141NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3

nurse leaders will have an opportunity to expand their understanding of the issues and importance surrounding IT system interoperability and health data exchanges includ- ing quality and patient safety, meaningful use, the TIGER Initiative (Technology Infor - matics Guid ing Educational Reform), and the HITECH Act (Health IT for Economic and Clinical Health). The column will provide a place where nurse leaders can discover the

latest information about health IT implementation issues such as electronic health records, decision sup- port, standardized vocabularies, and evidence-based practice in automated care planning and documenta- tion. Technology is only a means to an end and it can also contribute to nursing’s and health care’s strategic goal of safe and cost-effective patient-centered care. As technologies leverage and improve the workplace by providing data about the impact of nursing care, nurse leaders are able translate, synthesize, interpret, and manage the data into measurable outcomes.

Nursing Informatics and Patient-Center Care We are on the edge of moving beyond the elec-

tronic health record to a dynamic, clinically intelli- gent system that can provide the nurse and other pro- fessionals with useable, evidence-based data at the point of care. There are many informed decisions that managers, chief nursing officers, and others in part- nership with staff nurses need to make as we move into the new world of stimulus dollars. The implica- tions of these decisions are of great financial and patient care concern now and in the long term. Nurse leaders need to be present at the tables where clinical IT is discussed and be key players in the decision making. However, that requires competency in the world of IT. Hence, this column was conceived as an endeavor to provide some of the information needed to build and maintain these skills for the nursing leader. “Meaningful use,” interoperability, and health data exchanges are examples of topics stimulated by the HITECH Act that need the attention of clinical nursing leadership.

O NCE AGAIN, NURSING Economic$ is keeping its eyes on the horizon of contemporary nurs-

ing practice and is pleased to announce a new column enti- tled “Nursing Informatics (see page 204).” The decision to launch an information technology column was an easy one, and builds on an information systems and technology column previous- ly featured in the journal. As nurse leaders, we recognize health care is our business and, as such, we must respond seamlessly to clinical changes in the patient- centered care that will be created, supported, and enabled by technology. Therefore, to ensure our read- ership of nurse executives, managers, and faculty stay informed and knowledgeable about health infor- mation technology (IT) and the essential informatics competencies required to function within the patient-care environment, we asked Judy Murphy, RN, FACMI, FHIMSS, vice president - information services, Aurora Health Care, Milwaukee, WI; a HIMSS Board Member; and a member of the federal HIT Standards Committee to lead and manage the column’s content.

Why Nurse Leaders Need to Stay Informed It is our belief the use of IT to improve the efficien-

cy, safety, and quality of health care delivery combined with the unique role of nursing warrants our undivid- ed attention. Nursing leaders have a dual responsibili- ty to develop systems in the world of IT to first, enable safer patient care and second, to support the work of managers and leaders by leveraging IT. Competency in clinical IT is an essential foundational tool for the lead- ership practice of managers and leaders and will become more important in the future as we develop more sophisticated clinical IT. This inaugural column of nursing informatics will act as a formidable reminder on how nursing informatics as a specialty (American Nurses Association, 2008), including the development of scope of practice, competencies, and certification has been invaluable to the nation’s health IT dialogue and nursing’s presence on federal IT boards and com- missions (American Nurses Credential ing Center, n.d.). By including nursing informatics as a featured column,

Editorial

Nursing Informatics: Why Nurse Leaders Need to Stay Informed

Donna M. Nickitas, PhD, RN, CNAA, BC; Karlene Kerfoot, PhD, RN, CNAA, FAAN

Donna M. Nickitas Editor

Karlene Kerfoot Editorial Board Member

continued on page 158

NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3158

Timing Is Everything! Ever since the passage of the Recovery and Reinvestment Act of 2009,

nurse leaders have come to recognize the promise made by President Obama when he committed federal funding of $19 billion in incentives allocated towards “meaningful use” of electronic health records (EHRs) in hospitals and ambulatory settings beginning in 2011 and ensuring that all medical records will be digitized by 2014. This commitment towards computerized health records will help avoid dangerous mistakes, reduce costs, and improve quality. The EHR helps connect and align patient-cen- tered care into information that is distilled and used for good decision making towards improving quality and patient safety. We believe that launching the “Nursing Informatics” column will keep you connected and informed about meaningful, timely IT information for sound clinical decision making. We hope you believe so too. $

REFERENCES American Nurses Association. (2008). Nursing informatics: Scope and standards of prac-

tice. Silver Spring, MD: Nursebooks.org. American Nurses Credentialing Center (n.d.). Nursing informatics certification. Retrieved

from http://www.nursecredentialing.org/NurseSpecialties/Informatics.aspx

Editorial continued from page 141

Copyright of Nursing Economic$ is the property of Jannetti Publications, Inc. and its content may not be copied

or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.

However, users may print, download, or email articles for individual use.

“The Nurse Informatics Leader” Program Transcript

ROY SIMPSON: Let's talk about leadership in complex organizations, whether it's acute care, it's a vendor, it's a supplier, it's whatever it is. One of the things that we constantly have to be mindful of is that organizations are more and more matrix structured today than they were in the past. And in order to facilitate change, there are certain components to change.

But one of them is communication. You have to be engaged in relationships in the organization in order to be able to make change happen. You have to have a vision. You have to have resources. You have to have an action plan.

You have to have the right set of other types of circumstances in order to get change to happen in your organization. And leadership is about change. And so change is important for the nurse informatician in that the introduction of technology as a leader changes everyone's actions.

And it's important for us to be aware that every time we have an upgrade, every time we have a discussion about a new technology, that we're changing people's work environments and that this has tremendous impact. And we have to be mindful of what other types of activities are going on at the same time because it's not only IT that's changing and technology changes. There are clinical practice changes.

There are other types of domain knowledge changes that are going on for evidence-based practice. And that's a lot of change sometimes in an organization. So as a leader, it's important that you understand change and that you embrace change and you're willing to change with it.

The other aspect that I find the most interesting is is that nursing has a hard time coming together to describe its nomenclature and taxonomy. And it's very difficult when you have over 1,000 different colors of urine to get everyone to come to the same page and say, maybe we only need 10 colors. And I'm not exaggerating. I mean, these are actual cases I've seen.

And that probably is the most difficult, is that political dynamic that I need 1,000 administrations, and I only need 10. Where are we going to meet in the middle, and how can we get there to get this to happen sooner rather than later? But typically, it fails, systems failures basically because people didn't take time to get everybody educated. Communication and education. Those are the two key variables for any systems implementation.

When we look at change agents in an organization, one of the things that I've experienced in executive leadership is people who are specifically hired to be a

© 2012 Laureate Education, Inc. 1

change agent, people that are change agents that will manage over time and still be a part of the organization when it changes, and then change agents that are short-term, short-lived, and only there for an explicit amount of time. And one of the things I think as nurse informaticians, especially when we're called in a leadership role, is to be a change agent. And I think you have to know on the front end whether you're asked to be a change agent, and that when you change, you have to leave the organization, versus a change agent who may stay there.

And I've seen both types happen. And I think the most painful is when someone has been hired, and they don't know that they have been hired to be a change agent, and that they're a short-term change agent, and that all the bad goes out with them when they leave the organization. And as I say to my colleagues, that's OK if they paid you for the back end of it, and you knew it all on the back end, and you had down time in order to be able to reposition yourself in the marketplace for another job.

But it's not OK when you're hired, and you don't know that that was what your job was. And I do think that happens in technology because if you take physician order entry, a lot of times, CIOs are hired specifically to get in physician order entry. And there's such bad feelings when everybody is quote, "forced" to be on CPOE that that person has to leave the organization.

And they know it on the front end. If they know they have to have some major obstacle to overcome, that they may be asked to leave, and that that's part of the agreement, if that's on the front end, you're OK. But if you're caught in the middle of it, it's horrible. And it's an experience that people clearly will engage in their life as a nurse informatician, if they don't do a good assessment on their job opportunity when they go for their interviews.

GAIL LATIMER: I think one of the important messages for a nurse informatician is to be successful, you must be a leader and demonstrate leadership skills and know where your strengths are and know where you know you need to grow and select a coach to help you in the areas where you need to grow. And that coach may change over the evolution of your career because you're going to be constantly growing because we're lifelong learners. But make sure that you mentor and coach others that are coming up through the field of nursing informatics. Because that's just as critical to give back to the profession as the learning and the coaching that's been given to you.

Secondly, I think it's very critical that people can get caught up-- do I report to the CIO, or do I report to nursing? Why I wanted to go with your leadership first is it doesn't matter where you report. If you are a good leader, you're a good change agent, you're respected by your peers from a clinical practice perspective, it doesn't matter where you report on an org chart.

© 2012 Laureate Education, Inc. 2

And this gets to our power base. You want to be an expert power base, and you're recognized for your expert power. You don't want to be recognized for where you sit on the org chart because that is not the correct leadership position that you should want to have. And titles and places on org charts have never been important to me. What's been important is that I'm making a contribution and that my colleagues see that I am contributing, and I know that I am contributing.

Realize that you're a liaison, and a liaison to that C-suite. If you're in the midst of an implementation, make sure you take 15 minutes or 30 minutes a week to update the executives in the C-suite. And it may not be a face-to-face meeting every week, but maybe you send an email that has the three bullets.

It's got to be short. It's got to be crisp. It's got to be that type of a message. But keep them informed because they're your best advocates in what's happening.

So align with the executives and make sure that they understand the role and how the implementation is going or how the optimization is going. I think those are some real critical components of leadership that are very, very valuable. But the most important thing is give back to the profession.

PATRICIA BUTTON: As the Chief Nursing Officer in my company, as a member of the senior management team, I mean, a great deal of it is the typical things that a leader needs to do. And that is, in a culturally, politically sensitive way of participate in the management of the company. Now, in my particular company-- and this is not unique to my company. It originated as a physician-led company. It was founded by physicians.

It was very, very focused on providing information, clinical decision support for physicians. And the CEO of the company called me and said, you know, one of my nurse colleagues said we really ought to do something for nurses. And we wondered if you'd be interested in doing a market analysis as a consultant, for whether that's something that would be wise for our company to do.

So I did the market analysis, and it was very, very clear that there was really a critical need for nursing and the interdisciplinary team to have clinical decision support the same as physicians. So I reported that. To make kind of a long story short, they then wanted to recruit me to come and work at the company, not function as a consultant.

The tag line of the company at that time was the leader in evidence-based medicine. And I was very excited about this opportunity because to be in on the ground floor, to develop this clinical decision support solution, to support nursing in the interdisciplinary team, was very exciting to me. But I said to the CEO, you know, I can't come and work with you and this company to develop a solution for

© 2012 Laureate Education, Inc. 3

nursing and the interdisciplinary team when the company's tagline is a leader in evidence-based medicine.

He said, well, why not? I said, because medicine is what doctors practice. Health care is what the whole team practices.

And I think it's those kinds of situations where one has to clearly but thoughtfully express not so much an opinion as a position, as a leader, to influence. I mean, in this case, it's the tag line of my company, which evolved into the leader in evidence-based health care, and has evolved a few more times since then. But you know, to really influence what be it a company or an organization is doing, to really move toward their goals because it was then and is the intent of my company to be a clinical decision support provider to the whole health care team, but to really identify the opportunities to make that clear and open and something that everyone buys into.

© 2012 Laureate Education, Inc. 4

Innovativeness of nurse leaders

KAREN CLEMENT-O’BRIEN D N P , R N 1, DENISE F. POLIT P h D 2,3 and JOYCE J. FITZPATRICK P h D , R N , F A A N 4

1Director, Albany Medical Center, The Center of Learning & Development, Albany, NY, 2President, Humanalysis, Inc., Saratoga Springs, NY, USA, 3Adjunct Professor, School of Nursing, Griffith University, Gold Coast, Queensland, Australia and 4Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA

Introduction

The support of nurse leaders for the implementation

of practice innovations is crucial to establishing an

environmental culture that adopts and values evidence-

based practice standards. The ANCC Magnet Recog-

nition Program [American Nurses Credentialing Center

(ANCC) 2008] guides organizations to promote out-

comes and superior performance. The Magnet program

components were developed to evaluate how work

environments support excellence in nursing practice.

Demonstrations of innovations in nursing practice are

the outcome of transformational leadership, empower-

ing structures and processes and exemplary professional

practice in nursing. To achieve Magnet status, the chief

nursing officers (CNOs) of acute health care organiza-

Correspondence

Karen Clement-O�Brien Albany Medical Center

The Center of Learning &

Development

31 Nicklaus Drive

Gansevoort

New York

NY 12831

USA

E-mail: [email protected]

C L E M E N T - O ’ B R I E N K . , P O L I T D . F . & F I T Z P A T R I C K J . J . (2011) Journal of Nursing Management

19, 431–438

Innovativeness of nurse leaders

Aim The purpose of the present study was to describe the innovativeness and the rate of adoption of change among chief nursing officers (CNOs) of acute care

hospitals, and explore the difference in the innovativeness of CNOs of Magnet

hospitals vs. non-Magnet hospitals. Background There is little evidence to guide the description of innovativeness for

nurse leaders, crucial to the implementation of evidence-based practice standards.

Method CNOs of acute care hospitals of New York State participated in a mailed

survey which incorporated the Scale for the Measurement of Innovativeness. The

response rate was 41% (106/261).

Results The majority of the sample was prepared at the master�s level with 5– 10 years of experience in the CNO role. A significant relationship was found

between the innovativeness scale scores and the innovativeness diversity index. The

CNOs who completed more leadership courses had implemented significantly more

types of innovations and had higher innovativeness scale scores.

Conclusion Graduate level education, years of CNO experience and leadership course

completion were identified as significantly influencing innovativeness of CNOs.

Implications for nursing management The characteristics of innovativeness for

nurse leaders presented in the present study may assist organizations, CNOs and the

Magnet recognition programme to describe innovativeness that supports organi-

zations to continuously improve the quality of patient care.

Keywords: change, innovativeness, nurse leader, scale for the measurement of innovativeness

Accepted for publication: 22 September 2010

Journal of Nursing Management, 2011, 19, 431–438

DOI: 10.1111/j.1365-2834.2010.01199.x ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd 431

tions are evaluated on evidence of innovativeness.

However, there is little evidence to guide the description

of innovativeness for nurse leaders.

Purpose of the study

The purpose of the present study was to describe the

innovativeness and the rate of adoption of change

among CNOs of acute care hospitals. In addition, the

degree of innovativeness of CNOs of Magnet hospitals

and non-Magnet hospitals was compared. Examples of

innovativeness, according to the Magnet sources of

evidence criteria, were identified.

Conceptual framework

The Diffusion of Innovation Theory (Rogers 2003)

provided a framework for this study. The innovation-

decision making process describes how an individual

moves through the learning of a new idea, develops an

attitude and determines whether he or she will fully

implement and adopt an innovation or reject the new

practice.

Rogers (2003, pp. 245–252) categorized individuals

into groups according to their rate of adoption of an

innovation. These categories were defined statistically,

based on the number of standard deviations from the

mean adoption time. Individuals that fall within the

innovator classification are people who are considered

mavericks; they are more willing to travel and to take

risks to achieve personal interests or causes in which they

are heavily invested. Those in the early adopter category

are opinion leaders who are socially very well connected

and promote the local change. Early adopters are wat-

ched by others to see the dynamics and the impact of

innovation on their practice area. Members of the early

majority category learn more from other people than

from theory and science. They will listen to others and

will adopt an innovation if it readily helps them with an

immediate need. The late majority watches the early

majority, and the laggards bring up the rear; they are

traditionalists who make wise decisions for the good of

the organization at large (Berwick 2003).

The manner in which nursing practice has historically

been disseminated was frequently based on traditions

and experience (Sleep et al. 2002). The ability to

implement evidence-based practice is a challenge and

has been reported to take as long as 17 years in the

medical community (Liang 2007), with 10–20 years

before innovations are fully put to use (Ervin 2002).

Generating good practice ideas through research is not

the problem; getting good ideas to be used is the chal-

lenge, and the essence of the diffusion of innovation

(Berwick 2003).

Research questions

The research questions that guided this study were: (1)

What is the innovativeness of acute care hospital chief

nursing officers? (2) What is the rate of adoption of

change among acute care hospital chief nursing officers?

and (3) Is there a difference in the degree of innova-

tiveness of chief nursing officers of Magnet hospitals

compared with CNOs of non-Magnet hospitals?

Background

Characteristics of the leader

There is support in the literature for the view that the

characteristics of the leader influence change and the

motivation for adoption in an organization (Leonard-

Barton & Deschamps 1988, Longo 2007, Damanpour

& Schneider 2008). The main characteristics of the

leader that were found to influence change were their

motivation, leadership and commitment (Longo 2007).

Support from top management and championship

may have a significant effect on an adoption decision.

Leaders must first accept change before assisting others

with the change process (Rogers 2003). Innovation

takes time and there must be a perceived value for

adoption to occur. Gaining internal support for adop-

tion of an evidence-based practice change was one

challenge identified by Bradley et al. (2004) among 32

hospital administrators and leaders.

Innovativeness and change

The leader is key to preparing an organization for

change. If it is perceived that the leader does not value

the change or that the leadership team does not share

the same desire for the goal, staff are less likely to be

willing to accept the change (Litaker et al. 2008). Based

on their case studies, Kimball et al. (2007) and Morji-

kian et al. (2007) found that nurse leaders reported that

innovation depends on teamwork, building leadership

capacity and participation on all levels. This is a critical

strategy for generating new ideas, sustaining the change

momentum and being effective as a change agent. The

resources and support that nurse leaders provide made a

difference in the optimal utilization of evidence-based

nursing practice (n = 43; P < 0.05) (Wang & Ahmed

2004, Alfred & Byers 2005). Nurse leaders may have a

significant influence on the attitude of staff towards the

K. Clement-O�Brien et al.

432 ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 431–438

use of evidence-based practice and the implementation

of practice changes within their organization (Larrabee

et al. 2007). Lukas et al. (2007), in a longitudinal study

of descriptions of successful change, found that all ele-

ments (impetus to transform, leadership commitment to

quality and change, improvement initiatives, alignment

and integration) of the change matrix need to be part of

the organizational transformation and all are required

to interact collaboratively to maintain urgency for

change and forward movement of the organization.

Organizations are more likely to continue to use

implementation methods that they have used previously,

but these are not necessarily the best for the culture or

the outcomes to be achieved. Facilitation of practice by

clinical teams was shown to be the most effective strat-

egy 79% of the time and educational programmes least

effective at 42% (81% response rate) (Wallace et al.

2001). Collins et al. (2000) found the use of opinion

leaders superior to traditional methods, in enhancing

compliance with scientifically supported practice

guidelines. Cadden (2007) reported that multiple inter-

vention strategies, based on assessment of potential

barriers to change, are more likely to be effective than a

single intervention. Structured and systematic ap-

proaches were found to support organizational learning.

Higher levels of science-based and practice-based inno-

vativeness were associated with better clinical hospital

performance (Salge & Vera 2009).

Change leadership is described as continuously seek-

ing or encouraging others to seek opportunities for

innovative approaches to address organizational prob-

lems. Over a 3-year period, change management was

consistently identified as a learning and development

need of leaders (Wolf et al. 2005).

The literature review includes several qualitative

studies of populations such as health care staff at large,

government officials and a limited number of nurse

leader groups (Leonard-Barton & Deschamps 1988,

Wallace et al. 2001, Longo 2007, Litaker et al. 2008).

Measures of change have focused on attitudes, the

number of products implemented, characteristics of

nurse leaders and practice change implementations

(Grover 1993, Bradley et al. 2004, Alfred & Byers

2005, Larrabee et al. 2007, Damanpour & Schneider

2008). Rate of adoption to change among nurse leaders

and Magnet status comparisons were not found in the

literature. The present study was designed as a

beginning description of these variables among nurse

executives in acute care hospitals in New York State.

There is also no literature found comparing innova-

tiveness of nurse executives in Magnet-designated

hospitals and non-Magnet designated hospitals.

Methods

The study was approved by the Institutional Review

Board before data collection. The setting for the study

was acute care hospitals in the State of New York

(n = 261). The sample included the registered nurse

designated as the CNO at each facility. All CNOs,

regardless of length of service, were invited to partici-

pate in the study. Surveys were addressed and mailed

generically to the CNO at each facility.

Instrument

The operational definition for the rate of adoption was

the assignment of subjects to the categories of innova-

tiveness: innovators, early adopters, early majority, late

majority and laggards as described by Rogers (2003).

The instrument used to measure the innovativeness

variable was the Scale for the Measurement of Innova-

tiveness, which was designed to measure an individual�s willingness to change, not actual adoptive behaviour.

The scale allows assignment of respondents to categories

of innovativeness (Berwick 2003, Rogers 2003). The

total score on the scale is 70 with higher total scores

indicative of a greater degree of innovativeness and

greater willingness to change (Hurt et al. 1977). In

assessing the instrument�s reliability, Hurt et al. (1977) and Pallister and Foxall (1998) obtained Cronbach�s alphas at 0.83 and 0.80, respectively. In the present

sample the reliability of the instrument was tested by

calculation of the alpha coefficient (r = 0.72) which is

lower than the reliability scores obtained previously.

To further describe innovativeness of the sample, the

number and types of innovations implemented were

collected. These options were based on Magnet sources

of evidence for innovation (ANCC 2008): (1) the

structure and process by which nurses are involved with

the evaluation and allocation of technology and infor-

mation systems to support practice, (2) nurses� partici- pation in architecture and space design to support

practice, (3) an improvement in practice as a result of

nurse involvement in technology and information sys-

tem decision making, or (4) an improvement resulting

from nurses� participation in architecture and space design. The survey tool also included an open-ended

question for the purpose of collecting from CNOs their

perception of one of the �most innovative projects they have implemented�. The qualitative data were catego- rized according to the Magnet sources of evidence for

innovation (ANCC).

Other data collected were information about partici-

pation in leadership courses by type and number. The

Innovativeness of nurse leaders

ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 431–438 433

categories of leadership courses were listed according to

the leadership curriculum of the University of Pennsyl-

vania, Wharton School of Business for Nurse Executives.

Demographic and background variables measured

included: age, gender, ethnicity, highest degree earned,

number of years at degree level and number of years in

the CNO role. Data regarding the organization included

Magnet status and number of years employed in a

Magnet organization if applicable.

Procedures

The subjects were asked to complete the survey tool and

return the survey via mail within a 3-week period. One

week after the tool was distributed a follow-up postcard

was sent as a reminder. One week later another follow-

up postcard was mailed to the administrative assistant

of the CNO. Each survey tool was coded with a number

for the purpose of tracking each tool sent and to do a

targeted second mailing to those who had not re-

sponded 6 weeks after the first survey mailing. Once the

sample was obtained the association of the coded tool

to the hospital from which it came was discarded. As an

incentive for CNOs to complete the survey, the cover

letter explained that a donation of one dollar would be

made to Nurses House, a national fund for nurses in

need, upon receipt of the completed tool.

Results

Characteristics of the sample

The target population for this study was CNOs of acute

care hospitals of New York State. The number of par-

ticipants returning the survey was 133 or 51%. Of the

133 subjects, 106 (79.7%) met the inclusion criteria for

the study, CNO of an acute care hospital of New York

State, for a response rate of 41% (106/261). Those

excluded from the study were not employed in an acute

care facility (n = 27, 20.3%). The participants included

99 females (93.4%) and seven males (6.6%). The age

range of participants was as follows: 31–39 (n = 5,

4.7%); 40–49 (n = 13, 12.3%); 50–59 (n = 67, 63.2%)

and 60–65 (n = 21, 19.8%) years. The level of educa-

tion of the participants was as follows: 12 participants

(11.3%) had bachelor�s degrees or less; 82 (77.4%) were at the master�s level; and 12 (11.3%) were at the doctoral level of preparation. The majority of the

participants were white females (n = 99, 93.4%), age

50–59 (n = 67, 63.2%) years, at the master�s level of education preparation (n = 82, 77.4%), with 5–

10 years� experience in the CNO role (n = 40, 37.7%).

Results related to the research questions

Research question 1: �What is the innovativeness of acute care hospital chief nursing officers who work in

New York State?� Overall, the mean score for the innovativeness scale for the sample was 59.81 [standard

deviation (SD) = 6.82; range 40–70]. Five participants

had perfect innovativeness scale scores of 70; two had

scores of 37. The innovativeness diversity index, the

number of types of innovations, ranged from 0 to 5. The

overall mean score was 2.93 (SD = 1.28).

�Do characteristics of CNOs predict their innova- tiveness scores?� The relationships among age, educa- tion and CNO years of experience, innovative scale

scores and the innovativeness diversity index were

analysed. The age groups (<50 for 31–39 and 40–

49 years) and education level ( £ BS for diploma, associate and baccalaureate) were collapsed because of

small numbers per cell. Higher levels of education cor-

related with higher scores on the innovativeness diver-

sity index (F = 4.47, P = 0.01). The number of years as

a CNO, when using collapsed three-group categories

(<5 years for <1 year, 1–3 years and 3–4 years), was

significantly related to the innovativeness diversity in-

dex (F = 4.37, P = 0.01) (see Table 1).

�Is the innovativeness scale score correlated with number of different types of innovation projects?� Using Pearson�s correlation, a significant relationship was found between innovativeness scale scores of the sample

and their innovativeness diversity index, r = 0.34,

P < 0.00.

Research question 2: �What is the rate of adoption of change among acute care hospital chief nursing officers

of New York State?� The rate of adoption of change and the willingness to change groupings were distributed

according to Rogers (2003) categories. The innova-

tiveness scale scores ranged from 37 to 70. The inno-

vator group was populated by participants with a

perfect score of 70, representing 4.7% of the sample.

The sample was significantly non-normal (Kolmogoriv–

Amirnov test of normality P = 0.01) and significantly

positively skewed (Shapiro–Wilk P = 0.00). The fre-

quency and percentage for the remaining groups were:

early adopters, 13 (12.3%); early majority, 35 (33.0%);

late majority, 37 (34.9%); and laggards, 16 (15.1%).

The education level, in the three-group categories, is

significantly related to the willingness to change classi-

fications (r = 15.93, P = 0.04) (see Table 2).

Research question 3: Is there a difference in the de-

gree of innovativeness of chief nursing officers of

Magnet hospitals compared with chief nursing officers

of non-Magnet hospitals?

K. Clement-O�Brien et al.

434 ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 431–438

There is considerable similarity in the two groups in

terms of demographics, the innovativeness scale scores,

the innovativeness diversity index and the willingness-

to-change categories. The average scores of the Magnet

group (mean = 59.5) and the non-Magnet group

(mean = 59. 88) on the innovativeness scale score (t =

0.21, P = 0.83) were similar. Using a chi-square test

(v2 = 3.13, P = 0.54), there was no difference in the distribution of willingness-to-change categories be-

tween groups. Those in Magnet hospitals were more

likely to be both laggards and innovators, but the

differences were not significant.

Additional analysis

Question number 12 asked participants to �Describe one of the most innovative projects you have implemented�. The more experience, the greater number of different

types of innovation projects reported. The overall theme

of �one of the most innovative projects� responses in- cluded: building or renovating emergency departments;

development and implementation of an electronic

medical record and other information technology to

support safe patient care; implementation of shared

governance structures; implementation of a nursing

model of care; design and development of new con-

struction; and development of an unique nurse role.

Discussion

In the acute care hospital setting, the influential role of

the chief nursing officer is instrumental in effecting

change in the clinical practice environment. The will-

ingness to change among CNOs influences the success

of the diffusion of an innovation. This study is unique

because of the focus on the descriptive characteristics of

innovativeness of the CNO, the Magnet status com-

parison and the statewide sampling of CNOs of acute

care hospitals. The recordings of examples of the

CNOs� most innovative projects are also unique. Most previous research on this topic is qualitative and does

not provide a descriptive analysis of the innovativeness

of nurse leaders.

Greater experience correlated with larger numbers

and different types of innovation projects. The man-

ager�s personal characteristics have a significant direct effect on the adoption of innovation (Greenhalgh et al.

2004, Damanpour & Schneider 2008). The present

study would suggest that the manager�s education level and professional experience influence their willingness

Table 1 Innovativeness scores by age, edu- cation, chief nursing officer (CNO) years of experience

Innovativeness scale score Mean (SD) F

Innovativeness diversity index Mean (SD) F

Age <50 60.22 (6.24) 0.04 3.11 (1.61) 0.26 50–59 59.69 (6.59) 2.87 (1.14) 60+ 59.86 (8.25) 2.95 (1.43)

Educational attainment £ BS 57.92 (7.18) 2.72 2.25 (1.49) 4.47**

MS 59.50 (6.8) 2.90 (1.23) Doctorate 63.83 (5.7) 3.75 (.97)

CNO years experience <5 years 58.06 (6.95) 2.11 2.58 (1.38) 4.37** 5–10 years 60.20 (7.3) 2.83 (1.32) >10 years 61.40 (5.67) 3.47 (.90)

Significance *P < 0.05, **P < 0.01; d.f. = 2.

Table 2 Willingness to change category by education and chief nursing officer (CNO) years of experience

£ BS N (%)

MS N (%)

Doctorate N (%)

<5 years N (%)

5–10 years N (%) 10 years N (%)

N (% of total) 12 (11.3) 82 (77.4) 12 (11.3) 36 (34.0) 40 (37.7) 30 (28.3) Laggards 1 (8.3) 14 (14.0) 1 (8.3) 6 (16.7) 6 (15.0) 4 (13.3) Late majority 7 (58.3) 26 (31.7) 4 (33.3) 18 (50.0) 12 (30.0) 7 (23.3) Early majority 4 (33.3) 30 (36.6) 1 (8.3) 10 (27.8) 12 (30.0) 13 (43.3) Early mdopters 0 (0.0) 9 (11.0) 4 (33.3) 1 (2.8) 8 (20.0) 4 (13.3) Innovators 0 (0.0) 3 (3.7) 2 (16.7) 1 (2.8) 2 (5.0) 2 (6.7)

r = 15.93, P = 0.04 r = 10.431, P = 0.24

Innovativeness of nurse leaders

ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 431–438 435

to change and the number of innovative projects

implemented. The main drivers of change are the

characteristics of those driving the change: their moti-

vation, leadership and commitment (Longo 2007).

The CNOs recorded examples of their most innova-

tive projects and their level of involvement in the pro-

jects. Schroeder et al. (1986) observed that a hands-on

approach from top management was critical to the

technical, managerial and institutional support of an

innovation. The leader provides the context for change

(Greenhalgh et al. 2004). Key strategies for the CNO as

a change agent include building a business case and

communicating effectively about an innovation. The

current study suggests that CNOs of organizations

where more projects are implemented, with a higher

innovativeness diversity index, may create an environ-

ment that is positioned to accept change and have a

readiness to integrate change into the manner in which

daily work is accomplished. The leader builds a case

and is effective with the communication needed to bring

about change. The nurse leader needs to prepare

the environment, educate the staff, involve staff in the

change process and communicate the value of the

innovation. Without the support of leaders, who in

turn support staff with the use of evidence-based prac-

tice, moving clinical practice forward is very difficult

(Penz & Bassendowski 2006).

There was no difference in the innovativeness of

CNOs of acute care hospitals by Magnet status. The

results would suggest that hospital Magnet status does

not predict the innovativeness of the CNO. However,

the results do suggest that the innovativeness diver-

sity index of the CNO reflects their personal innova-

tiveness.

Limitations of the study

The selection of the statewide setting limits the gener-

alizability of the findings; however, it was the most

appropriate setting for the study of innovativeness of

CNOs and Magnet status. The series of mailings were

effective because of the consistency and repetitive nat-

ure; however, it was expensive. As there was no course

description for each leadership course listed or course

objectives, an assumption was made that there was

consistent interpretation of the meaning of each course

by title. The listings of the types of innovations imple-

mented were presented as they appear in the ANCC

Magnet Recognition Program criteria (2008). This was

done to minimize erroneous translation; however, the

phrases were long and complex, which may have

influenced the interpretation of statements. The open-

ended question asked for �one of the most innovative projects implemented�; however, it did not ask for the strategies utilized to implement the innovation, or how

the CNO involved staff in the innovation. The inno-

vative leader, with higher scores, may be more willing

to respond to the survey and share more experiences

than the low scorer. The willingness-to-change portion

of the survey recorded a reliability of 0.72 (alpha

coefficient), which is lower than Hurt et al.�s (1977) scores of 0.83 and 0.80. Respondents may have been

able to interpret which of the answers was the desirable

response. The CNO would want to be scored positively

toward innovativeness.

Implications for nursing management

As there is little evidence found in the current literature

to guide the description of innovativeness for nurse

leaders, the present study adds to this body of knowl-

edge. Graduate level education, years of CNO experi-

ence and leadership course completion were identified

as significantly influencing innovativeness of CNOs.

These characteristics of the CNO may support organi-

zations and health care at large to implement the evi-

dence-based practice needed to continuously improve

the quality of care delivered and patient outcomes. The

CNOs related many initiatives they had implemented to

meet the regulatory demands of the CMS, the Joint

Commission (TJC) and the Institute for Healthcare

Improvement (IHI). The present study identifies char-

acteristics of the CNO that can support the demands of

the health care industry. The open-ended comments

speak of the desires of nurse leaders to improve practice

and make practice safer, more effective and more sat-

isfying to the nurse. The present study strived to identify

the characteristics that support these initiatives. The

greater number of achievements, longer time of expe-

rience and advanced education support innovativeness.

Generating good practice ideas through research is not

the problem, but getting good ideas to be used is the

challenge, and the essence of the diffusion of innovation

(Berwick 2003). Leaders with the characteristics de-

scribed in the present study support the diffusion of

innovation dissemination.

Leadership is instrumental to practice standard sus-

tainability (Gustafson et al. 2003). The present study

supports the development of nurse leaders through

completion of leadership courses that may support

CNOs to achieve greater success in project implemen-

tation. CNOs, as hospital leaders, are often the indi-

viduals with accountability for implementation of

innovations. The endorsement and active support from

K. Clement-O�Brien et al.

436 ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 431–438

top management play a key role in project adoption

(Grover 1993).

Recommendations for future research

The leader provides the context for change (Greenhalgh

et al. 2004). The structure of the communication,

organizational process and strategies that are used

influence the spread of the innovation. Innovation de-

pends on teamwork; however, building leadership

capacity and participation on all levels becomes a crit-

ical strategy for generating new ideas and sustaining the

change momentum (Kimball et al. 2007). For the fu-

ture, study of the time it takes to implement projects,

the sustainability of projects and further work to iden-

tify successful strategies for implementing innovations

would enrich the body of nursing knowledge. The staff

is able to act on new opportunities when the leadership

team is strong and shares a common goal (Litaker et al.

2008). If internal support is not in place, adoption of an

evidence-based practice change remains a challenge

(Bradley et al. 2004). The nurse leader needs to be in-

volved in the change process.

Conclusion

Graduate level education, years of CNO experience and

leadership course completion were identified as signifi-

cantly influencing innovativeness of CNOs. The

opportunity to identify the willingness to change among

nurse leaders has helped identify characteristics that

support a more rapid diffusion of an innovation and the

delivery of quality patient care (IOM 2001). The main

drivers of change are the characteristics of those driving

the change: their motivation, leadership and commit-

ment (Longo 2007). Personal characteristics have a

significant direct effect on the innovation adoption

(Damanpour & Schneider 2008).

The ANCC Magnet criteria are focused on evidence

that promotes outcomes and superior performance. The

description of the innovativeness of leaders presented in

this research may assist organizations and their CNOs to

organize descriptions for Magnet recognition pro-

gramme evaluation, as well as add to the description of

sources of evidence for innovation provided by the

ANCC. The identification of the leader characteristics

that support a willingness to change among nurse leaders

will assist nurse leaders to: lead change, assist the work-

force to accept and adopt changes in a more efficient and

timely manner; assist organizations to achieve a more

rapid diffusion of an innovation; and assist staff to deliver

safe, effective, patient-centred, timely, efficient and

equitable patient care (IOM 2001). Staff are able to act on

new opportunities when the leadership team is strong and

shares common goals (Litaker et al. 2008). If internal

support is not in place, adoption of an evidence-based

practice change remains a challenge (Bradley et al. 2004).

The results provide evidence to support health care

organizations to meet public and regulatory demands.

The characteristics of innovativeness for nurse leaders

presented in the present study may assist organizations,

CNOs and the Magnet recognition programme to de-

scribe innovativeness that supports organizations to

continuously improve the quality of patient care.

Acknowledgements

The authors would like to thank Carol M. Musil, PhD, RN, FAAN, Professor of Nursing, Case Western Reserve Univer- sity, Cleveland, Ohio and Mary Jo LaPosta, MS, PhD, RN, Vice President/Chief Nursing Officer, Saratoga Hospital, Saratoga Springs, New York, for their guidance and support throughout the Doctor of Nursing Practice Thesis Defense.

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JCN JCN Excellence in Practice Awards runner-up, Lorna Glenn discusses the process of change management when introducing the concept of clinical supervision within a community nursing team

CHANGE MANAGEMENT

Key words: Cflange agents Resistance to chani Leadership styles

Implementing change

Lorna Glenn Dip HE Nursing (Adult), BSc (Hons) Community Health Nursing is a District Nurse, Handsworth, Birmingham

Article accepted for publication: September 2009

H ealth professionals have beenfaced with exfraordinary changesin recent years, due to major developments in clinical practice and reorganisation within the work place (Upton & Brooks, 2000). Consequently, change can have a devastating effect on people exposing them to feelings of loss, doubt, stress and impulsiveness, as well as feelings of comfort, where they experi- ence a sense of achievement, pride or belong (Marquis & Huston, 2006). In the light of these predicaments, it is viable to adapt to being an effective change agent throughout the change process, as it is vital within the role of the leader (Marquis Sz Huston, 2006).

For these reasons, this article seeks to initiate and discuss a planned change within a district nursing team, whereby clinical supervision was introduced to the staff members in offering support and guidance, in delivering safe, effective care to patients. Although the change agent was assumed, a transformational leader- ship style and a normative-re-educative approach to change were also adopted, where all identified stakeholders were encouraged to act as change agents also. The strategies used for the change process were based upon Lewin's (1951) and Roger's (1995) theory of change. Driscoll's (2007) force field analysis was incorporated to illustrate the forces acting to promote or restrain the successful implementation of clinical supervision.

Rationale Clinical supervision within the nursing profession is a relatively recent innova- tion that found itself in publication of the Department of Health (DOH) document, A Vision for the Future (DH, 1993). More recently in documents such as 'Our NHS Our Future' and' High Qualify Care for All', the Darzi Reporf emphasises the impor- tance of patient safety as being the first element of introducing quality care by reducing avoidable harms to patients (Darzi, 2008). Furthermore, research identified key factors in improving staff engagement, by recognising the aim of clinical supervision which is to identify training needs and promote confidence through supervision (DH, 2008) which is defined as:

'An exchange between professionals to enable the development of professional skills' (Butterworth's 1998:12)

This definition shows a similarity in relationship of shared experiences between both parties involved in the dialogue, whilst learning from each other. However, Lynch et al, (2008) suggest that clinical supervision is more of an interaction between two or more professionals, whereby the focus is to provide support for supervisee(s) to promote self awareness, professional development and growth in the context of their environment. For this reason, the innovation of clinical supervision will be based around these definitions, as the supervisor and supervisee not only shares joint responsibility, but they also seek to support each other.

Often there is a theme in the literature describing what clinical supervision is not, rather than what it is. However, several authors advocate that clinical supervision is not a means of controlling individuals, nor a system intended to discipline practitioners undergoing clin- ical supervision (Lynch et al,, 2008; Fejes, 2008; Clouder & Sellars, 2004). In consid- ering the definitions highlighted earlier clinical supervision should be seen for what it is.

Organisational mapping Prior to any innovation taking place, a comprehensive analysis of the organisa- tion is essential (Cutcliff & Bassett, 1997). Upton and Brooks (2000) suggest organi- sational mapping is a necessary technique that can be used to measure the total environment influenced and affected by the system we want to change. When any change transpires there are stakeholders involved who will be affected to a greater or lesser degree. This is illustrated as concentric rings which are known as the interacting level of diagnosis (Figure 1 ),

In this particular instance, the changes that clinical supervision will affect are the district nurses (stakeholders), in terms of providing support and guidance for the team. It is important to identify people most affected by the change, since funda- mental to creating a change culture, is getting the commitment and involve- ment of the stakeholders and using their energy and expertise to generate and sustain the change (Upton & Brooks, 2000).

The community trust will also be affected by the change, in that practi- tioners who are supported will

10 Journal of Community Nursing September/October 2010, volume 24, issue 5

CHANGE MANAGEMENT

ORGANIZATION

EXTERNAL ENVIRONMENT

Figure 1: The interacting levels of diagnosis

experienced less stress and consequently have less time off work. The general practitioner will also benefit through nurses improving their standards. In addition, the patients may benefit from staff becoming more proficient in service delivery. However, one has to bear in

mind, the lack of experiential evidence highlighted within the literature pertaining to patient satisfaction (The NHS Confederation, 2008).

In order to facilitate the innovation within the district nursing team, a leader- ship role had to be assumed. Research on

leadership demonstrates that there are many styles of leadership, however, it is recommended that the approach used is appropriate to the demands of the situa- tion (Marquis & Huston, 2006; Norton, 2007). As well as possessing knowledge, energy, enthusiasm and the persistence required to drive change forward, effec- tive leaders have also been described as having the ability to help colleagues articulate and develop i(deas (Goodwin, 2006).

Managing ciiange For the purposes of managing change and innovation, Goodwin (2006) proposes two leadership styles. The transactional leader who is concerned with bargaining and focusing on management issues over a short term and the transformational leader, who has a long term focus on visions, ideas and prompting ownership whilst aiming to empower others to make changes. Conversely, the transactional approach to leadership has been criticised as it can lead to loss of vision and energy, whereas a transformational leader can keep a distance and thereby retain a view of the whole (Frankel, 2008). Nevertheless, Northouse (2007) and Goodwin (2006)

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Journal of Community Nursing September/October 2010, volume 24, issue 5 11

CHANGE MANAGEMENT

warn that although transformational qualities are highly desirable, they need to be joined with the more traditional qualities of day to day management skills, if the transformational leader wishes to avoid failure.

Considering the need to have both the vision to promote change and implement practical skills successfully, a combina- tion of the transformational and transactional leadership styles were adopted in implementing clinical super- vision. By combining these approaches to leadership, a democratic or participa- tive model was agreed, whereby team members were involved with the deci- sion making along with the team leader and their views are considered equally. Moreover, the author was able to foster staff members' ownership of the change, encouraging them to work collectively, as well as providing them with practical help and support, such as providing information on clinical supervision. Frankel (2008) recognises that this style is considered to obtain more cooperation and commitment from staff. However, the weakness of this style is that some members of staff with less experience may need more direction and stronger tactics (Northouse, 2007).

Resistance to change Driscoll (2007) identified two types of forces within an organisation described as either pushing or resisting forces (referred to as a force field analysis). The pushing forces are the strengths within the culture that aids with the implemen- tation of the change. Whilst the resisting forces are negative aspects of the culture or a weakness that can slow down or impede the change. In order to plan and implement change the manager has to examine the forces and shift the balance between these two forces.

Individuals to whom the change is presented may resist change because of the lack of knowledge about clinical supervision, anxiety about what change may bring and changes in work practices. Resistance to change is not necessarily a negative thing, because it may temper and prevent a rush into a situation without planning (Harvey, 1995). Never- theless, Buonocore (2004) observed that no matter how well planned a change may be, there will always be some resist- ance. In fact, Curtis and White (2002) proposed that change without resistance is no change at all, and so is viewed as an illusion of change. As resistance should always be expected, it is essential that nurses are able to recognise it, then plan

and implement strategies to reduce it (Upton & Brooks, 2000).

Nevertheless, the job of the change agent must be to increase the pushing forces, in ensuring that change is brought about within this particular implementa- tion of clinical supervision. This is achieved by motivating staff to take ownership, involving them in the proposed innovation and emphasise clinical supervision is about support, as opposed to a control tool to regulate prac- tice (Cutcliffe & Bassett, 1997). In line with Woodcock's (1979) theory which focuses on team development, the district nursing team is a mature team where feelings are open, a wide range of options are considered and working methods are methodical. The team leader contributes to the work of the team and all team members are seen to be fiexible. The team recognises its account- ability to the wider organisation and team members are aware of their respon- sibilities. Therefore, it is not a team that functions in isolation.

Change innovation/action plan In implementing clinical supervision into the district nursing team, a change agent is required. Flunder (2009), describes a change agent has a person who leads by example and as a result generates ideas, introduces innovation, develops an appropriate climate and then implements and evaluate the proposed change. Enfold within the description of the change agent is the person's ability to be a creative thinker, a strategic planner and one who sets the scene for the change to happen. Flunder (2009) identifies two types of change agents; these are the external and internal change agents. For this particular inno- vation the author adapted the internal change agent as this type of agent is recognised to be familiar with policies, procedures and politics of the organisa- tion (Recklies, 2001 ).

Organisational change In carrying out the organisational change, it was necessary to select a strategy for change to facilitate the change process. By choosing a change strategy, this not only reduces resistance, but it encourages commitment to the envision change (Upton & Brooks, 2000). The proposed strategies the change agent used were Lewin's (1951) change theory and Rogers (1995) diffusion theory. Lewin (1951 ) suggests that change can be brought about by a three step process: unfreezing, moving and refreezing.

Rogers (1995) describes five stages in the implementation of change, these are knowledge, persuasion, decision, imple- mentation and confirmation which is an expansion on Lewin's three phrases of change. Rogers (1995) proclaims that even if change is rejected at the first attempt, then there is no reason why it cannot be implemented again at a later stage and if a different approach is taken, it might be implemented successfully. However, Cutcliffe and Bassett (1997) recognised that if change is accepted, one cannot presume permanence, hence the reason for using both strategies.

In considering Lewin's (1951) unfreezing stage, here the motivation to create change is born. This stage is considered vital, as prior to any change occurring, the people affected by the change must believe that the change is necessary (Burnes, 2000). Therefore, it is the responsibility of the change agent to firstly build up trust, respect and moti- vate the team. Goodwin (2006) stresses that motivation is essential in promoting change and highlighted that this provides momentum to disturb the normal equilibrium of existing habitual practices. It is within this stage that present conditions are critically analysed and are assumed to be frozen. Once the present level of equilibrium is known, a plan to maximise and minimise driving forces can be undertaken (Burnes, 2000).

During the unfreezing stage the author incorporated Chin and Benne's (1976) empirical rationale approach to unfreeze individuals. This approach assumes that individuals will adapt the proposed change if it can be rationally justified and again be demonstrated. Therefore, the author proposes to carry out educational sessions as well as provide evidence base information around the importance of clinical supervision. This is identified in the first stage of Rogers (1995) theory as 'knowledge', which is making the team aware of the innovation and its purpose. Moreover, if the armouncement of the change can be made well in advance of the implementation, the team will have time to adjust to the idea of change. This view is supported by Rogers (1995) second stage 'persuasion'.

The third stage of Rogers (1995) theory is 'decision'. This is where the team comes to a decision as to whether or not to accept clinical supervision via a team meeting where their views are heard. At this stage it was useful to incorporate Chin and Benn's (1976) normative re- educative approach, as this allowed team members to participate with the change

12 Journal of Community Nursing September/October 2010, volume 24, issue 5

CHANGE MANAGEMENT

agent in identifying problems foreseen in clinical supervision. Implementing a questionnaire in conjunction with the strategy was used to determine who was desirous of implementing the change and who should be supervisor. The advan- tage of the questionnaire is that it allows anonymity, where staff can respond honestly, feeling less pressured in deciding what models to use and how clinical supervision should be imple- mented (Haffer, 1986). Lynch et ai (2008), believes that supervisors should not be hierarchical and that peers are therefore best suited to fulfil the supervisory role. Conversely, Hyrkas et al. (2005) found that staff welcomed clinical supervision when it was carried out by a line manager, nevertheless Jones (2006) argued that managers who have no clin- ical function should not be involved in clinical supervision. Erom the change agent perspective the supervisory role should be taken on by an individual who is knowledgeable and experienced in order for the benefits of this change to be maximised.

The moving phase of Lewin (1951) equates with Rogers (1995) fourth stage theory of 'implementation', which is where the change is employed. If the

equilibrium has been upset in a favourable fashion, such as the driving forces exceed the restraining forces, then change occurs (Driscoll, 2007). Analysing the results of the question- naires will enable the change agent to determine who the team would like to be supervisor, what models of clinical supervision they would prefer to use and how the team would like clinical supervi- sion to be implemented. Jones (2006) believes that clinical supervision should take place with an agreement or contrac- tual framework. The proposed contract would include a definition of supervi- sion, the time involved and the location where supervision will take place. Record keeping also needs to be discussed and guidelines drawn up as they may have to be disclosed as evidence in court (Royal College of Nursing, (RCN) 2003). Issues of confi- dentiality .should be clearly addressed in the contract to prevent either party feeling compromised by the possibility of conflict, this is particular important given the legal duty of care (Nursing & Midwifery Council 2008).

Various models can be used when carrying out clinical supervision (RCN, 2003); however the model used will

depend on who the team chooses to be supervisor, where the change agent will seek to implement one to one or group supervision. Jones (2006) believes one to one supervision offers more opportuni- ties for participants to counsel each other, whilst reflecting on practice. Alterna- tively, group supervision has greater benefits, in that a broader perspective can be gained. Although group supervision has got its advantages, one has to bear in mind that it must be well facilitated so that its effort can be constructive and objective (McBride, 2007).

Refreezing The refreezing stage is the final stage of Lewin's theory, which aims to restore the equilibrium by being supportive and listening to the group's apprehensions, following the trial period of clinical supervision. Marquis and Huston (2006) recognise that refreezing has been estab- lished when new attitude and behaviour are apparent by the team, hence positive talk about clinical supervision and actions and statements are consistent. In Rogers (1995) 'confirmation' stage, which parallels with Lewin refreezing stage, the team reinforces that the deci- sion to implement clinical supervision is

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lournal of Community Nursing September/October 2010, volume 24, issue S 13

CHANGE MANAGEMENT

acceptable. The change agent would set aside time for the team to evaluate the change through reflection on the effec- tiveness of clinical supervision and identify any problems. Subsequently, the change agent would incorporate three monthly re-evaluation of clinical super- vision. This would allow the change agent to gain overall comprehensive picture of how people are adapting to the change, giving the team members time to settle into the new way of practicing. Furthermore the change agent must be willing to take calculated risks and be able to cope when set back occurs (Timmons, 2008).

Conclusion Clinical supervision is recognised to be a valuable tool for nurses benefiting patients and NHS organisation. Before clinical supervision can be employed, however, the organisational culture must be examined. Introducing the innovation of clinical supervision can be a complex operation. Therefore, combining Lewin's (1951) and Rogers (1995) strate- gies enables the change agent to understand the process of change and to minimise resistance. Nurses taking on the role of clinical supervisor must be knowledgeable and skilled; therefore the need for ongoing training for profes- sional development is required. Furthermore, having mandatory study days to ensure that clinical supervisors and supervisee are kept updated with current trends and practices would raise the profile of clinical supervision. Addi- tionally having structures in place to monitor performances such as peer review would serve as a mechanism to ensure that clinical supervision remains an effective tool in the development of nursing practice.

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