Nadia Rodriquez is a leader on a hospital steering committee that has been working on introducing new practice standards for its obstetric units. The standards are part of updated national guidelines for obstetric care.

When leaders present the standards to staff, Nadia and her fellow committee members are surprised by staff resistance to the practice changes. Initial rollout of the standards fails because staff nurses see the standards as a huge inconvenience thrust on them by leaders who are insensitive to their current workload.

Scenarios like this are common. Many initiatives either fail or never achieve the intended outcomes. Nadia and leaders like her often struggle when they try to introduce change. They quickly learn that staff may fail to see the value of a new practice or policy.

The problem may lie in how leaders frame the change. In The Power of Framing: Creating the Language of Leadership, Gail Fairhurst suggests framing is one of the most important but least talked-about leadership communication skills. How leaders use language to frame situations and events has important consequences for how staff make sense of leaders’ actions. The ability to clearly frame what’s happening is important, especially during turbulent times. When misunderstandings arise, staff are likely to become disengaged.

We’ve seen this happen in our changing healthcare environment. Recent nationwide research by the Advisory Board (a global healthcare research, consulting, and technology firm) show only 32.8% of registered nurses (RNs) are actively engaged in their work, while 7.4% are actively disengaged. To build engagement, leaders must help staff feel ownership of the process.

This can be a challenge. In today’s healthcare workplace, staff may develop “initiative fatigue” and expend their energy trying to preserve the status quo. In Made to Stick: Why Some Ideas Survive and Others Die, Chuck and Dan Heath conclude from their research that to succeed, proposed changes need to be simple, concrete, and credible and must resonate with the value system of those affected by the changes.

Too often, leaders spend a lot of time talking about the what and how of change but little time talking about the why. Yet explaining why gives leaders the chance to connect with the staff’s value system when presenting practice changes. In Start with Why: How Great Leaders Inspire Everyone to Action, Simon Senek urges leaders to start by explaining why—because before you can explain how or what, staff need to buy into why something needs to be done.

Start with why

When explaining why, the leader’s first task is to effectively communicate a shared vision of the goals of the organization, department, or unit—including explaining how the initiative will contribute to the organization and community served. If you can’t clearly articulate why, you’ll have trouble engaging staff in the initiative.

Success in healthcare endeavors requires a team effort. Most staff can agree that providing high-quality care is an important value. Many changes, including those proposed by Nadia’s committee, are driven by a new focus on value-based purchasing. Not only are there important practice reasons for implementing the changes, but ultimately, the obstetric department’s economic survival could be at stake.

Explaining why takes on new importance in today’s value-based healthcare environment. This new payment approach shifts the focus from the number and types of services delivered to rewarding quality, safety, efficiency, and lower costs. With value-based care, payers expect that the best standards of evidence are being used. Nadia’s healthcare system can expect that payers who reimburse the hospital for care will scrutinize patient care records closely. Failure to implement new practice guidelines based on revised national recommendations ultimately could result in lower reimbursement.

Unfortunately, most nurses working on the frontlines of care know little about the massive changes brought about by healthcare reform—or how these changes ultimately will affect their practice. Too few leaders have created what John Kotter describes in Leading Change as a sense of urgency about the need to do things differently in practice today. Many leaders make inaccurate assumptions about the baseline information staff have about healthcare reform. In both academic and practice settings, leaders have inadequately educated nurses about the business of healthcare. Whether or not we like it, health care is a business and under tremendous pressure to reduce costs and improve value.

That’s why starting with why is a key first step in introducing any new initiative. Explaining why gives leaders a key opportunity to educate staff about the complexities of the new healthcare environment while providing a context for proposed changes. A good way to explain the why of any initiative is to ask and then answer the following questions:

• Why is what we do important?
• What do our patients expect of us?
• What do we expect of ourselves?
• What do we contribute to our organization?
• What would happen if we stopped getting referrals because of quality issues?
• What haven’t we considered in planning this?

Then move to how

Being asked to change how they practice can make staff nurses feel powerless and confused. Well-designed initiatives need to include good structures and systems, and planners need to consider the knowledge, skills, and abilities of frontline staff who are expected to implement the initiative. Many good initiatives fail from lack of detailed planning about how, where, and when to initiate a change. People are more likely to understand and implement changes when they feel they have some control. In The Leadership Challenge: How to Make Extraordinary Things Happen in Organizations, Kouzes and Posner describe this as the practice of enabling others to act. Leaders who enable others to act are more effective in fostering collaboration and building trust in teams.

Explaining how can help reduce feelings of lack of control by clearly laying out the actions to be taken to implement the initiative. Leaders need to prepare for such questions as:

• How will this change our practice?
• What new knowledge will I need to have?
• What’s the timeline?
• Will I receive training?

Finish with what

Staff responses to organizational change can range from fear and panic to enthusiastic support. Leaders need to have a clear vision of what the change will accomplish and spell out specific anticipated outcomes. In his business bestseller, The Trust Edge: How Top Leaders Gain Faster Results, Deeper Relationships, and a Stronger Bottom Line, David Horsager points out that trust flows from individuals, not organizations. People trust what’s clear and mistrust what’s ambiguous.

The words a leader uses to explain what are critical. The words can either signal a high degree of optimism, inclusiveness, and teamwork or make the leader seem untrustworthy or dictatorial. Instead of using “you” when speaking to staff, leaders need to use “we.” Think of “we” as one of the most important words in leadership language. “We” is inclusive, builds a team culture, and helps break down organizational silos.

Be prepared to explain to staff nurses their role in the change and what new behaviors they will need to implement. Also be prepared to describe what success will look like when the initiative is implemented. People don’t like unexpected surprises. Instead, explain:

• what changes will be implemented and when
• team members’ specific roles in implementing the change
• evaluation process that will be used to study outcomes.

Help staff find more meaning in their work

Change will continue to be a powerful force in health care. In most situations, we substitute the new and unfamiliar for old practices and behaviors. This can make staff feel insecure about their work. How leaders introduce changes has a powerful effect on staff. By starting with why, leaders like Nadia not only can create more buy-in for initiatives but also help staff find more meaning and value in their work.

Rose O. Sherman is a professor of nursing and director of the Nursing Leadership Institute at the Christine E. Lynn College of Nursing at Florida Atlantic University in Boca Raton. You can read her blog at www.emergingrnleader.com. Note: Names in scenarios are fictitious.

References

Fairhurst GT. The Power of Framing: Creating the Language of Leadership. 2^nd ed. San Francisco: Jossey-Bass; 2010.

Heath C, Heath D. Made to Stick: Why Some Ideas Survive and Others Die. New York: Random House; 2007.

Horsager, D. The Trust Edge: How Top Leaders Gain Faster Results, Deeper Relationships, and a Stronger Bottom Line. New York: Free Press; 2012.

Kotter JP. Leading Change. Boston, MA: Harvard Business Review Press; 2012.

Kouzes JM, Posner BZ. The Leadership Challenge: How to Make Extraordinary Things Happen in Organizations. 5^th ed. San Francisco: Jossey-Bass; 2012.

Sinek S. Start with Why: How Great Leaders Inspire Everyone to Action. London: Penguin Books; 2009.

Virkstis K. The National Prescription for Nurse Engagement: Best Practices for Enfranchising Frontline Staff in Organizational Transformation. April 10, 2014. www.advisory.com/research/nursing-executive-center/studies/2014/national-prescription-for-nurse-engagement