Nursing Notes

February 2, 2010

The Myth of Best Practice

We all hear about Best Practice and Evidence-Based Practice and such in the nursing profession.  I read this article to see if looking at these ideas from another perspective would help.  I think it did.  I found several statements in the following article that “spoke to me” about how we go about facilitating change in our environments–with our peers, with our patients, with our families.

Mr. Frisina states the importance of “buying into” the reason for change as tantamount to making any change.  He also points out that knowing about the need for change does not equate with making the change, or making the change work.  This makes perfect sense to me.

Please read this article and let me know what you think.  Does it make sense to you too?

By Michael E. Frisina
Improving organizational performance is possible only when a leader convinces caregivers that changing behavior is paramount.

Michael E. Frisina

Similar organizations may share a common mission and purpose, but they do not share the fundamental elements of performance: the people who work there. For this reason, implementing a best practice that worked so well to improve organizational performance in one organization often fails to produce the same results when applied to a similar organization.

The core of culture is behavior—the “how we do it around here” common to any organization. You can try to import any best practice process into an organization, but when you fail to account for behavior—the collective behavior of the primary people responsible for doing 80 percent of the work of the organization—you are setting yourself up for failure.

However, when behavior changes are expressed in terms of the work people do, it’s much easier for people to understand the changes and why they are needed. For example, when nurses comprehend how their behavior impacts the safety and quality of care, they are more likely to change it.

Knowledge Does Not Equal Behavior Change

The heart of organizational performance is collective individual performance. Individual behavior changes drive organizational performance. When those individual behavior changes are positive, there is a correlative change in positive organizational performance. The opposite is equally true: Negative behaviors influence negative performance.

For example, if a patient care provider believes that pressure ulcers are inevitable, then pressure ulcers on patients cared for by this person will continue. If a care provider believes that a certain number of patient falls are inevitable, then some number of patients cared for by this person will continue to fall. Regardless of the demonstrated best practices, what is exhibited from belief to behavior is a subconscious self-fulfilling prophecy: What people choose to believe, even if their belief is in error, determines how they choose to behave.

The Centers for Disease Control and Prevention (CDC) still advocates hand washing as the No. 1 means for preventing the spread of infection. Tragically the CDC also reports that nearly 100,000 patient deaths annually due to hospital-acquired infections—that is nearly twice the total number of U.S. fatalities in the Vietnam War.

Countless hours and dollars are spent nationally providing continuing educational programs on the value of hand washing. Yet you can go into any restroom, of any hospital, on any given day, and sadly observe the staff of that hospital not following the CDC hand-washing guidelines. One thing is certain: Knowledge alone does not contribute to a change in behavior.

Tipping the Balance in Behavior Change

What does make a difference is the conviction that failing to change results in consequences too hurtful, revolting and unpalatable. We must become truly dissatisfied with the level of performance in our organizations before we can contemplate any successful change initiatives in behavior and then in performance. There is power in the status quo—and in feeling “pretty good” about who we are and how we perform—that feeds the level of resistance to any significant change initiative.

Organization development experts Richard Beckhard and Reubin Harris first published their change equation in 1977 in Organizational Transitions: Managing Complex Change. Though dated, the book is still applicable today. For change to happen successfully, the following statement must be true: Dissatisfaction x Desirability x Practicality > Resistance to Change.

Without a high degree of dissatisfaction with the current practice, the best practice initiative will fail every time.

Everything Rises and Falls on Leadership

Organizational performance is a leader’s responsibility. An influential leader, a person who is taking on tough problems and solving them, must have a high level of dissatisfaction with the status quo. He or she must be unwilling to allow pain and suffering to continue needlessly—unwilling to waste precious resources and settle for second-rate productivity and financial performance.

When leaders can give their people a meaningful purpose, a vision to release their inner desire to create something of value—before they educate them and give them knowledge related to the change—they stand a greater likelihood of people adopting change behavior. Influential leaders have developed the ability to communicate to people the why of change before they attempt to teach the how of change.

Communicating the why of change requires leaders who are emotionally competent, not just technically competent. Influencing people to change their behavior is extremely difficult (some say near impossible). That is why your inner conviction must be so passionate and dominant in your life. Knowledge and attitude are essential elements of behavior change, but they are not sufficient to drive change that really matters, such as implementing a “best practice.”

Why Behavior Trumps Best Practice

Influential leaders are keenly aware of the need to create organizational cultures and climates where people are free to take personal responsibility for doing their jobs well and are accountable for their own actions. In this type of culture, people discover the most effective and efficient solutions within the organization. Influential leaders create the climate for these types of self-discovered solutions to emerge.

Individual, organizational and culture change happens not because people are being pushed, cajoled or threatened toward better and more-effective behavior but because they have learned and accepted that this behavior change is simply a better way to behave for themselves, their co-workers, their patients and customers, and their organization.

Influential leaders delegate authority and provide resources to release the energy, creativity and engagement of their followers. Influential leaders are still in charge—they are still the leaders—but they are a different kind of leader, wielding influence to maximize the overall success of their team members and their organizations. How would you like to work for this kind of leader?

Michael Frisina, Ph.D., is the founder and president of The Frisina Group, LLC, in Elgin, S.C. He is also a member of Health Forum’s Forum Faculty Speaker Service.

Here’s the link to the original article

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  1. Honestly? It’s about 750 words that are as content-free as possible. Take a random paragraph:

    “When leaders can give their people a meaningful purpose, a vision to release their inner desire to create something of value—before they educate them and give them knowledge related to the change—they stand a greater likelihood of people adopting change behavior. Influential leaders have developed the ability to communicate to people the why of change before they attempt to teach the how of change.”

    What the hell does that mean? Really.

    Comment by torontoemerg — February 2, 2010 @ 3:03 pm | Reply

  2. Shirley, thank you for posting my article on best practice for comment. I replied to torontoemerg to provide explanation for several key elements of the article. Here is what the quotation cited is supposed to mean:
    1. People do not follow a leader until they believe in the vision of the leader – where the leader intends to take them and the organization.
    2. People can have technical knowledge and understanding of how to apply the knowledge (best practice) and still not do the best practice.
    3. Influential leaders, leaders people actually respect, listen to, and follow, understand that they must make connection with people on an emotional level to get them to understand the urgency of change, “why” the change is necessary to improve performance before they try to cram the change down people’s throat – the typical health care organizational approach. Many thanks for providing me the opportunity to comment. Warm regards, Michael

    Comment by Michael Frisina — May 16, 2010 @ 1:00 pm | Reply

  3. Dear torontoemerg – thank you for comment and I regret the lack of clarity to provide you understanding as to why most best practice intiatives fail.
    1. Organziational performance is a leadership responsibility.
    2. Most health leaders lack an understanding of how their behavior affects the work performance of the people of the organization.
    3. Performance is more of an emotional factor than a technical one. Performance is defined as technical skill times motivation. Motivation is behavioral not technical. Hence zero motivation, then zero performance. Any number times zero is zero.
    4. Most leaders try to “shoe horn” change via best practice into an organization with the misconception that if people understand the technical, science, evidence for change they will logically adapt to new behavior. The failure of this thinking is evident in hand washing where we still hover at about a 60 % compliance rate nationally according to the CDC and WHO.
    5. To get people to adapt to new change you must first get emotionally connected to them with the urgency of change linked to their own self-interest. This is the “why” of change. Once people understand the necessity of change-saving lives for example-they are far more likely to adopt the best practice and organizational performance improves. I look forward to your comments and continuing our learning on this topic together. Warm regards, Micahel

    Comment by Michael Frisina — May 16, 2010 @ 1:06 pm | Reply

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