Using strategies of persuasion to achieve small wins

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Using strategies of persuasion to achieve
small wins

• Trish Reay (U of Alberta)
• Karen Golden-Biddle
• (Boston U.)
• HEC Montreal, Nov. 15/ 07

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Presentation based on 2 papers

• Reay, Golden-Biddle GermAnn. Legitimizing a new
  role Small wins micro-processes of change.
  Academy of Management Journal. 2006.
• Reay Golden-Biddle. Strategies of Persuasion
  The Efforts of Nurse Practitioners in
  Institutionalizing a New Role. Forthcoming book
  chapter in McKee, L., Ferlie, E. Hyde (Eds.),
  Organizing and Re-organizing Power and change in
  health care organizations. London Palgrave

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Theoretical Background

• Institutional change
• Combination of institutional forces and actor
  agency required for change to occur.
• Change is usually exogenous.
• Sometimes change is endogenous.
• Actors must become dis-embedded in order to
  function as change agents.

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Jolts
De- institutionalization
Pre-institutionalization
Theorization -justification -legitimacy
Re-Institutionalization
Diffusion
Fads or fashions
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Profiled case of change

• Introduction of new role NPs into well
  established health system (Alberta).
• Nurse practitioners are RNs with additional
  education and experience. In particular, they can
  diagnose, treat and prescribe.
• Embedded individual actors attempting to
  accomplish endogenously driven change
• How change in institutional practices can occur
  through
• purposeful, continual actions of determined
  individuals who draw on their institutional
  embeddedness as resource

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Prior understanding of change in institutional
practice

• Developed from macro level studies of
  organizational actors
• Individuals within organizations perceived as
  passive participants in change process
• Limited view of micro-processes (exceptions
  Zilber, 2002 McGuire et al., 2004)
• Research Question
• How do individuals draw on their embeddedness to
  enact change in institutional practice?

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Research Approach

• Longitudinal and processual study of change
• Opportunity to gather rich field data about early
  attempts to institutionalize change
• Collected three types of data over 4 years
• Interviews Meeting observations Archival data
• Iterative approach to theorizing
• Data, our analyses, reading extant literature

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Legitimizing a new way of working

• I guess when youre trying to make a change in
  something thats been established for such a long
  time, you just have to keep at it. Its
  persistence, persistence and persistence. And I
  think I probably need a little more patience,
  because to keep at it that is tough but then
  all of a sudden resistance backs off. I think
  were slowly getting there but I feel like Ive
  been swimming uphill. (NP)

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Findings

• Ongoing and simultaneous activities by NPs and
  managers in attempting to legitimize new role
• Not yet taken for granted but no longer
  scattered, isolated examples
• Still need to justify role
• Efforts to achieve change in institutional
  practice constituted in three micro-processes and
  small wins

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1. Cultivating opportunities to advance change

• Knowing when and where to take action for maximum
  impact
• Recognizing windows of opportunity
• Sometimes creating windows of opportunity
• Drawing on experience and knowledge of this
  specific health care delivery system

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Cultivating opportunities to advance change

• We need to institutionalize the use of NPs and
  quickly, while there is a window of opportunity.
  The conditions are favorable right now because we
  have a shortage of medical residents, but I think
  the window will definitely close in the future.
  (Manager)
• Ive met moms in the grocery store and they had
  questions about their babies and Im not going to
  say, My shift is over, Im not going to do
  that. You cant do that in a small townrural
  people here are very connected and they remember.
  If you help them, you will get it back tenfold.
  (NP)

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2. Fitting change into prevailing systems and
structures

• Classifying NP role as nursing
• Keeping role outside medicine
• Incorporating job description into HR systems
• Job descriptions Salary banding
• Fit with national, provincial associations
• Ongoing attention to remove system barriers
• List all the problems work on them one by one

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Fitting change into prevailing systems and
structures

• Im not a physician extender! Im a nurse. Nurse
  practitioners are not mini-doctors Nurse
  practitioners just try to be better nurses. (NP)
• In my mind, the NPs should fit among our most
  professional nurses. They should be our most
  expert group of nurses and in addition to the
  clinical work that they are doing they should be
  advancing the profession of nursing. They
  shouldnt be mini-doctors. They shouldnt be
  replacement doctors. They shouldnt be those
  things. (Manager)

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3. Proving the value of change to others

• Act to gain trust, responsibility, recognition
  for NP role
• Convincing people one by one
• showing capability with new tasks
• Physicians nurses patients families
• Developing more general recognition of
  capabilities
• Draw on experiences in similar health care
  delivery settings

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Proving the value of change to others

• Physicians sometimes look at the title and are
  leerybut what breaks through the barrier is
  getting to know them showing them what you
  know, partnering with them, and then you slowly
  see the skepticism being dissolved they start
  handing you more and more. (NP)
• Ive worked in various places and what Ive
  learned over time is that you cant come in as a
  bull moose. I know this all like that just
  doesnt work. So you just kind of come in and you
  just kind of quietly move through and do a few
  things..

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Small wins

• Controllable opportunities of modest size that
  produce visible and tangible outcomes (Weick
  2001)
• Not big events and often go unnoticed until
  accumulation of them
• Mark and consolidate progress along the way,
  while shifting attention/energies to next arena
• Example Executive committee approval (including
  Medical Affairs) of model that classified NP as
  nursing role
• Signaled next direction of developing
  implementation plan

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Conclusions

• We showed how institutional practices can occur
  through purposeful and continual action of
  seasoned individuals who capably draw on their
  embeddedness as resource in implementing change
• Not just momentary action, but continual
• Not just one level but multi-level
• Not just tenure or longevity, but ability to tap
  experience and knowledge as resource

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Our forthcoming book chapter

• Based on expanded data set (5 years) continuing
  to follow creation and expansion of NP role.
• 60 interviews meeting observations documents
• Build on previous findings take an even closer
  look at experiences of front line professional
  in institutional change.
• Focus on political entrepreneurship as important
  component
• individuals engaging in an oblique style of
  politics where changes occur under the radar
  (Buchanen Badham, 1999)

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Research Question

• From previous research
• NPs engaged in efforts to persuade others to
  change their established work routines.
• Tried to convince others to do something they
  would not otherwise do (example of use of power)
• We wanted to understand these actions by
  investigating power dynamics within an
  institutional change perspective.
• Question How do individual actors try to
  persuade others to accommodate the introduction
  of a new role?

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Two general strategies

• Consistently and persistently explaining the NP
  role and its advantages to others. For example
• Talking to everyone who would listen
• Making work better for others so that there were
  few disadvantages and many advantages of
  accepting NP role. For example
• Reduce physicians hours of work
• Allow physicians to focus on complex cases
• Provide rapid response for nurses
• Surprisingly, both strategies used for 5 years.

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What happened with long term use of same
persuasion strategies?

• In some settings, NP role is taken-for-granted.
  In others less clear.
• Continual repetition re What is an NP? What can
  she or he do?
• Always encountering new people
• Adverse effects from Strategy 2 (Making work
  better for someone else)
• Turning into handmaidens
• Increasing frustration.

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Quotes regarding frustrations

• Well, Ive been the one that stays late. Last
  week, two duty docs couldnt get in on time
  well it was me that stayed late. Its going to
  happen to me once this week, and then Im going
  to say to her the resident, no, youre staying
  because I need to go home today.
• I So, this physician wanted you by his side all
  the time?
• R Yes, and I was having difficulty with this
  physician because he did not understand the nurse
  practitioner role. He didnt understand that it
  was more than being the physicians handmaiden,
  and there was no moving him beyond that in spite
  of my best efforts. I talked with management,
  and then I talked with the physician and said, I
  cant do this.

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More quotes

• I think were helping out physicians and it
  sometimes worries me a little bit that we do a
  lot of their discharge work. So, well do the
  discharge summary -- which is tedious, but it
  frees them up so that they can go see people
  waiting in Emergency, or review consults with the
  residents or fellows. That seems like a really
  good use of their time, but if its just so that
  they can go have coffee with their cronies while
  the NP is doing five or six discharge summaries,
  I dont think thats a good use of time.

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Conclusions

• Highlight the political efforts of individuals in
  process of institutional change
• Nature of under the radar strategies
  political dynamics may result in unexpected
  consequences e.g. handmaidens
• Individual efforts may require organizational or
  system level support to be successful
• Important role of persuading others needs more
  attention.

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Future investigations

• NPs are one of four cases we are investigating
  how individuals attempt to diffuse new ways of
  working.
• We are intrigued with political work of
  individuals in institutional change.
• Different sources of power
• Persuasion vs Use of authority
• QUESTIONS? COMMENTS?