.6) and that in the field of Alcohol and Other Drugs (AOD) it has required a ‘sea-change of thinking’ about the AOD workforce and alcohol related issues and problems are managed at a system level, as well as at an individual level. NCETA (2005, p.2) agrees that workforce development requires a ‘major paradigm shift’. This means that leaders and managers need to stop thinking about training as the panacea for organisational problems and refocus on ‘organisational development, change management, evidenced-based knowledge transfer and skills development’ (p.2). Too often when something goes wrong, the manager arranges an in-service training session or sends staff members off to a course but neglects to consider whether it was a training issue or issues related to the systems, processes, resources or supervision and support that was needed by the individuals or teams carrying out the work. Workforce development is an evidence-based, multi-level, systems approach that impacts on a many aspects of work effectiveness (NCETA, 2005). Workforce development also needs to focus on removing or reducing barriers to efficient and effective work practices (NCETA, 2005). These barriers may include a slow and bureaucratic process for recruitment, a lack of funding to fill vacancies, a lack of staff to cover for training and development, poor access to information management systems and a work environment that is not conducive to learning, change and innovation. ⦁ Workforce Development Models Models are useful in providing a description of component parts of a system and their interrelationships and they may help explain or predict certain outcomes. In workforce development there are a number of models that bring together the ‘systems, settings and people’ (Roche, 2000) as an aid to leaders and managers who wish to improve their systems thinking in relation to organisational development, capacity building, workforce development and change management in health care. NCOSS (Community on Social Services of NSW) in a 2007 paper entitled Models of Workforce Development provide an overview of five existing models or approaches to workforce development that bring together the concepts related to the different levels of systems, organisations and individuals or teams. NCOSS, Models of Workforce Development (2007).Retrieved on 28/01/17 from http://nceta.flinders.edu.au/files/6412/7250/1074/ENNP5.pdf Conway et al. (2006) have presented quite a different style of workforce development framework. Their conceptual framework was not as descriptive or prescriptive as the one compiled above from the Staron (2008) model. Conway et al. (2006, p. 134) used terms such as: ⦁ Our Communities: Our Clients: Our Carers ⦁ Our Workplace ⦁ Our Work practices ⦁ Our Workforce ⦁ Our People: Learning, Innovating and Growth According to Conway et al. ( 2006) the conceptual framework came from a consultative process that involved all the key stakeholders in workforce issues within the health service, hence the ownership expressed in the use of the word ‘Our...’ . It says WHAT they want to focus on and achieve with workforce development, rather than HOW they will go about workforce development which comes through more clearly in the Staron model. Activity 2.4 Staron (2008) provides a comprehensive Workforce Development Model which can be customised to suit different contexts. The original model was developed for the Technical and Further Education (TAFE) and Vocational Education sector, but it brings together the important elements of workforce development and it could be readily adapted for other systems or organisations. For the purposes of this Unit of Study it has been adapted for the health care sector. Reflect on the material that has been covered in this Unit so far and consider how you might apply this model to your health system and/or organisation. Consider this as you think about the second assignment for planning a performance improvement or examining an organisational change strategy. ⦁ What are the forces driving change and improvement in work practices and performance in your organisational environment? ⦁ What do you want to achieve with the workforce development program (Outputs)? ⦁ What outcomes do you want for the workforce and the consumers of health care (Outcomes)? ⦁ What does your system/organisation need to do differently in terms of planning, managing and developing the workforce to achieve its vision, mission and strategies? ⦁ What barriers and enablers need to be addressed? Reading 2.6 Stanley, D. (2011). Clinical leadership. South Yarra: Palgrave McMillan. Chapter 7, pp 118-145 This chapter explains the links between leadership and change. It describes the Change management iceberg which reinforces the challenge for anyone considering change if they fail to consider the “submerged” section of the iceberg. Approaches to planning and implementing change are explained and the various models can be compared. Conway et al. (2006) developed a conceptual framework for workforce development from an Area Health Service perspective. That framework focuses directly on the vision and mission of the health service and the communities, clients and carers that are served by that health service. It then focuses on what is required to achieve the desired outcomes for the communities, clients and carers including the workplace, the work practices, the workforce capacity building and the people who provide the services; their learning, development and growth. See page 134 of the following reading for the conceptual framework. Reading 2.7 Kotter, J.P. & Schlesinger, L.A. (2008). Choosing strategies for change. Harvard Business Review, 86, (7/8), 130-139. This article explains the reasons why people resist change, suggests strategies for analysing the situation and overcoming that resistance and provides a comprehensive analysis. Strategies and techniques suggested for overcoming resistance include: education and communication, participation and involvement, facilitation and support, negotiation and agreement, manipulation and co-option, and both explicit and implicit coercion if absolutely necessary. Activity 2.5 ⦁ Consider how you might use these strategies in any performance improvement or change management strategies in the workplace. ⦁ Examining your own attitudes towards change and developing an understanding of whether you are change adverse or pro-change, can help you understand your feelings in relation to change. Reading 2.8 Jacobs, R., Mannion, R. Davies, H.T.O., Harrison, S. Konteh, F. & Walshe, K. (2012). The relationship between organizational culture and performance in acute care hospitals. Social Science & Medicine, 76, 115-125. This reading discusses the links between organizational performance and Schein’s (1997) theory which identifies culture as the beliefs and values of the group as a whole, providing the framework for the functioning of the group. Activity 2.6 Identify the beliefs and values of your workplace and identify any helpful and non-helpful aspects of the culture. The reading focuses on acute care hospitals and particularly identifies the role of the senior managers in creating the culture on the workplace. ⦁ If leaders can not only be senior managers, are there people who influence your workplace culture from further down the chain of command? ⦁ Would you think a charismatic leader could influence the workplace culture? Additional reading. This reading is under the module 1 link. Please read it and consider how you think the culture of the organisation, led to the breakdown in health care standards expected by the community they served and the mission they espoused. Casali, G. & Day, G.E. (2010). Treating an unhealthy organisational culture: the implications of the Bundaberg hospital inquiry for managerial ethical decision making. Australian Health Care Review, 34, 73-79 This reading will help you to think through the steps needed in order to achieve sustainable change. Cummings, S. Bridgman, t. & Brown, K.G. (2016). Unfreezing change as three steps: Rethinking Kurt Lewin’s legacy for change management. Human Relations, 69 (1) 33-60 retrieved 27/01/17 from http://journals.sagepub.com/doi/pdf/10.1177/0018726715577707 ⦁ References for Module 2 Antrobus, S., and Kitson, A. (1999). Nursing leadership: Influencing and shaping health policy and nursing practice. Journal of Advanced Nursing, 29(3), 746-753. Australian government health workforce Australia. 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