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New Lens, New Opportunities for Change

Here, we present a case study to demonstrate nurses paying attention in the here and now processes of formation for individual and collective identities in their clinical practice that was influenced by evidence-based guidelines. In this case study, nurses demonstrated interdependence and identity as they worked together on a medical–surgical–telemetry unit. These nurses were engaged in self-organizing nonlinear interactions. They embraced uncertainty and diversity in workflow solutions, and as a result they were able to respond rapidly and creatively to environmental changes. Ultimately this led to the nurses being able to safely administer ordered medication to patients. A second mini case study is presented that explores the interplay between leadership and health service innovation and organizational identity.

This first case study describes nurses formed by and forming identity while endeavoring to improve patient outcomes with a medication administration process. Nurses administer medications after verifying the five rights: right patient, right drug, right route, right dose, and right time (Federico, 2011). According to the evidence, the use of bar code medication administration (BCMA) improves patient outcomes with medication administration; thus, it should be implemented in hospitals to enhance the quality and safety of patient care (Institute of Medicine, 2001; Koppel, Wetterneck, Telles, & Karsh, 2008; Poon et al., 2010).

 CASE EXAMPLE: IMPROVING PATIENT OUTCOMES WITH BCMA

To improve the medication administration process, a Magnet hospital in the southwest United States implemented BCMA technology. On one medical–surgical–telemetry unit of the hospital, the nurses found that the BCMA technology did not function as they had been shown two months prior to the technology going live in their training sessions. Several of the nurses said the way they were shown to use the technology was to take the medication into the patient’s room, scan their employee identification badge, and look at the top bar of the computer screen to ensure they were in the correct clinical application. Then they were to use the handheld scanner to pick up the bar code on the patient’s wristband to confirm the right patient to receive the medication. Next, the nurse was to review the medication administration screen on the computer to ensure the correct screen was displayed because there are two different computer modules: one for documenting medications and another for intravenous fluids. If tablets were to be administered, the nurse would then look at the screen to confirm that the correct medication module of the electronic medication record was displayed. Then the nurse would scan the bar code on the medication package, look at the computer screen for alerts (such as not on medication list or administering too early), then the medication would be automatically highlighted in yellow on the screen to indicate that the five rights were aligned. The nurse would then give the tablets to the patient and select OK on the screen to save the information.

However, the nurses found that the technology did not operate as they expected. The nurses scanned the bar code on their employee identification badge to record who was administering the medication. Then they scanned the bar code on the patient’s identification band, but the patient’s electronic medication record did not appear on the computer screen. When a nurse first experienced this obstacle, she stopped the medication process and located a coworker to ask for help. In the interaction between the two nurses, they found that they experienced the same problem in the BCMA process. One nurse called the in-house help desk while the other nurse asked a more experienced nurse about his experience with BCMA. The help desk technician was unable to guide the nurse through the BCMA process because he did not understand the designed process from a clinician’s point of view. From the interaction among the three nurses at the patient’s bedside, they found that they could use the computer keyboard and mouse to highlight the patient’s name. Then, instead of scanning the bar code on the patient’s identification band, the nurses used the keyboard and mouse to highlight the patient’s name and scanned the bar code on the medication package. The nurses looked at the computer screen for any alerts before administering the medication to the patient.

The nurses agreed that the technology was not bringing up the patient’s electronic medication record as expected. It was a norm on this unit for nurses to place patients’ needs at the center of their activities, including administering ordered medication to patients at the scheduled time. Each nurse in this interaction valued efficient and safe medication administration. The nurses consulted with another nurse and tried again to follow the designed process for BCMA.

In the interaction, the nurses found that if they responded to the designed process in their local situation, they could highlight the patient’s name in the electronic medical record using the keyboard and mouse, then highlight the patient’s electronic medication record. After the patient’s electronic medication record was on the computer screen, they could scan the bar code on the medication package and look for alerts on the computer screen, such as a violation of the five rights. If no alert was on the screen, the nurse would administer the medication and press the Enter key three times to record the medication administration. A new practice pattern emerged in the current situation as the nurses were forming and formed by individual and collective identity. As other nurses experienced this same problem with the BCMA, they asked their coworkers for a solution, and the use of the keyboard and mouse became the standard of practice within this unit.

The emerging medication process came out of the nurses’ interactions that were influenced by norms, values, and power relations. The nurses worked on a unit where efficient and safe care was a norm. Each nurse in this medical–surgical–telemetry unit had an individual compulsion to find a way to administer the medication using BCMA in what they believed was an efficient and safe manner. The work-around to pull up the patient’s electronic medication list using the keyboard and mouse became the standard process because their actions were influenced by power relations, including norms and values. The nurses, who were respected by their peers and who used persuasive language to respond to the evidence to improve medication administration safety with the designed process in their local situation, were forming the in group with the revised way to use BCMA. In these interactions, the nurses were formed by and forming identity while working on the edge of evidence.

Identity Forming in the Absence of Relationship

As demonstrated in this case example, it was in the interactions that identity was formed by and forming. There are occasions when workers do not interact, yet identity is formed by and forming in the absence of relationships. For example, consider a manager who does not engage in discussion with workers but puts out a memo describing a future state and directions for workers to achieve that future state. This manager may find himself in the “out” group while the more persuasive workers of the “in” group envision a different future state. The persuasive “in” group of workers will be engaged in interactions to advance the future state that is more aligned with norms and values of the workgroup rather than what was presented in a memo. The power, in this scenario, is held by the “in” group forming and being formed by identity that may possibly exclude the manager.

Questions

1. How did evidence stimulate a practice change?

2. Describe a situation in which you participated in a discussion with coworkers to find a better way to achieve the desired outcome.

3. Was a better way to achieve the outcome met? How was the outcome received by those outside the discussion? Who else do you think should have been involved in the discussion?

4. How many times a week do you think you participate in such discussions?

 CASE EXAMPLE: ORGANIZATIONAL IDENTITY REFORMATION AS INNOVATION

The previous case example demonstrated the process of change within a work team within a healthcare organization. The following case explores the path taken as an organization undergoes significant transformation as it reinvents itself. This is a good time to introduce the case study organization because it is this story that exemplifies the dynamic tension between the necessity for organizational stability in competition with an equally necessary need for transformation of the organization during turbulent times in its history. Although the story might be related from any number of lenses, it is in a discussion of the process of organizational identity reformation that brings these discussions to life.

As is the case with any organization that succeeds in sustaining its presence over years, there had been transitions and changes throughout the twenty-year history of the community-based health organization. However, a change like this one had not been previously encountered. The change agenda was highlighted by the departure of the organization’s one and only chief executive throughout its years of operation. A significant number of the organization’s staff had worked together with the chief executive since its inception. Others still had been employees over many years. Kjaergaard (2009) has opined it is important to acknowledge that organizational identity is regarded as a key variable in shared beliefs, the emotional processes associated with sense making, and the actions undertaken by organizational staff leading ultimately to the success of the organization itself. Indeed, over the years of establishing the organization, the staff had collaborated in the development of established routines, practices, and mythologies through relationships during their history together. The origins of many of these were unknown at this point in the history. People simply knew what were organizational norms and values that informed relationships and practices.

To complicate matters, not only were staff dealing with the emotionally charged departure of their only chief executive, they would also be required to work with a chief executive hired with whom they did not have a previous relationship. Adding to the already palpable anxiety was the emergence of major government policy mandating the transformation of service delivery processes. The specific manner by which these changes were to be deployed remained ambiguous. It was regardless another departure from the past. The response of people in the organization might be categorized as predictable. The tremendous anxiety being experienced in the staff group created conditions that encouraged the clustering of staff around strong themes or stories to stabilize (Stacey, 2001) against the perceived internal and external threats to the prevailing organizational identity.

What Is a Leader to Do?

Davidson (2017, pp. 308, 444) proposed that adopting complex responsive processes is, in essence, adopting a view of “organization as conversation.” Pragmatically, this then focuses attention on how communication occurs within the organization. More specifically, there is a focus on the themes that are organizing discussions throughout the organization (Stacey, 2001). In the organization being discussed, officially there were formal and conscious legitimate conversational themes within the organization acknowledging the new chief executive as the leader of the organization. Yet simultaneously, there were informal fully conscious, in-the-shadows communicative processes (Stacey, 2001) that were preserving stories and cultural artifacts to sustain the old organization.

Reflexively, the newly implanted chief executive understood the power differentials and the likelihood of failure of exerting energy to enforce formal, conscious and legitimate communications and actions to create a new organizational identity. Such practical judgment (Stacey, 2012) provided the chief executive an alternative to being organized by boundaries that would pit him against the staff, thereby creating a lose-lose scenario. Instead, the chief executive opted to move the organization forward deliberately utilizing communicative action based within an informal yet consciously acknowledged legitimate process of power dynamics.

According to Stacey (2012), the best use of power dynamics is to engage in processes that will open rather than close down conversations that move too quickly to solutions. This is a deliberate process view of emergent change. Within the organization, the chief executive engaged managers in conversations identifying the kind of organization desired. These transformative conversations were shared with staff through long-serving managers who were able to elicit their preferences for the future. These discussions that identified/verbalized staff ideas for the organization capitalized on the trust present in those long-term relationships. An example of this process is exemplified by a manager holding individual conversations with each staff member to explore what was good in the organization and what needed to change, and also sought aspirations of the staff for the future. These conversations were assimilated into aggregate feedback around themes that emerged that were, in turn, shared with staff. At the conclusion of the feedback, interactions occurred forming identity around shared organizational goals so that members knew how to interact with others to live the new reality. In these interactions informal shadow communication became part of the formal legitimate conversation of the organization. This action represents a robust example of power relations through complex responsive processes.

The introduction of an evidence-based practice that would formulate treatment delivery across the services provided by organizational staff created powerful norms that has brought staff together through common language and that has habituated behavior through which organizational identity is being formed. Power was shared through interactions by those who were accepted by the in group. These power relations created influence across the organization through coaching practices. The consistent messaging delivered through these communicative acts encouraged the formation of an organizational identity as these practices were embraced by clinical staff. These coaches engaged colleagues to embrace changes as the new identity of the organization emerged. The organization emerging from these practices is one shaped through spontaneity and continuous transformation while sustaining the core of its mandate and purpose. Increasingly, there is emerging an organizational identity that celebrates creativity and innovation. The organization continues to deliver the service for which it was created and is also expanding the identity of the organization internally and externally as it diversifies offerings.

Questions

1. Organizations experience both formal—conscious—legitimate and informal—conscious—shadow (gossip) communicative acts. As a leader, how might you contend with these competing processes?

2. Recall a time when there was tension and perhaps conflict in an organization in which you worked. If the leadership opted to create space for dialogue, how do you believe that shifted the relationships of the personnel? Alternatively, if leadership opted to shut down conversation, how do you believe that shifted relationships? What impact might both have upon the relationships of the personnel?

3. In what ways does a leader pay attention to the presence or absence of anxiety in the workplace?

4. How does reflexive process inform your practice?

5. Organizational patterns made up of human interactions advance evidence into practice. Leaders who hold the CRP perspective on organizational change recognize the practice pattern response to evidence occurs in human interactions in the present moment and that these interactions are influenced by norms, values, and power relations. To be part of the practice pattern response to the evidence, leaders will put themselves in relationships—in interactions with other members of the organization at the point of service. The leader understands the power relations dynamic that is influenced by norms and values of the work group. This leader will have a practice based in reflexivity because he or she knows to pay attention to interactions including evidence, the patient or client, clinicians, professional practice communities, researchers or authors, and other members of the organization. Conversations with those who are most persuasive will influence when and how evidence advances practice that forms and is forming identity.

6. FIGURE 3-2 schematically depicts the processes involved in emergent meaning (innovation) creation and implementation of innovation from the lens of CRP. This depiction of a Venn diagram demonstrates that the processes associated with innovation in the moment, relational conversations, knowledge, evidence, and negotiation of diversity interact with one another in a pattern that has no definitive direction or order. The processes are iterative as the experience of energy and anxiety ebb and flow as the conversational processes progress. The diagram also depicts meaning emerging with the confluence of these practices, also calming anxieties that are associated with such transformation. Alternatively, should any of the four processes be underdeveloped so that anxiety prevails, the core of the process, emergent meaning, will remain an elusive target and the previous process will persist. The best hope that there will be sufficient awareness of the potential for innovation in the moment is the presence of reflexive processes by the members of the team. Through such action, sensitivity to the identity of each member as a team and of the team itself will pave a pathway grounded in the trust built in relationships to implement new practices.

Four elements in the innovation process.

A leader who practices reflexivity is conscious and pays attention to the present moment, knowing innovation in the form of local response will emerge in human interaction. Emergence of new patterns and the disruption of ineffective patterns occurs in local interactions of clinical practice. As clinicians, patients or clients, professional practice communities, researchers or authors, and other members of the organization interact to respond to the evidence, the human patterns emerge from each individual and the collective by paying attention to their experience in the here and now.