Leading the Way
0 Informal leaders and cultural change
Informal leaders are crucial to the success of a change involving the nursing team, yet they are often overlooked. A literature search of nursing publications over the past 5 years found only a small sampling of journal articles that used the key words “informal leaders.” Leadership was often discussed in terms of positions and roles such as the “nurse manager” or the “nursing administrator.”
A review of the business and management literature also found a number of articles that dealt directly with leadership types related to change and teams but likewise did not discuss the role of informal leaders. The literature in both nursing and business describe the role of the “follower,” which displays attributes of the informal leader.
Nursing leaders at Wake Forest Baptist Medical Center tapped into the valuable resource of informal leaders when implementing a new professional practice model, which ultimately transitioned to a theoretical basis for our model of care.
Role of the informal leader
Before we could implement a change that significantly impacted nursing culture, we had to understand the nature of informal leadership. Teams may operate without explicitly assigned roles or established authority and as a result are classed as “informal.” Informal leaders in nursing are often nurses with a high level of clinical competency who are recognized as experts. This type of leader influences the group, comes from the team, and is chosen by the team.
Informal leaders don’t have the power to hire or fire other staff or influence compensation, but are often charismatic, with an outspoken nature or a strong will. Many informal leaders in nursing can be troubleshooters, super users, and champions who volunteer for extra jobs, serve on unit or hospital-wide committees, and shared governance councils. The informal leader is often tapped to provide feedback for new projects and may assume supportive roles such as preceptor, educator, or charge nurse.
Informal leadership is often an innate characteristic found in many nurses and integral to the role of “advocate.” Autonomy and empowerment in the work environment are key attributes supporting advocacy. Advocacy hones communication skills in order to follow through with, or change, interventions to create more positive outcomes for patients.
Informal leaders are in a unique position to influence the groups they work with. The influence can be used in a positive or obstructive way when change is involved. The informal leader is most influential when a group is first exposed to the change and the knowledge base is just beginning to form. As the group becomes more certain and experiences success, the informal leader’s influence may diminish.
Informal leaders can also be excellent followers. A follower is often thought of as weak, ineffectual, or prone to failure, but that is usually far from the truth. Followers can easily move in and out of informal leadership roles by supplying energy, enthusiasm, and interest. Followers often have an emotional attachment to the leader. A mentor relationship may exist and with cultivation the follower may become a formal leader. The relationship between the follower and leader varies depending upon the type of change or intensity of the change that is undertaken. Through the relationship with the leader, the follower may attain a fair degree of power.
Starting the change
We undertook a redirection of nursing practice: developing a formal model of care, or philosophy of nursing, articulated and owned by staff. The model of care transitioned to a deeper, theoretical format. We enlisted the support of informal leaders within pilot units to facilitate this change.
In preparation for implementing the new model, we used several techniques to strengthen a healthy and caring environment including role playing, team-building exercises, and leveraging empowerment and autonomy. Education and discussion took place in a venue incorporating all selected representatives and was led by a formal leadership team, with delegated responsibility for the model of care by the chief nursing officer (CNO).
Two RN nurse champions were chosen by the unit staff to represent their practice areas with recognized content experts and resources in caring practice. Relationship-based care was implemented using a wave progression where model units completed small, incremental steps through the Shared Governance structure. The Nurse Champions in Caring Practice led the education, discussion, and implementation of core strategies unique to each area. Strategies addressed care of patient/family, care of self, and care of team.
Staff developed two strategies specific to their work areas. As the model units completed their work, the next wave of practice areas participated in the same process. As all units stabilized, the champions assisted in planning the next transition in the model of care—operationalizing Jean Watson’s Theory of Human Caring.
Value of informal leaders
Informal leaders are important to any change process. The leader of the change needs to be available and provide information. Team members often address concerns and issues with informal leaders that are not shared with managers. The leader of a significant change event should be visible to coach informal leaders by providing direction with informing, educating, observing, and giving positive feedback. Teachable moments are critical and even small successes should be celebrated. Expectations should be clear, specific, and written. The Nurse Champions in Caring Practice were developed to coach the staff in their areas. Few limitations were put on the strategies and creativity was encouraged. Development occurred within unit-based shared governance councils so that all staff was a part of the projects.
Even when staff agrees that a change is positive, acknowledgement of loss of routine, feelings of competence, the formation of a new team and new role definitions is important in the transition period. Change is more successful if framed in terms of the effect on the team and should be addressed in a direct way. Questions that arise as a result of change often represent different points of view. The manager/leader may be outcome focused and ask:
- What is the goal?
- What will it look like?
The informal leader or staff may question how they are directly impacted by the change and ask:
- What am I getting?
- What am I losing?
- What will be different?
Tangible and discreet events may help smooth a change that impacts culture and allow for time to adjust emotionally within the context of a larger project. The analogy, “How do you eat an elephant? One bite at a time,” may elicit buy-in and investment from the informal leaders who can then act as coaches with other staff.
The informal leaders formed a core group who acted as role models and assisted other nurses in establishing appropriate patient goals, which helped make the change occur more smoothly. The informal leaders also provided follow-up and assistance if goals were missing.
An early success came when the CNO held town hall meetings about the new professional practice model. The meetings were web-cast throughout the medical center. A nurse in the audience shared her experience with several of the patient-centered strategies while her husband was a patient on a pilot unit. His course was complicated and difficult, but she felt there was a difference in his outcome as a result.
Resistance to change
When informal leaders do not exert a positive influence, it is important to provide information and directly address their role in the change. Resistance is a natural part of change and demonstrates that staff is engaged. The leader needs to maintain a clear focus during the transition period.
If the informal leader continues to resist, the leader should work to find a part of the plan that the informal leader can live with and enlist support for that part. This endorsement often positively affects the rest of the project. Regular meetings to provide information to all staff will narrow the gap between an informal leader and other staff, especially if the informal leader is highly resistant and blocking change. Involvement of all staff, focusing on development of the team and assessing the need for skills training, is equally important.
An example of resistance occurred when we began bedside reporting as part of patient care. Bedside reporting was supported as a tool to increase patients’ participation in their plan of care by providing direct information and improving communication between the staff at shift change as well as supportive of the development of the nurse patient relationship.
Report shifted from the conference room to the bedside and included nursing assistants. All staff felt uncomfortable with this change at first and hesitated to share sensitive information. They believed the histories were too complex to deliver in the presence of the patient. Their feedback reflected the challenge with communication skills in this type of report.
Several informal leaders were especially vocal and unless the manager invited them to move to the bedside, they resisted. Individual discussion and coaching occurred on several levels and actions were taken to avoid making this change a compliance issue.
The resistance was defused in several ways. Nurse managers met with charge nurses, the nurse champions. As informal leaders, the nurse champions addressed the issue through the shared governance process and developed a flow sheet for report that provided more structure for inexperienced nurses. The process was changed so that histories and sensitive information were discussed outside the room and report at the bedside was shorter in preparation for a fuller version in the future when the comfort and skill level of the nurses improved. The patient was asked if he or she preferred report given in front of visitors, or a private report. Additional inservices using low fidelity simulations were scheduled to discuss scripting, family or visitor appropriateness, privacy issues, and other barriers defined by the staff.
A valuable resource
The following strategies may be used to best integrate informal leaders into the change process:
- Obtain staff buy-in and feedback in the selection of informal leaders to lead change.
- Provide information and make it safe for informal leaders to ask questions, take risks, and challenge the change by providing different perspectives.
- Ask for suggestions and find common ground following feedback.
- Incorporate the feedback provided by the informal leader into the change or the process leading to the change.
- Break the change down into parts with the informal leaders sponsoring the different components to avoid the perception of one person “owning” the change.
- Give the informal leader frequent feedback and share outcomes.
Effective change requires a nursing team of members who feel that the environment is supportive, the change has value, and they are acting together. The informal leader is a critical part of this process.
Deborah L. Krueger is the director of nursing for the Center for Nursing Research and Magnet Program Director at Wake Forest Baptist Health, Winston-Salem, North Carolina.
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