Sunday, April 15, 2007

Structural Barriers to Change and Innovation in Nursing

Beatrice J. Kalisch, Ph.D., RN, FAAN, Titus Professor of Nursing, University of Michigan
Suzanne Begeny, MS, RN, Ph.D. Applicant, University of Michigan

This blog is based on an article published in the peer-reviewed academic journal Nursing Administration Quarterly in October/December 2006 (Vol. 30, No. 4, pp. 330-339). It is available for purchase at the journal’s website under the title Nurses Information Processing Patterns: Impact on Change and Innovation. This blog summarizes and extends the findings reported in that article. Information on the “I Opt” tools used can be found on Information on the intellectual underpinnings of “I Opt” technology can be found on

The focus of this research was the ability of nurses to accept, adopt and sponsor change in an era of high volatility in health care. The research was conducted at two geographically separated hospitals and involved a total of 578 nurses.

The research drew on the fully validated “I Opt” instrument that measures information processing preferences. It is based on the simple idea that the kind of information sought and accepted from the environment limits or facilitates certain types of behavior. For example, if you do not pay attention to detail, your responses cannot be precise. It does not matter how you "feel" about it. Similarly, if you choose to rigorously apply well-understood methods, you foreclose your ability to discover new, groundbreaking things. Closely following established methods blinds you to unexpected options. By governing the knowledge available a person’s "I Opt"
(Input-Output-Processing-Template) profile systematically governs the behavior that can and will appear.


The study was designed to address specific hypothesis with a high degree of academic rigor. Statistical significance testing used the academically accepted standard of p<.05 (95% probability that the result was not due to chance) or better. In the journal these findings are presented in a standardized academic format. Here they are presented in an operationally accessible manner more useful to executives and managers who are positioned to make use of them.

Finding 1: Nurses Differ Markedly from Non-Nurses
Nurses were compared to other functional areas. These areas included:

Customer Service Personnel (n=599)

Hourly Industrial Workers (n=71)

Plant Operations Management (n=593)

School Teachers (n=608)

Engineers (n=945)

Scientists (n=48)

Corporate Managers (n=721)

The findings indicated that nurses most closely resemble Customer Service Personnel. Customer Service is typically involved in authoritatively answering client questions by referring to approved information sources. There was no significant difference across all four “I Opt” Strategic styles between nurses and customer service personnel.

At the other extreme, nurses had significant differences along all four “I Opt” Strategic styles with Engineers, Scientists and Corporate Managers. These disciplines consistently scored higher in the unpatterned input strategies of Relational Innovator
(ideas) and Reactive Stimulator (decisive action) than their nursing counterparts. These are the adaptive styles that are able to initiate and accommodate change with relative ease.

In the middle zone, nurses were significantly less idea oriented
(RI) than schoolteachers and Plant Operations management. The nurses significantly exceeded these functions in disciplined action (LP). This suggests that these areas will find change and innovation more palatable than will nurses. Hourly Industrial workers significantly exceeded nurses in both disciplined action (LP) and analysis (HA) but equaled nurses in ideas (RI) and decisive action (RS).

The picture painted by this analysis is that nurses are among the least able to initiate and accept change among the functions reviewed. Their favored information processing strategy relies on certainty, precision and step-by-step operational knowledge. This posture forecloses information needed to initiate change
(unproven possibilities, unexpected associations, etc.) and accept it readily (e.g., a willingness to use tools that may not be fully specified).

Nurses can, of course, adapt to change. However, if the same methods as used for engineers, scientists and corporate managers are applied to nurses the road will be difficult. And, it will be difficult for everyone. Nurses are likely to feel emotional pain as they are forced out of their preferred approach to life. The sponsors of change will feel pain as they meet reluctance and resistance. Standard business school management strategies must be modified if they are to be fully effective in nursing situations.

Finding 2: Nursing Specializations are more Similar than Different
The nursing data identified the specialization within which the nurse respondents worked. These areas included:

Emergency Room
Intensive Care

The results of the research showed that there was no statistically significant difference between specialties in the disciplined action (LP) or analytical (HA) strategic styles. This means that all specialties are about equally committed to structured approaches.

There was some variation in unpatterned strategies (RS/RI). Nurses in Intensive Care and psychiatric were more idea oriented (RI) than the others. This seems to make some sense in that these areas are most likely to encounter cases that do not yield to standardized approaches.

The other nursing specialties scored significantly lower in either decisive action (RS) or novel ideas and approaches (RI). For example, surgical was significantly lower in spontaneous decisive action (RS). Again this makes sense. The operating room is a hierarchical system functioning under the direction of the surgeon. There is little room for independent nursing action.

This area of research has an implication. The commonality of disciplined action (LP) and analysis (HA) means that all of the nurses can be successfully approached using the same methods. This means that a uniform change management can be applied. The efficiencies available in a common approach can be captured.

Finding 3: Staff Roles are Different

The data collected identified the organizational role of the individuals sampled. This allowed direct comparisons of staff roles.

The first comparison was between Registered Nurses (n=344) and Nurse Aides (n=101). The Nurse Aides registered statistically higher levels disciplined action
(LP). In all other dimensions the RNs exceeded levels of the Nurse Aides. This suggests that the difficulties with change and innovation extend down the organization. The RN’s reluctance to change will be magnified by the Nurse Aides who support them.

The RNs were then compared to Unit Secretaries (n=40). Like the Nurse Aides, the Unit Secretaries are significantly more committed to disciplined action
(LP) than are the RNs. This means that there is still another layer of potential resistance to change that regularly interacts with and influences the RNs.

Finally, RNs were compare to Licensed Practical Nurses. The LPNs were significantly more committed to disciplined action
(LP) than are the RNs. Still another layer of change resistance is added below the level of the RN.

The general sense arising from this portion of the analysis is that the difficulty in accepting, adopting and sponsoring change is even more difficult than it first appears. The nurses rest on an organizational support system that is even more reluctant to change than they are. Since these support functions interact constantly with the RNs, they are positioned to magnify the RNs basic disinclination toward change. A difficult job has become more difficult.

The implication of this finding is that change initiatives must be organizationally sensitive. They must understand that addressing the RNs is not the end game. They must also address the levels organizationally below the RN. They must also understand that the RN will face a challenge when they ultimately accept change. They must then turn around and “sell” it to their support staff. This is likely to be as difficult as “selling” the change to the RNs in the first place.

Finding 4: Nursing Managers are Different than RNs

Staff nurses in all specialties (n=344) were compared to Nurse Managers (n=52). The Nurse Managers had much higher levels of RI
(ideas) and RS (decisive action). Overall, they resemble the average manager in other functional areas of society.

The implication of this is that Nurse Managers faces a challenge in sponsoring and guiding change initiatives. They do not think like the people that report to them. If they follow the “golden rule” they will do unto the staff as they would have done unto themselves. If they do this, the result will fall far short of optimal. The average RN does not want to be treated like a manager. They are sensitive to different variables, have different standards and are comfortable in different environments.

An analysis done outside of this study suggests that Nurse Managers strongly resemble managers in other industries. But there is a difference. In other industries the staffs being supervised are more diverse. Diversity means that there is likely to be someone relatively near the manager’s posture who can interpret matters in a way others can understand and accept. This creates “emissaries” to help managers “sell” their ideas and postures to the larger staff.

Nurse Managers do not have this luxury. Their job is more difficult. As shown in the next section, they face a solid wall of likely resistance. This means that Nurse Managers will need to be taught to lead people who are very different from themselves. Standard business school management education applies but must be supplemented if Nurse Managers are to be fully effective.


In addition to the distinctions cited above, another aspect of the nursing staff became visible in the course of the study. The nurses are tightly clustered. This condition is shown in Graphic 1. It shows the distribution of actual nurses in one section of a major hospital. It is representative of the general distribution encountered in both hospitals and across all areas.


Each dot on the graphic represents the centroid (point of central tendency) of the information processing profile a particular nurse. There is a clear clustering in the lower right hand quadrant. This is the “Conservator” pattern. It seeks to conserve or preserve things that are proven and known to work. People using it strive for excellence and precise execution. It is the information processing posture that has the most structural resistance to change.

The implication of this condition is that it magnifies the difficulty of change even further. The nurses are personally disinclined toward change and have a staff that is even more reluctant to change. In addition, there is now a coalition factor. Nurses are likely to magnify their reluctance to change in there interactions with each other. The tight clustering means that they tend to think alike and will see much merit in each other’s judgments. A very difficult job has just been made more difficult.

The overall picture painted by this research and outlined in this blog is that Change Management in nursing will present a unique challenge to all involved. The internal capacities of a hospital are likely to require external support if success is to be enjoyed. A possible general framework for approaching change in a hospital environment might be:


1. Clearly define the goals of the change initiative and the areas of the hospital affected.

2. Collect “I Opt” Survey data for all levels of the areas affected—from executives to Nurse Aides. There is no substitute for exact measurement of the current condition.

3. Plot and analyze the “I Opt” findings. Assess the difficulty likely to be encountered by areas affected. Develop an overall plan to initiate the change that will be common to all areas. Develop sub-plans that will address unique aspects discovered in the analysis.

4. Initiate context specific Leadership training for all managers affected. This is not generalized “Leadership” instruction. Rather each leader will be trained to guide the specific group for which they are responsible. This is performance based training rather than developmental. Tools like “I Opt” LeaderAnalysis™ can be used to support this process.

5. Apply the generalized program created in Item 3 above to the RNs and their staffs. Create and apply supplemental training appropriate to the education and role of each staff category
(e.g., RN, LPN, NA, US). Use the data collected in Item 2 above to design the supplemental material to exactly target the people involved.

6. Initiate a team based program to support the effort. This will help mitigate the coalition effects by focusing the people involved on their immediate interests and responsibilities. Tools like “I Opt” TeamAnalysis™ can be applied to initiate the effort.

7. Expect this process to take time. The Logical Processor style can and will change. But their information processing style demands a linear, step-by-step, exacting approach. The global Change Management programs currently popular in other industries are unlikely to yield any enduring gains.

8. If money is an issue, consider a viral strategy. Implement the above program in a relatively narrow area. People in other areas will see the success. At minimum, this will cause them to be more amenable to accepting the program. At best it will cause them to demand that they also get the benefits of the program. In this implementation the program is designed to act as a virus “infecting” other parts of the hospital in a positive manner.


This research has proven to be eye-opening. Specific measurement has replaced opinions. Fully grounded, validated tools have replaced “on the fly” surveys. A well-defined “what causes what and why” theory has displaced speculative guesses. Most importantly, “I Opt” technology actually works when it is used in field settings. It is an excellent mix of academic rigor and operational utility.

One mark of productive research is that it gives rise to more questions. This was the case here. As a result of this study we are now involved in another study. This study will trace the causes and implications of the high level of commonality found among the nurses. Even at this point we are able to see the outlines of the system that has created the current condition. But for now, the above is a step in the right direction.