Promoting change | Association of Anaesthetists

Promoting change

How do we promote change within our organisation?

Producing change within an organisation can seem like a daunting task. Anybody who's embarked on quality improvement projects within their workplace will have experienced the frustrating obstacles created by politics, policies and organisation structure. 

Change and the resistance to change are major areas within occupational psychology. Global strategy consulting firm Strategy& detail five factors that make the greatest difference in fostering the new behaviours needed for a transformation.

All of them reflect the basic importance of people in implementing and embedding change:

1. Understand and spell out the impact of change on people (and the function of the department)

It's vital to consider how any proposed changes will impact on staff and services, either directly or indirectly. Being able to demonstrate that you have performed a clear assessment of this will reassure people that you are aware of the potential impact of change – both positive and negative

2. Build an emotional and rational case for change

People are engaged most when both emotional and rational reasons for change are present. Describe the positive impact the change will have for employees and show them the practicalities that will make it work. This will ensure commitment.

3. Ensure that the leadership within the organisation is a role model for the change

Staff cannot be expected to change if the leadership are not. Businesses begin transformation with the executive team, which demonstrated the commitment of the organisation to the change. 

4. Mobilise employees to 'own' and accelerate the change

Although most change starts centrally within organisations, it is most effective if the staff feel they've contributed to what's happening, rather than it being imposed upon them. Strategy& emphasise the importance of 'peer‐to‐peer interactions' in promoting and sustaining change. 

5. Embed the change in the fabric of the organisation

Avoid the temptation to relax at the first sign of change. The real marker of success is when the change becomes part of the organisations' business-as-usual.

Demonstrating awareness of any lessons learned and bringing these forward by integrating them into ongoing education programmes and standard processes will help to ensure change sticks. Engaging the human resources team in the change can be key to guaranteeing it is sustained.

Changing rest culture facilities - an example

Potential ways to apply these five factors are illustrated below using the example of rest culture and facilities within a department.

The purpose of this is to give ideas about how this issue could be addressed. We realise some examples may not be appropriate or possible for your department, but hope others will be relevant and easier to achieve.

1. Understand and spell out the impact that improved rest culture and the presence of rest facilities will have on people and the department

Separate, private rest areas will be needed within our department, each furnished with a bed and a lamp. This will involve use of the stock room next to the office being divided into two and funding sourced for this, plus furniture. We anticipate this will cost £1,500 in total. 

The hospital estates staff will undertake the minor renovation but this will be paid for by money from source X.

The trainee rep has agreed to order two single beds and they will be delivered to the department. They will be assembled by trainee volunteers. 

The cleaning of the rooms will be carried out by the hospital domestic staff though the room should be kept tidy by those using it. Hospital bedding will be used and laundered on site. 

The secretaries will be affected by the removal of the stock room and another location will need to be sought for storage of office supplies. It's proposed that two large cupboards be placed in the corridor outside their office with extra shelving above this. 

Once the sleeping areas are in place, it's hoped that trainees will be able to cross-cover each other for breaks during their out of hours shifts. This may result in a brief period of each trainee working within a different environment.

Nurses will need to be made aware that bleep handovers will happen but that there will always be someone available to provide cover for the patients. 

Problems may arise during busy out of hours periods when neither trainee is able to take a break. We need to monitor this and whether it is occurring more frequently. The new junior doctors' contract is very specific about rest breaks for trainees and this may have an impact on the on-call consultant so we may need a plan to address that. 

Fatigue levels of doctors should be appraised regularly (at handover, while on shift if breaks have not been taken) and they should feel supported to say when they feel too tired to work safely. This should be encouraged and individuals should be given the opportunity to rest. 

Fatigue assessment tools should be employed (SLEPT NOD). The Association fatigue infographics will be displayed on the noticeboard within the department, the theatre coffee room and the changing rooms. This will re-emphasise that the organisation promotes and supports a positive rest culture for all. 

2. Build a rational and emotional argument for the need for improved rest facilities and culture

Doctors who have had the opportunity for a restorative break (lying in the dark without a bleep, a nap) will demonstrate improved cognition and decision making. This will result in enhanced safety for doctors, patients and the general public. 

Decreased fatigue will help to maintain health and resilience. Rested doctors are less likely to suffer circadian rhythm disturbances to the same extent as unrested doctors. This will minimise chronic sleep disturbance and help to prevent chronic health conditions such as diabetes and hypertension etc. These factors are likely to positively impact on sickness and staffing levels. 

Regular, proper rest breaks are mandatory according to the new junior doctors' contract. Failure to provide these will signify failure of organisational responsibility and neglect of safety needs of staff. 

We currently struggle to recruit locums. Trainees say this is because the shifts are more exhausting than in other hospitals due to the absence of rest facilities. Addressing this is likely to improve the recruitment problem. 

Adequate rest facilities and an open fatigue culture will improve employee wellbeing and make doctors feel valued and cared for. In recent GMC feedback, doctors stated that while they'd worked in this hospital, they'd experienced excellent learning opportunities and a supportive environment. But, they explained they'd felt fatigued to the extent that they had considered leaving their jobs.

As a department, we have no choice but to act on this to ensure that trainees who come to work with us are not compromised by their role within our department. The consultant body is committed to ensuring that we produce enduring change in this area so we can continue to provide a happy, healthy and nurturing environment for all of our staff.

3. Ensure the clinical and managerial leadership within the organisation is a role model for change

We have appointed a nominated consultant (Dr X) to the role of taking responsibility for overseeing the provision of rest facilities and promoting the positive rest culture while it becomes standard practice. Consultants will openly ask each other and trainees about fatigue levels and use fatigue assessment tools if necessary. 

The clinical director regularly emails all staff (doctors, nurses, ODPs) to remind them about the importance of taking proper and regular breaks, particularly overnight. Each group is encouraged to support their colleagues in achieving adequate breaks in optimal environments (dark, quiet).

Before going home at night, consultants have started to check that new trainees know where rest facilities are and encourage them to use them during and after shifts. They have advised them to take a taxi home rather than driving home after a night shift. Our department features fatigue awareness tools, adverts about fatigued driving and sleep advice. These will also form part of the teaching programme at induction.

4. Mobilise trainees to 'own' and accelerate the improvements in rest facilities and culture

Trainees will be instrumental in ensuring this positive change occurs quickly and permanently within our department. 

They should be encouraged to speak of the need for rest facilities and request their existence until they are provided for them. They should be encouraged to view adequate rest and an appropriate rest environment as the norm and the organisation should support them in this. 

The department is in the process of recruiting trainee volunteers to undertake and arrange different elements of the development plan. Roles include:

  • Sharing information about rest facility progress with colleagues via email
  • Delivering journal club teaching on circadian rhythm and sleep
  • Auditing rest facilities before and after implementation in order to demonstrate change
  • Liaise with colleagues within other hospitals to discuss ongoing rest facility plans and share advice and support

It's vital our trainees recognise they have our support in this area. 

Between the following dates (X - X), our department will run a 'BreakAway' initiative. All employees will be paired to help each other to take a full 30 minute break away from their working environment for the sole purpose of resting (no paperwork, no pre-assessments etc). Those pairs who do not achieve this will have to pay £2 to the BreakAway fund which, at the end of the initiative period, will go to fund two supersized bean bags for the staff room.

5. Embed the improvements in the fabric of the department organisation 

Much of this relates to ensuring that changes are well established by making all members of the department aware of what will be available to trainees and how the behaviour of team members is expected to reflect their support of rest and fatigue prevention among all those working within the organisation. 

Consultants and trainees should be proud of the services they've created together and these should be seen as a true plus point of their job within our department. As mentioned in point 4, we will audit our rest facilities and fatigue prevention culture on a regular basis and continue to listen to our trainees and colleagues to ensure we are doing what we can as a department to ensure people working within it are as well looked after as they can be. 

Further reading

Ashley Harshak, DeAnne Aguirre, and Anna Brown. Making change happen and making it stick. 20 December 2010. 

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