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Managing Resistance to Change Along the Journey to High Reliability
Managing Resistance to Change Along the Journey to High Reliability
To improve safety performance, many health care organizations have embarked on the journey to becoming high reliability organizations (HROs). HROs operate in complex, high-risk, constantly changing environments and avoid catastrophic events despite the inherent risks.1 HROs maintain high levels of safety and reliability by adhering to core principles, foundational practices, rigorous processes, a strong organizational culture, and continuous learning and process improvement.1-3
Becoming an HRO requires understanding what makes systems safer for patients and staff at all levels by taking ownership of 5 principles: (1) sensitivity to operations (increased awareness of the current status of systems); (2) reluctance to simplify (avoiding oversimplification of the cause[s] of problems); (3) preoccupation with failure (anticipating risks that might be symptomatic of a larger problem); (4) deference to expertise (relying on the most qualified individuals to make decisions); and (5) commitment to resilience (planning for potential failure and being prepared to respond).1,2,4 In addition to these, the Veterans Health Administration has identified 3 pillars of HROs: leadership commitment (safety and reliability are central to leadership vision, decision-making, and action-oriented behaviors), safety culture (across the organization, safety values are key to preventing harm and learning from mistakes), and continuous process improvement (promoting constant learning and improvement with evidence-based tools and methodologies).5
Implementing these principles is not enough to achieve high reliability. This transition requires significant change, which can be met with resistance. Without attending to organizational change, implementation of HRO principles can be superficial, scattered, and isolated.6 Large organizations often struggle with change as it conflicts with the fundamental human need for stability and security.7 Consequently, the journey to becoming an HRO requires an understanding of the reasons for resistance to change (RtC) as well as evidence-based strategies.
REASONS FOR RESISTANCE TO CHANGE
RtC is the informal and covert behavior of an individual or group to a particular change. RtC is commonly recognized as the failure of employees to do anything requested by managers and is a main reason change initiatives fail.8 While some staff see change as opportunities for learning and growth, others resist based on uncertainty about how the changes will impact their current work situation, or fear, frustration, confusion, and distrust.8,9 Resistance can overtly manifest with some staff publicly expressing their discontent in public without offering solutions, or covertly by ignoring the change or avoiding participation in any aspect of the change process. Both forms of RtC are equally detrimental.8
Frequent changes in organizations can also cause cynicism. Employees will view the change as something initially popular, but will only last until another change comes along.8,9 Resistance can result in the failure to achieve desired objectives, wasted time, effort, and resources, decreased momentum, and loss of confidence and trust in leaders to effectively manage the change process.9 To understand RtC, 3 main factors must be considered: individual, interpersonal, and organizational.
Individual
An individual’s personality can be an important indicator for how they will respond to change. Some individuals welcome and thrive on change while others resist in preference for the status quo.8,10 Individuals will also resist change if they believe their position, power, or prestige within the organization are in jeopardy or that the change is contrary to current personal or organizational values, principles, and objectives.8-12 Resistance can also be the result of uncertainty about what the change means, lack of information regarding the change, or questioning motives for the change.9
Interpersonal
Another influence on RtC is the interpersonal factors of employees. The personal satisfaction individuals receive from their work and the type of interactions they experience with colleagues can impact RtC. When communication with colleagues is lacking before and during change implementation, negative reactions to the change can fuel resistance.11 Cross-functional and bidirectional communication is vital; its absence can leave staff feeling inadequately informed and less supportive of the change.8 Employees’ understanding of changes through communication between other members of the organization is critical to success.11
Organizational
How organizational leaders introduce change affects the extent to which staff respond.10 RtC can emerge if staff feel change is imposed on them. Change is better received when people are actively engaged in the process and adopt a sense of ownership that will ultimately affect them and their role within the organization.12,13 Organizations are also better equipped to address potential RtC when leadership is respected and have a genuine concern for the overall well-being of staff members. Organizational leaders who mainly focus on the bottom line and have little regard for staff are more likely to be perceived as untrustworthy, which contributes to RtC.9,13 Lack of proper education and guidance from organizational leaders, as well as poor communication, can lead to RtC.8,13
MANAGING RESISTANCE TO CHANGE
RtC can be a significant factor in the success or failure of the change process. Poorly managed change can exponentially increase resistance, necessitating a multifaceted approach to managing RtC, while well-managed change can result in a high success rate. Evidence-based strategies to counter RtC focus on communication, employee participation, education and training, and engaging managers.8
Communication
Open and effective communication is critical to managing RtC, as uncertainty often exaggerates the negative aspects of change. Effective communication involves active listening, with leadership and management addressing employee concerns in a clear and concise manner. A psychologically safe culture for open dialogue is essential when addressing RtC.9,14,15 Psychological safety empowers staff to speak up, ask questions, and offer ideas, forming a solid basis for open and effective communication and participation. Leaders and managers should create opportunities for open dialogue for all members of the organization throughout the process. This can be accomplished with one-on-one meetings, open forums, town hall meetings, electronic mail, newsletters, and social media. Topics should cover the reasons for change, details of what is changing, the individual, organizational, and patient risks of not changing, as well as the benefits of changing.9 Encouraging staff to ask questions and provide feedback to promote bidirectional and closed-loop communication is essential to avoid misunderstandings.9,15 While open communication is essential, leaders must carefully plan what information to share, how much to share, and how to avoid information overload. Information about the change should be timely, adequate, applicable, and informative.15 The HRO practice of leader rounding for high reliability can be instrumental to ensure effective, bidirectional communication and collaboration among all disciplines across a health care organization through improving leadership visibility during times of change and enhancing interactions and communication with staff.3
Employee Participation
Involving staff in the change process significantly reduces RtC. Engagement fosters ownership in the change process, increasing the likelihood employees will support and even champion it. Health care professionals welcome opportunities to be involved in helping with aspects of organizational change, especially when invited to participate in the change early in the process and throughout the course of change.7,14,15
Leaders should encourage staff to provide feedback to understand the impact the change is having on them and their roles and responsibilities within the organization. This exemplifies the HRO principle of deference to expertise as the employee often has the most in-depth knowledge of their work setting. Employee perspectives can significantly influence the success of change initatives.7,14 Participation is impactful in providing employees with a sense of agency facilitating acceptance and improving desire to adopt the change.14
Tiered safety huddles and visual management systems (VMSs) also can engage staff. Tiered safety huddles provide a forum for transparent communication, increasing situational awareness, and improving a health care organization’s ability to appropriately respond to staff questions, suggestions, and concerns. VMSs display the status and progress toward organizational goals during the change process, and are highly effective in creating environments where staff feel empowered to voice concerns related to the change process.3
Education and Training
Educating employees on the value of change is crucial to overcome RtC. RtC often stems from employees not feeling prepared to adapt or adopt new processes. Health care professionals who do not receive information about change are less likely to support it.7,12,15 Staff are more likely to accept change when they understand why it is needed and how it impacts the organization’s long-term mission.11,15 Timely, compelling, and informative education on how to adapt to the change will promote more positive appraisal of the change and reduce RtC.8,15 Employees must feel confident they will receive the appropriate training, resources, and support to successfully adapt to the change. This requires leaders and managers taking time to clarify expectations, conduct a gap analysis to identify the skills and knowledge needed to support the planned change, and provide sufficient educational opportunities to fill those gaps.8 For example, the US Department of Veterans Affairs offers classes to employees on the Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) Model. This training provides individuals with the information and skills needed for change to be successful.16
Safety forums can be influential and allow leadership to educate staff on updates related to change processes and promote bidirectional communication.3 In safety forums, staff have an opportunity to ask questions, especially as they relate to learning about available resources to become more informed about the organizational changes.
Engaging Managers
Managers are pivotal to the successful implementation of organizational change.8 They serve as the bridge between senior leadership and frontline employees and are positioned to influence the adoption and success of change initiatives. Often the first point of contact for employees, managers can effectively communicate the need for change, and act as the liaison to align it with individual employee motivations. Since they are often the first to encounter resistance among employees, managers serve as advocates through the process. Through a coaching role, managers can help employees develop the knowledge and ability to be successful and thrive in the new environment. The Table summarizes the evidence-based strategies.
CONCLUSIONS
Implementing change in health care organizations can be challenging, especially on the journey to high reliability. RtC is the result of factors at the individual, interpersonal, and organizational levels that leaders must address to increase chances for success. Organizational changes in health care are more likely to succeed when staff understand why the change is needed through open and continuous communication, can influence the change by sharing their own perspectives, and have the knowledge, skills, and resources to prepare for and participate in the process.
- Merchant NB, O’Neal J, Dealing-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37:504-510. doi:10.1097/JMQ.0000000000000086
- Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. 2022;18:e320-e328. doi:10.1097/PTS.0000000000000768
- Murray JS, Baghdadi A, Dannenberg W, et al. The role of high reliability organization foundational practices in building a culture of safety. Fed Pract. 2024;41:214-221. doi:10.12788/fp.0486
- Ford J, Isaacks DB, Anderson T. Creating, executing and sustaining a high-reliability organization in health care. The Learning Organization: An International Journal. 2024;31:817-833. doi:10.1108/TLO-03-2023-0048
- Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68:151-157. doi:10.1097/JHM-D-00056
- Myers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf. 2022;31:845-848. doi:10.1136/bmjqs-2021-014141
- Nilsen P, Seing I, Ericsson C, et al. Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res. 2020;20:147. doi:10.1186/s12913-020-4999-8
- Cheraghi R, Ebrahimi H, Kheibar N, et al. Reasons for resistance to change in nursing: an integrative review. BMC Nurs. 2023;22:310. doi:10/1186/s12912-023-01460-0
- Warrick DD. Revisiting resistance to change and how to manage it: what has been learned and what organizations need to do. Bus Horiz. 2023;66:433-441. doi:10.1016/j.bushor.2022.09.001
- Sverdlik N, Oreg S. Beyond the individual-level conceptualization of dispositional resistance to change: multilevel effects on the response to organizational change. J Organ Behav. 2023;44:1066-1077. doi:10.1002/job.2678
- Khaw KW, Alnoor A, Al-Abrrow H, et al. Reactions towards organizational change: a systematic literature review. Curr Psychol. 2022;13:1-24. doi:10.1007/s12144-022-03070-6
- Pomare C, Churruca K, Long JC, et al. Organisational change in hospitals: a qualitative case-study of staff perspectives. BMC Health Serv Res. 2019;19:840. doi:10.1186/s12913-019-4704-y
- DuBose BM, Mayo AM. RtC: a concept analysis. Nurs Forum. 2020;55:631-636. doi:10.1111/nuf.12479
- Sahay S, Goldthwaite C. Participatory practices during organizational change: rethinking participation and resistance. Manag Commun Q. 2024;38(2):279-306. doi:10.1177/08933189231187883
- Damawan AH, Azizah S. Resistance to change: causes and strategies as an organizational challenge. ASSEHR. 2020;395(2020):49-53. doi:10.2991/assehr.k.200120.010
- Wong Q, Lacombe M, Keller R, et al. Leading change with ADKAR. Nurs Manage. 2019;50:28-35. doi:10.1097/01.NUMA.0000554341.70508.75
To improve safety performance, many health care organizations have embarked on the journey to becoming high reliability organizations (HROs). HROs operate in complex, high-risk, constantly changing environments and avoid catastrophic events despite the inherent risks.1 HROs maintain high levels of safety and reliability by adhering to core principles, foundational practices, rigorous processes, a strong organizational culture, and continuous learning and process improvement.1-3
Becoming an HRO requires understanding what makes systems safer for patients and staff at all levels by taking ownership of 5 principles: (1) sensitivity to operations (increased awareness of the current status of systems); (2) reluctance to simplify (avoiding oversimplification of the cause[s] of problems); (3) preoccupation with failure (anticipating risks that might be symptomatic of a larger problem); (4) deference to expertise (relying on the most qualified individuals to make decisions); and (5) commitment to resilience (planning for potential failure and being prepared to respond).1,2,4 In addition to these, the Veterans Health Administration has identified 3 pillars of HROs: leadership commitment (safety and reliability are central to leadership vision, decision-making, and action-oriented behaviors), safety culture (across the organization, safety values are key to preventing harm and learning from mistakes), and continuous process improvement (promoting constant learning and improvement with evidence-based tools and methodologies).5
Implementing these principles is not enough to achieve high reliability. This transition requires significant change, which can be met with resistance. Without attending to organizational change, implementation of HRO principles can be superficial, scattered, and isolated.6 Large organizations often struggle with change as it conflicts with the fundamental human need for stability and security.7 Consequently, the journey to becoming an HRO requires an understanding of the reasons for resistance to change (RtC) as well as evidence-based strategies.
REASONS FOR RESISTANCE TO CHANGE
RtC is the informal and covert behavior of an individual or group to a particular change. RtC is commonly recognized as the failure of employees to do anything requested by managers and is a main reason change initiatives fail.8 While some staff see change as opportunities for learning and growth, others resist based on uncertainty about how the changes will impact their current work situation, or fear, frustration, confusion, and distrust.8,9 Resistance can overtly manifest with some staff publicly expressing their discontent in public without offering solutions, or covertly by ignoring the change or avoiding participation in any aspect of the change process. Both forms of RtC are equally detrimental.8
Frequent changes in organizations can also cause cynicism. Employees will view the change as something initially popular, but will only last until another change comes along.8,9 Resistance can result in the failure to achieve desired objectives, wasted time, effort, and resources, decreased momentum, and loss of confidence and trust in leaders to effectively manage the change process.9 To understand RtC, 3 main factors must be considered: individual, interpersonal, and organizational.
Individual
An individual’s personality can be an important indicator for how they will respond to change. Some individuals welcome and thrive on change while others resist in preference for the status quo.8,10 Individuals will also resist change if they believe their position, power, or prestige within the organization are in jeopardy or that the change is contrary to current personal or organizational values, principles, and objectives.8-12 Resistance can also be the result of uncertainty about what the change means, lack of information regarding the change, or questioning motives for the change.9
Interpersonal
Another influence on RtC is the interpersonal factors of employees. The personal satisfaction individuals receive from their work and the type of interactions they experience with colleagues can impact RtC. When communication with colleagues is lacking before and during change implementation, negative reactions to the change can fuel resistance.11 Cross-functional and bidirectional communication is vital; its absence can leave staff feeling inadequately informed and less supportive of the change.8 Employees’ understanding of changes through communication between other members of the organization is critical to success.11
Organizational
How organizational leaders introduce change affects the extent to which staff respond.10 RtC can emerge if staff feel change is imposed on them. Change is better received when people are actively engaged in the process and adopt a sense of ownership that will ultimately affect them and their role within the organization.12,13 Organizations are also better equipped to address potential RtC when leadership is respected and have a genuine concern for the overall well-being of staff members. Organizational leaders who mainly focus on the bottom line and have little regard for staff are more likely to be perceived as untrustworthy, which contributes to RtC.9,13 Lack of proper education and guidance from organizational leaders, as well as poor communication, can lead to RtC.8,13
MANAGING RESISTANCE TO CHANGE
RtC can be a significant factor in the success or failure of the change process. Poorly managed change can exponentially increase resistance, necessitating a multifaceted approach to managing RtC, while well-managed change can result in a high success rate. Evidence-based strategies to counter RtC focus on communication, employee participation, education and training, and engaging managers.8
Communication
Open and effective communication is critical to managing RtC, as uncertainty often exaggerates the negative aspects of change. Effective communication involves active listening, with leadership and management addressing employee concerns in a clear and concise manner. A psychologically safe culture for open dialogue is essential when addressing RtC.9,14,15 Psychological safety empowers staff to speak up, ask questions, and offer ideas, forming a solid basis for open and effective communication and participation. Leaders and managers should create opportunities for open dialogue for all members of the organization throughout the process. This can be accomplished with one-on-one meetings, open forums, town hall meetings, electronic mail, newsletters, and social media. Topics should cover the reasons for change, details of what is changing, the individual, organizational, and patient risks of not changing, as well as the benefits of changing.9 Encouraging staff to ask questions and provide feedback to promote bidirectional and closed-loop communication is essential to avoid misunderstandings.9,15 While open communication is essential, leaders must carefully plan what information to share, how much to share, and how to avoid information overload. Information about the change should be timely, adequate, applicable, and informative.15 The HRO practice of leader rounding for high reliability can be instrumental to ensure effective, bidirectional communication and collaboration among all disciplines across a health care organization through improving leadership visibility during times of change and enhancing interactions and communication with staff.3
Employee Participation
Involving staff in the change process significantly reduces RtC. Engagement fosters ownership in the change process, increasing the likelihood employees will support and even champion it. Health care professionals welcome opportunities to be involved in helping with aspects of organizational change, especially when invited to participate in the change early in the process and throughout the course of change.7,14,15
Leaders should encourage staff to provide feedback to understand the impact the change is having on them and their roles and responsibilities within the organization. This exemplifies the HRO principle of deference to expertise as the employee often has the most in-depth knowledge of their work setting. Employee perspectives can significantly influence the success of change initatives.7,14 Participation is impactful in providing employees with a sense of agency facilitating acceptance and improving desire to adopt the change.14
Tiered safety huddles and visual management systems (VMSs) also can engage staff. Tiered safety huddles provide a forum for transparent communication, increasing situational awareness, and improving a health care organization’s ability to appropriately respond to staff questions, suggestions, and concerns. VMSs display the status and progress toward organizational goals during the change process, and are highly effective in creating environments where staff feel empowered to voice concerns related to the change process.3
Education and Training
Educating employees on the value of change is crucial to overcome RtC. RtC often stems from employees not feeling prepared to adapt or adopt new processes. Health care professionals who do not receive information about change are less likely to support it.7,12,15 Staff are more likely to accept change when they understand why it is needed and how it impacts the organization’s long-term mission.11,15 Timely, compelling, and informative education on how to adapt to the change will promote more positive appraisal of the change and reduce RtC.8,15 Employees must feel confident they will receive the appropriate training, resources, and support to successfully adapt to the change. This requires leaders and managers taking time to clarify expectations, conduct a gap analysis to identify the skills and knowledge needed to support the planned change, and provide sufficient educational opportunities to fill those gaps.8 For example, the US Department of Veterans Affairs offers classes to employees on the Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) Model. This training provides individuals with the information and skills needed for change to be successful.16
Safety forums can be influential and allow leadership to educate staff on updates related to change processes and promote bidirectional communication.3 In safety forums, staff have an opportunity to ask questions, especially as they relate to learning about available resources to become more informed about the organizational changes.
Engaging Managers
Managers are pivotal to the successful implementation of organizational change.8 They serve as the bridge between senior leadership and frontline employees and are positioned to influence the adoption and success of change initiatives. Often the first point of contact for employees, managers can effectively communicate the need for change, and act as the liaison to align it with individual employee motivations. Since they are often the first to encounter resistance among employees, managers serve as advocates through the process. Through a coaching role, managers can help employees develop the knowledge and ability to be successful and thrive in the new environment. The Table summarizes the evidence-based strategies.
CONCLUSIONS
Implementing change in health care organizations can be challenging, especially on the journey to high reliability. RtC is the result of factors at the individual, interpersonal, and organizational levels that leaders must address to increase chances for success. Organizational changes in health care are more likely to succeed when staff understand why the change is needed through open and continuous communication, can influence the change by sharing their own perspectives, and have the knowledge, skills, and resources to prepare for and participate in the process.
To improve safety performance, many health care organizations have embarked on the journey to becoming high reliability organizations (HROs). HROs operate in complex, high-risk, constantly changing environments and avoid catastrophic events despite the inherent risks.1 HROs maintain high levels of safety and reliability by adhering to core principles, foundational practices, rigorous processes, a strong organizational culture, and continuous learning and process improvement.1-3
Becoming an HRO requires understanding what makes systems safer for patients and staff at all levels by taking ownership of 5 principles: (1) sensitivity to operations (increased awareness of the current status of systems); (2) reluctance to simplify (avoiding oversimplification of the cause[s] of problems); (3) preoccupation with failure (anticipating risks that might be symptomatic of a larger problem); (4) deference to expertise (relying on the most qualified individuals to make decisions); and (5) commitment to resilience (planning for potential failure and being prepared to respond).1,2,4 In addition to these, the Veterans Health Administration has identified 3 pillars of HROs: leadership commitment (safety and reliability are central to leadership vision, decision-making, and action-oriented behaviors), safety culture (across the organization, safety values are key to preventing harm and learning from mistakes), and continuous process improvement (promoting constant learning and improvement with evidence-based tools and methodologies).5
Implementing these principles is not enough to achieve high reliability. This transition requires significant change, which can be met with resistance. Without attending to organizational change, implementation of HRO principles can be superficial, scattered, and isolated.6 Large organizations often struggle with change as it conflicts with the fundamental human need for stability and security.7 Consequently, the journey to becoming an HRO requires an understanding of the reasons for resistance to change (RtC) as well as evidence-based strategies.
REASONS FOR RESISTANCE TO CHANGE
RtC is the informal and covert behavior of an individual or group to a particular change. RtC is commonly recognized as the failure of employees to do anything requested by managers and is a main reason change initiatives fail.8 While some staff see change as opportunities for learning and growth, others resist based on uncertainty about how the changes will impact their current work situation, or fear, frustration, confusion, and distrust.8,9 Resistance can overtly manifest with some staff publicly expressing their discontent in public without offering solutions, or covertly by ignoring the change or avoiding participation in any aspect of the change process. Both forms of RtC are equally detrimental.8
Frequent changes in organizations can also cause cynicism. Employees will view the change as something initially popular, but will only last until another change comes along.8,9 Resistance can result in the failure to achieve desired objectives, wasted time, effort, and resources, decreased momentum, and loss of confidence and trust in leaders to effectively manage the change process.9 To understand RtC, 3 main factors must be considered: individual, interpersonal, and organizational.
Individual
An individual’s personality can be an important indicator for how they will respond to change. Some individuals welcome and thrive on change while others resist in preference for the status quo.8,10 Individuals will also resist change if they believe their position, power, or prestige within the organization are in jeopardy or that the change is contrary to current personal or organizational values, principles, and objectives.8-12 Resistance can also be the result of uncertainty about what the change means, lack of information regarding the change, or questioning motives for the change.9
Interpersonal
Another influence on RtC is the interpersonal factors of employees. The personal satisfaction individuals receive from their work and the type of interactions they experience with colleagues can impact RtC. When communication with colleagues is lacking before and during change implementation, negative reactions to the change can fuel resistance.11 Cross-functional and bidirectional communication is vital; its absence can leave staff feeling inadequately informed and less supportive of the change.8 Employees’ understanding of changes through communication between other members of the organization is critical to success.11
Organizational
How organizational leaders introduce change affects the extent to which staff respond.10 RtC can emerge if staff feel change is imposed on them. Change is better received when people are actively engaged in the process and adopt a sense of ownership that will ultimately affect them and their role within the organization.12,13 Organizations are also better equipped to address potential RtC when leadership is respected and have a genuine concern for the overall well-being of staff members. Organizational leaders who mainly focus on the bottom line and have little regard for staff are more likely to be perceived as untrustworthy, which contributes to RtC.9,13 Lack of proper education and guidance from organizational leaders, as well as poor communication, can lead to RtC.8,13
MANAGING RESISTANCE TO CHANGE
RtC can be a significant factor in the success or failure of the change process. Poorly managed change can exponentially increase resistance, necessitating a multifaceted approach to managing RtC, while well-managed change can result in a high success rate. Evidence-based strategies to counter RtC focus on communication, employee participation, education and training, and engaging managers.8
Communication
Open and effective communication is critical to managing RtC, as uncertainty often exaggerates the negative aspects of change. Effective communication involves active listening, with leadership and management addressing employee concerns in a clear and concise manner. A psychologically safe culture for open dialogue is essential when addressing RtC.9,14,15 Psychological safety empowers staff to speak up, ask questions, and offer ideas, forming a solid basis for open and effective communication and participation. Leaders and managers should create opportunities for open dialogue for all members of the organization throughout the process. This can be accomplished with one-on-one meetings, open forums, town hall meetings, electronic mail, newsletters, and social media. Topics should cover the reasons for change, details of what is changing, the individual, organizational, and patient risks of not changing, as well as the benefits of changing.9 Encouraging staff to ask questions and provide feedback to promote bidirectional and closed-loop communication is essential to avoid misunderstandings.9,15 While open communication is essential, leaders must carefully plan what information to share, how much to share, and how to avoid information overload. Information about the change should be timely, adequate, applicable, and informative.15 The HRO practice of leader rounding for high reliability can be instrumental to ensure effective, bidirectional communication and collaboration among all disciplines across a health care organization through improving leadership visibility during times of change and enhancing interactions and communication with staff.3
Employee Participation
Involving staff in the change process significantly reduces RtC. Engagement fosters ownership in the change process, increasing the likelihood employees will support and even champion it. Health care professionals welcome opportunities to be involved in helping with aspects of organizational change, especially when invited to participate in the change early in the process and throughout the course of change.7,14,15
Leaders should encourage staff to provide feedback to understand the impact the change is having on them and their roles and responsibilities within the organization. This exemplifies the HRO principle of deference to expertise as the employee often has the most in-depth knowledge of their work setting. Employee perspectives can significantly influence the success of change initatives.7,14 Participation is impactful in providing employees with a sense of agency facilitating acceptance and improving desire to adopt the change.14
Tiered safety huddles and visual management systems (VMSs) also can engage staff. Tiered safety huddles provide a forum for transparent communication, increasing situational awareness, and improving a health care organization’s ability to appropriately respond to staff questions, suggestions, and concerns. VMSs display the status and progress toward organizational goals during the change process, and are highly effective in creating environments where staff feel empowered to voice concerns related to the change process.3
Education and Training
Educating employees on the value of change is crucial to overcome RtC. RtC often stems from employees not feeling prepared to adapt or adopt new processes. Health care professionals who do not receive information about change are less likely to support it.7,12,15 Staff are more likely to accept change when they understand why it is needed and how it impacts the organization’s long-term mission.11,15 Timely, compelling, and informative education on how to adapt to the change will promote more positive appraisal of the change and reduce RtC.8,15 Employees must feel confident they will receive the appropriate training, resources, and support to successfully adapt to the change. This requires leaders and managers taking time to clarify expectations, conduct a gap analysis to identify the skills and knowledge needed to support the planned change, and provide sufficient educational opportunities to fill those gaps.8 For example, the US Department of Veterans Affairs offers classes to employees on the Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) Model. This training provides individuals with the information and skills needed for change to be successful.16
Safety forums can be influential and allow leadership to educate staff on updates related to change processes and promote bidirectional communication.3 In safety forums, staff have an opportunity to ask questions, especially as they relate to learning about available resources to become more informed about the organizational changes.
Engaging Managers
Managers are pivotal to the successful implementation of organizational change.8 They serve as the bridge between senior leadership and frontline employees and are positioned to influence the adoption and success of change initiatives. Often the first point of contact for employees, managers can effectively communicate the need for change, and act as the liaison to align it with individual employee motivations. Since they are often the first to encounter resistance among employees, managers serve as advocates through the process. Through a coaching role, managers can help employees develop the knowledge and ability to be successful and thrive in the new environment. The Table summarizes the evidence-based strategies.
CONCLUSIONS
Implementing change in health care organizations can be challenging, especially on the journey to high reliability. RtC is the result of factors at the individual, interpersonal, and organizational levels that leaders must address to increase chances for success. Organizational changes in health care are more likely to succeed when staff understand why the change is needed through open and continuous communication, can influence the change by sharing their own perspectives, and have the knowledge, skills, and resources to prepare for and participate in the process.
- Merchant NB, O’Neal J, Dealing-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37:504-510. doi:10.1097/JMQ.0000000000000086
- Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. 2022;18:e320-e328. doi:10.1097/PTS.0000000000000768
- Murray JS, Baghdadi A, Dannenberg W, et al. The role of high reliability organization foundational practices in building a culture of safety. Fed Pract. 2024;41:214-221. doi:10.12788/fp.0486
- Ford J, Isaacks DB, Anderson T. Creating, executing and sustaining a high-reliability organization in health care. The Learning Organization: An International Journal. 2024;31:817-833. doi:10.1108/TLO-03-2023-0048
- Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68:151-157. doi:10.1097/JHM-D-00056
- Myers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf. 2022;31:845-848. doi:10.1136/bmjqs-2021-014141
- Nilsen P, Seing I, Ericsson C, et al. Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res. 2020;20:147. doi:10.1186/s12913-020-4999-8
- Cheraghi R, Ebrahimi H, Kheibar N, et al. Reasons for resistance to change in nursing: an integrative review. BMC Nurs. 2023;22:310. doi:10/1186/s12912-023-01460-0
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- Cheraghi R, Ebrahimi H, Kheibar N, et al. Reasons for resistance to change in nursing: an integrative review. BMC Nurs. 2023;22:310. doi:10/1186/s12912-023-01460-0
- Warrick DD. Revisiting resistance to change and how to manage it: what has been learned and what organizations need to do. Bus Horiz. 2023;66:433-441. doi:10.1016/j.bushor.2022.09.001
- Sverdlik N, Oreg S. Beyond the individual-level conceptualization of dispositional resistance to change: multilevel effects on the response to organizational change. J Organ Behav. 2023;44:1066-1077. doi:10.1002/job.2678
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- DuBose BM, Mayo AM. RtC: a concept analysis. Nurs Forum. 2020;55:631-636. doi:10.1111/nuf.12479
- Sahay S, Goldthwaite C. Participatory practices during organizational change: rethinking participation and resistance. Manag Commun Q. 2024;38(2):279-306. doi:10.1177/08933189231187883
- Damawan AH, Azizah S. Resistance to change: causes and strategies as an organizational challenge. ASSEHR. 2020;395(2020):49-53. doi:10.2991/assehr.k.200120.010
- Wong Q, Lacombe M, Keller R, et al. Leading change with ADKAR. Nurs Manage. 2019;50:28-35. doi:10.1097/01.NUMA.0000554341.70508.75
Managing Resistance to Change Along the Journey to High Reliability
Managing Resistance to Change Along the Journey to High Reliability
