Emergent Change and its Implications for Professional Autonomy and Managerial Control: A Case Study from Midwifery

Planned change or emergent change implementation approach and nurses' professional clinical autonomy

BACKGROUND

Nurses' clinical autonomy is considered important for patients' outcome and influenced by the implementation approach of innovations. Emergent change approach with participation in the implementation process is thought to increase clinical autonomy. Planned change approach without this participation is thought not to increase clinical autonomy. Evidence of these effects on clinical autonomy is however limited.

AIMS AND OBJECTIVES

To examine the changes in clinical autonomy and in personal norms and values for a planned change and emergent change implementation of an innovation, e.g. intensive insulin therapy.

DESIGN

Prospective comparative study with two geographically separated nurses' teams on one intensive care unit (ICU), randomly assigned to the experimental conditions.

METHODS

Data were collected from March 2008 to January 2009. Pre-existing differences in perception of team and innovation characteristics were excluded using instruments based on the innovation contingency model. The Nursing Activity Scale was used to measure clinical autonomy. The Personal Values and Norms instrument was used to assess orientation towards nursing activities and the Team Learning Processes instrument to assess learning as a team.

RESULTS

Pre-implementation the measurements did not differ. Post-implementation, clinical autonomy was increased in the emergent change team and decreased in the planned change team. The Personal Values and Norms instrument showed in the emergent change team a decreased hierarchic score and increased developmental and rational scores. In the planned change team the hierarchical and group scores were increased. Learning as a team did not differ between the teams.

CONCLUSIONS

In both teams there was a change in clinical autonomy and orientation towards nursing activities, in line with the experimental conditions. Emergent change implementation resulted in more clinical autonomy than planned change implementation.

RELEVANCE TO CLINICAL PRACTICE

If an innovation requires the nurses to make their own clinical decisions, an emergent change implementation should help to establish this clinical autonomy.

Intensive insulin therapy implementation by means of planned versus emergent change approach

BACKGROUND

Nurses' participation in decisions about new care procedures and protocols is potentially of benefit for patient outcomes. Whether nurses' participation in decisions is allowed in the implementation of innovations depends on the implementation approach used for the introduction. A planned change implementation approach does not allow it, an emergent change implementation approach does.

AIM

To compare a planned change and an emergent change implementation approach to introduce an intensive insulin therapy to an intensive care unit (ICU).

DESIGN

A prospective comparative study in an ICU in the Netherlands of two teams of nurses using either implementation approach.

METHODS

Pre-introduction of the comparability of the two teams was assessed. The nurse compliance to the protocol was assessed as being nurses' behaviour according to the protocol and leading to acceptable glucose values. The effectiveness of the implementation was assessed by measuring the percentage of patients' glucose values within the target range, the occurrence of hypoglycaemic events and the time to glucose value normalization. Data were collected from December 2007 till January 2009.

RESULTS

In the emergent change approach team there was better nurse compliance measurements than in the planned change approach team (83.5% vs 66,8% conform protocol), a better percentage of glucose values in the target range (53,5% vs 52.8%) and a shorter time to glucose value normalization.

CONCLUSION

The implementation approach allowing nurse participation was associated with better nurse compliance and patient outcome measurements. The implementation approach did not conflict with introducing an evidence-based innovation. It was also associated with more effective adaptation of the protocol to changing circumstances.

RELEVANCE FOR CLINICAL PRACTICE

When a new treatment requires adaptability to changing circumstances to be most effective, nurses' participation in decisions about the implementation of the treatment should be considered.

Pilots for change: exploring organisational change through distributed leadership

Purpose

– Little is known about how and why pilots are useful in the context of organisational change. There has similarly been little attention to processes of distributed leadership in organisational change. The purpose of this paper is to develop a theoretical argument relating to how key aspects shaping organisational change can be addressed by distributed change leadership through the mechanism of pilots.

Design/methodology/approach

– The paper contribution is to review extant literature on change management and distributed leadership to build a model of distributed change leadership.

Findings

– The paper outlines how the model of distributed change leadership can be applied through a pilot strategy to help engender commitment and learning, as well as contextualising the change to cope with the complexities of the situation.

Practical implications

– The paper concludes with a discussion on the opportunities distributed leadership through pilots can bring to the effectiveness of organisational change interventions. The paper identifies a series of research propositions to help guide future directions for research. Finally the paper explores practical implications of the suggestions.

Originality/value

– There is an absence of discussion on distributed leadership within the context of change management. Further the mechanism of pilots shaped by distributed leadership has not been explored. This paper is intended to provide a stimulus for exploring this important area in terms of shaping thinking and designs for organisational change to enhance effectiveness.