NU804 Unit 5 Leading Change Seminar Reflection Example

I Could Not Order the Hospitalists to Wait: A Unit 5 Seminar Reflection on Leading Change Without Authority

[Student Name]

Purdue University Global

NU804: DNP Project II

Unit 5 Seminar Reflection

[Instructor Name]

[Date]

The seminar, hospitalists, classmates and events are composite; the sources cited are real.

The Problem

In the fifth week of implementation, the 3 West resource nurse told me that three patients that week had been discharged by mid-morning before giving a supervised dose on the pen going home. In each case the hospitalist had written the discharge order on early rounds, the bed was needed for an emergency department admission and the nurse had rushed the teaching or skipped it. The bundle cannot work if the patient leaves before the nurse can watch the injection.

I am a unit educator. I do not supervise hospitalists, and I cannot make them wait.

My First Response

My first response was a message to the hospitalist group's medical director, attaching the bundle's protocol and asking her to remind her physicians that patients on new insulin must complete the supervised dose before discharge. She replied politely that she would share it. Nothing changed. The next week, two more patients left early.

Looking back, I treated the problem as a compliance problem and tried to borrow authority from someone who had it. That approach rested on the assumption that hospitalists knew the rule and were ignoring it. In fact, most of them had never heard of the bundle beyond one email at go-live.

What the Seminar Offered

The facilitator asked each of us to describe a change we were leading and the people whose cooperation we needed but could not require. Then she asked a second question: what does that group want that your change could give them?

I had no answer. A classmate, Imani, who leads a mobility project in a surgical unit, said that she had won over her surgeons only when she showed them data on length of stay, which they cared about, rather than data on falls, which they assumed nursing would handle. Another classmate pointed out that I was asking hospitalists to give up something they valued, a morning discharge, without offering anything in return.

I had asked the hospitalists to change for the bundle's sake, when the only reason they would change was their own.

What the Literature Helped Me See

Kotter (1995), looking at why large change efforts stall, names two errors I had made: telling too few people about the change, and building a coalition that leaves out those who control the work. I had communicated the bundle to nurses for months and to hospitalists in one email, and my coalition had no physician in it. Uhl-Bien et al. (2007) describe leadership in complex organizations as including enabling work that creates conditions for people to adapt, not only direction from formal positions. My role was not to command but to create the conditions in which hospitalists would choose to wait.

The AACN Essentials expect doctoral nurses to work in interprofessional partnerships and to lead within systems, using communication and collaboration rather than position alone (American Association of Colleges of Nursing [AACN], 2021). That was exactly the competency the week had tested and I had not yet shown.

The Conversation That Worked

I asked to attend the hospitalists' weekly meeting for ten minutes. I brought two things they cared about. The first was data on returns: of the patients who had come back with a glucose problem in the pilot year, most had been readmitted to the hospitalist service, often within a week. The second was a proposal that served their interest in early discharges: the supervised dose would be moved to the evening before the expected discharge for any patient on new insulin, flagged at the evening huddle, so a morning discharge would no longer conflict with teaching.

The discussion lasted twenty minutes, not ten. One hospitalist asked whether a patient who did well the evening before needed another dose observed in the morning. We agreed not, which made the change easier. Another offered to add a line to the discharge order set, "Supervised insulin dose completed," that the order cannot be signed without. The medical director, who had forwarded my first message without comment, said the group would take it to the order set committee.

What Changed

Over the next three weeks, no patient on the four units left without a supervised dose. The order set change is pending. The bigger change was in my approach. For each group the bundle depends on, pharmacy, case management, oncology, I am now writing down what they want, what the bundle asks of them and what it can offer in return before I ask for anything.

Closing Thought

I came to the seminar frustrated that I lacked the authority to fix a problem. I left understanding that authority would not have fixed it; the hospitalists would have complied on paper and found ways around the rule. What fixed it was asking what they needed and building the change around it.

References

American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2021.pdf

Kotter, J. P. (1995). Leading change: Why transformation efforts fail. Harvard Business Review, 73(2), 59-67.

Uhl-Bien, M., Marion, R., & McKelvey, B. (2007). Complexity leadership theory: Shifting leadership from the industrial age to the knowledge era. The Leadership Quarterly, 18(4), 298-318. https://doi.org/10.1016/j.leaqua.2007.04.002