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Transforming the Organizational Culture of a School of Nursing Through Innovative Program Development
TRANSFORMING THE ORGANIZATIONAL CULTURE OF A SCHOOL OF NURSING THROUGH INNOVATIVE PROGRAM DEVELOPMENT JEAN W. LANGE, PHD, RN,⁎ GAIL INGERSOLL, EDD, RN, FAAN,y JEANNE M. NOVOTNY, PHD, RN, FAANz
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This article illustrates how a grant designed to promote new program development provided a vehicle for organizational transformation. The collaboration surrounding this initiative created a common focus within the school that more effectively channeled its resources and resulted in an unprecedented level of scholarly achievement and recognition. Faculty leveraged the success of this initial grant to procure additional funding for related projects. The importance of partnerships and teamwork were two valuable lessons learned. We believe that our experience is replicable in other schools of nursing interested in organizational transformation. Gibson and Barsade's model of managed change guided the project's implementation and evaluation processes. Recommendations for engaging faculty, gaining support, and developing a collaborative network are discussed in the article, with findings from a stakeholder-focused evaluation demonstrating new program goal achievement as well as the transformative changes that occurred in the organizational culture. A focused, theory-derived program plan, with comprehensive process and outcome evaluation components resulted in a major transformation of one school of nursing. Unanticipated outcomes included renewed synergy among faculty; the development of a preferred vision for the future; scholarly collaboration around a central theme that effectively channeled limited resources and dramatically increased productivity; increased regional and national recognition; and the creation of regional, national, and international partnerships. (Index words: Organizational culture; Organizational change; Faculty development; Curricular innovation) J Prof Nurs 24:371–7, 2008. A 2008 Elsevier Inc. All rights reserved.
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URSING SCHOOLS ARE facing a number of challenges, with increased enrollments and faculty shortages compelling schools to accomplish more with less. At the same time, changing demographic and global climates have redefined what faculty must teach to prepare nurses for entry into today's practice world.
*Associate Professor of Nursing, Fairfield University, Fairfield, CT. †Loretta Ford Professor of Nursing; Director, Clinical Nursing Research Center and Center for Outcomes Measurement and Practice Innovation. University of Rochester, School of Nursing and Department of Nursing Practice, Rochester, NY. ‡Dean and Professor of Nursing, Fairfield University, Fairfield, CT. Address correspondence to Dr. Lange: Fairfield University, 1076 North Benson Road, Fairfield, CT 06824. E-mail: [email protected] 8755-7223/$ - see front matter
Despite this need, most undergraduate programs have failed to implement the substantive changes required to meet the dramatic increase in basic nursing knowledge that has occurred over the past two decades (Long, 2004). Critical to the creation of responsive schools of nursing is the development of a faculty who can keep pace with the wealth of emerging information while also contributing to the translation of research into clinical practice and the dissemination of nursing knowledge. This need is particularly relevant at non-research-intensive universities where teaching quality has traditionally been more critical to faculty promotion than research productivity. This focus is evolving, however, with tenure requirements at many non-research-intensive universities increasingly emphasizing the importance of faculty scholarship and student exposure to evidence-based practice principles. Nursing faculty at such institutions
Journal of Professional Nursing, Vol 24, No 6 (November–December), 2008: pp 371–377 A 2008 Elsevier Inc. All rights reserved.
371 doi:10.1016/j.profnurs.2007.11.002
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are expected to develop new programs of research despite their limited prior experience with proposal writing and grants management or with forging partnerships to support that work. This change in faculty role focus is being driven in many cases by the professional mandate for evidence to guide practice and the imperative for nursing faculty to cultivate new skills and expertise that support this expanded role component (Melnyk & Fineout-Overholt, 2004). Internal resources to promote faculty development are often limited in many nursing departments where budget allocations may not increase in response to rising enrollments. The need for additional funds to secure sufficient clinical faculty and practice sites often preempts funds for faculty scholarship; thus, today's nursing schools face financial constraints that limit their leadership's ability to provide the resources necessary for faculty enrichment. A successful transition to environments supportive of curricular innovation and role change requires the full support of faculty and leadership. Within an environment of scarce resources, nontraditional pathways must be created to acquire faculty buy-in and the means necessary for accomplishing these goals (Larson, 2004). The purpose of this article was to illustrate how curricular initiatives can serve as a pathway to cultural change in schools of nursing that are confronted with similar challenges. The experience of implementing this project resulted in organizational change; stewardship of precious resources; and engagement of most faculty members in activities that support the organization's cultural transformation, university values, and contribution to the profession. The model of organizational change by Gibson and Barsade (2003) provided the framework for this initiative.
A Model for Cultural Change Within Organizations Some would argue that organizations have cultures, whereas others insist that organizations are cultures (Bolman & Deal, 1997). Gibson and Barsade (2003) believed that there are three layers to the culture of an organization. The first layer is composed of the visible aspects of an organization or the attributes that are apparent the minute you walk in the door. The second layer is composed of the norms of behavior that are expected or the boundaries and guidelines prescribed for that behavior. The third layer is constructed of the values, beliefs, and assumptions of how that particular world works. Understanding the complexity of these layers helps explain why making change in an organization is difficult. If change is to be sustained, it must take place at all three levels (Gibson & Barsade). Gibson and Barsade (2003) suggested that the best form of organizational change is through a managed process. According to their framework, five ingredients are essential to manage change that successfully moves an organization to a preferred future state: (a) visionary
leadership; (b) intentionally aligned structures, systems, and policies; (c) stakeholder participation; (d) consistent communication; and (e) ongoing feedback and evaluation about the structure, processes, and outcomes of change. The authors asserted that successful changes alter the organization's culture and lead to a higher level of functioning. These five elements guided this initiative and laid the groundwork for the cultural transformation that resulted.
Visionary Leadership According to Gibson and Barsade (2003), visionary leaders demonstrate their commitment to change through role-modeling behaviors and by allocating resources to support and sustain proposed action. The summer before this project began, a new dean was hired for the Fairfield University School of Nursing. During her assessment of the school's strengths and challenges, the dean recognized that the university had matured into a highly competitive institution capable of attracting the brightest students; however, nursing enrollments were low at the time. Concurrently, the university was expending substantial resources to improve its infrastructure and to expand scholarship opportunities among the faculty. These changes within the university laid the foundation for a major transformational change within the School of Nursing. Attracting highly qualified nursing students meant having accomplished faculty, creative programs, international opportunities, and access to key national leaders that enhance the typical curriculum. Of the 13 nursing faculty at the time, 11 were doctorally prepared. Three had secured prior funding for innovative projects; nonetheless, most had no active program of research. Faculty collectively produced an average of less than 10 publications per year. The school's previous allocation of resources to individual faculty to pursue discrete, unrelated scholarly interests had resulted in a considerable expenditure of resources in comparison with the return. The new dean recognized the need to improve the school's return on investment and that the school's reputation was closely linked to the accomplishments of its faculty. She noted that a dynamic image was needed to remain competitive in recruiting qualified faculty and students. To address these challenges, the dean organized a team composed of four faculty and a representative from the foundation grants office to apply for funding from the John A. Hartford Foundation (JAHF), in collaboration with the American Association of Colleges of Nursing (AACN), which supported programs designed to revamp gerontological content in undergraduate curricula. This initiative had broad support from faculty who recognized the need to more fully integrate gerontologic best practices into the nursing course content. The new dean envisioned this grant as an opportunity to focus faculty energy and to enhance the school's visibility beyond the region. Working within a 4-week time frame, the team defined member roles, expectations, and
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deadlines. Members shared ideas, researched background information, critiqued drafts, and recruited external partners to support the initiative. Three faculty prepared the initial draft; one faculty member incorporated edits into the final proposal. The grants officer and dean prepared the budget. At the time of application, none of the faculty was certified in gerontology; therefore, developing faculty expertise was a critical precursor to successful curricular enhancement. A budget was created to support two primary goals: (a) to assure that the faculty had the necessary expertise and resources needed to provide classroom and clinical learning experiences that engaged the community and stimulated students' interest in working with older adults and (b) to prepare students in the undergraduate program with the knowledge, experience, and commitment to advocate for and address the health needs and quality of life concerns of older adults. The news that the school was selected to receive a 3-year award from the JAHF/AACN set into motion a journey of managed change that would ultimately alter the culture of the school and set the stage for a preferred future. The project team shared a great sense of pride when the grant was awarded, and the entire faculty felt empowered by the knowledge that collaborative teamwork had enabled members to efficiently prepare a competitive application and to cultivate the support of six new community partners. Recognizing the need for faculty leadership of the project, the dean appointed one member of the team to direct its implementation. The project director devised a leadership strategy that embraced three critical elements: (a) engaging all faculty in the project, (b) accessing external experts to facilitate faculty development, and (c) creating mechanisms for collaboration with agency partners.
Intentionally Aligned Structures, Systems, and Policies The project director created an implementation structure guided by three key assumptions: (a) a fully integrated curriculum requires investment by all faculty; (b) faculty participation in the implementation process is essential to achieving their buy-in; and (c) external consultants are critical to broadening faculty perspectives and to contributing a level of expertise not accessible internally. The consultants posed new ideas and solutions to enlarge upon what was deemed possible by the faculty and ultimately enhanced the end product. To fully engage faculty, the director formed a geriatric subcommittee. All faculty were invited to serve on this committee and to undertake the necessary groundwork for the 3-year project (e.g., evaluating existing media and print holdings, visiting partner sites to explore clinical learning opportunities, organizing faculty development workshops, and gathering resources to support the project). The grant funded three nationally renowned gerontological experts to conduct a weeklong faculty workshop. Partners and faculty from other nursing schools in the state were invited to attend the workshop free of charge. This process helped foster good working
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relationships among participants and worked to establish the school's reputation for gerontological excellence. External experts in curriculum development and evaluation also were funded under the grant. A curriculum expert worked with six faculty to sequence content across semesters and to link this work to the objectives outlined in the grant application. An evaluation consultant visited the campus at the outset of the project and at the end of the funding period to review planning documents; to identify appropriate assessment methods for monitoring structure, process, and outcomes components; and to conduct a comprehensive summary assessment at the end of the project period. A critical component of the evaluation plan was the creation of structures to incorporate feedback from all vested parties. To this end, an advisory board representing faculty, community agencies, and lay elders was formed to provide semiannual feedback on the evolving curriculum enhancements. From these outside influences, faculty learned skills that would later transfer to new endeavors; among these were the value in seeking external consultants to enhance project outcomes and the importance of partnering with community stakeholders to ensure sustainability.
Stakeholder Participation Recognition and reward were used by stakeholder groups to promote active participation. Incentives for faculty participation included the opportunity to help shape the project outcomes through active involvement in program planning and public acknowledgment of individual contributions made. Mechanisms for recognition included publication of advisory board members' names on the school's Web site, e-mail updates, and reports at faculty meetings that highlighted the specific contributions of participating faculty. Photographs of participating faculty in a new recruitment brochure that focused on students practicing in older adult environments also recognized faculty involvement. During the second and third years of the project, subcommittee members presented and published their work. In addition, financial incentives were awarded to faculty for attending geriatricrelated conferences, for pursing geriatric certification, or for revising the curriculum. Each of these strategies contributed to an increase in faculty involvement over time. They also rewarded faculty contributors and enhanced the visibility of the project. University and community press releases, likewise, increased the school's visibility and recognition of faculty, partners, and students. Intensive support for the integration of curricular changes included the initiation of individual meetings with faculty to review new course content and to secure media to support the integration. An onsite resource room was created to house the numerous acquisitions obtained, promote easy access to materials, and increase the likelihood of their use. A gerontology expert was recruited for a full-time faculty position to provide additional support to the faculty.
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Participation by community partners was also critical to the success of this project. Incentives for participation included networking at semiannual advisory board meetings, opportunities for collaboration with the school on other joint ventures, free attendance of employees at faculty development workshops, and access to a potential pool of future employees through student clinical placements. Partners were highlighted on the Web site, in press releases, and in professional and lay presentations as well as in the recruitment brochure.
Consistent Communication Ongoing internal communication is crucial to the success of any organizational change initiative. To address this concern, feedback from the advisory board, faculty, and students was sought as part of a continuing process of evaluation and refinement. Regular reports at faculty meetings, e-mail updates, and the distribution of advisory board minutes were designed to maintain project visibility and solicit feedback. Publicized highlights from annual project reports showcased the project team's impressive progress and accomplishments. A survey designed to assess faculty confidence in teaching the geriatric competencies for baccalaureate students served as a basis for planning a second round of faculty development workshops.
Feedback and Evaluation of Structure, Process, and Outcomes Measuring organizational innovation requires attention to the structure, process, and outcomes of the change initiative. As a result, a combination of quantitative and qualitative data collection methods is required. This is particularly true when assessing transformational change in the organization's culture, where multiple initiatives, resources, and responses are likely. In keeping with the cultural change management model proposed by Gibson and Barsade (2003), evaluation activities were directed at determining whether the characteristics required for successful change in organizational culture (structure and process) were evident and how the organizational transformation, if evident, contributed to the educational and organizational outcomes (impact) seen. A stakeholder-focused evaluation approach was used to guide the evaluation process. This evaluation model assures that the needs and opinions of the persons or groups influenced by the program are included in the evaluation process and refinement of program approach. It is also the most useful method for providing relevant information to those who are likely to benefit from or make decisions about the program and its future direction (Ingersoll & Sauter, 1998). Moreover, a stakeholder-focused approach facilitates the assessment of organizational culture and change in values, beliefs, and perceptions over time (Rossi, Freeman, & Lipsey, 1999). In this evaluation method, data collection activities focus on the foundational documents of the program (the stated goals and objectives), the documents created over time (meeting minutes and reports), and the
internal (program planning members and staff) and external (administrators, decision makers, and policymakers) stakeholders who affect and are affected by the change. A review of foundational documents in this project provided the framework and data collection plan for the overall evaluation. Process and outcome objectives were outlined for each of the identified goals, with early activities directed at identifying sources of data to substantiate the achievement of goals and then selecting the most appropriate methods for accurate and consistent measurement of program process and outcome. Because of the potential for additional outcomes beyond those described in planning documents, the evaluation focused on both the intended and unintended outcomes of the project. The evaluator paid particular attention to the words and phrases used by participants during interviews and focus groups to determine whether evidence of change in organizational culture existed. Process evaluation activities were directed at periodic assessments of the extent to which stakeholder groups were involved in program planning and implementation activities and the ways in which program activities were implemented over time. An integral dimension of this assessment component, one that reinforces the flexibility dimension of effective transformation activities, was attention to the faculty's and community stakeholders' willingness to revise and modify program components in response to identified need or preference. Outcome evaluation activities were conducted at the end of the project implementation period and were overseen by an external evaluation consultant who reviewed program-related documents; met with students, advisory board members, dean, and faculty; and compared observations to program objectives and expected outcomes. Documents reviewed during the outcome evaluation segment included the following: program proposal, geriatric content grid for undergraduate curriculum, course descriptions, program progress summary report, list of advisory board members, program flier, evaluation plan, representative student papers and projects, program announcement materials, list of partnering clinical agencies, faculty development plan, benchmark outcome assessment reports, and assessment tools. Summary reviews of annual activities related to project development and implementation were prepared and made available to faculty and community stakeholders. Findings from the evaluation suggested that activities underway during the course of the project planning and implementation processes were consistent with those associated with successful culture change. Clearly apparent were the faculty's consistent efforts to understand students' and stakeholders' response to the change and the faculty's willingness to adapt project plans to fit the needs of the stakeholder groups. Feedback to students was less formal, although students were aware of changes made based on their evaluations of courses and learning activities. Stakeholders and faculty, likewise,
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reported awareness of revisions to the implementation plan based on individual and group feedback. The availability of an external evaluation consultant contributed to the stakeholders' perceptions of the value of the project and the rigor with which it was being assessed. Anticipated Outcomes. The two goals identified for this project were achieved. Quantitative and qualitative evidence supported positive changes in students' knowledge, their commitment to the care of older adults, and their interest in studying the health care concerns of older people. During focused discussions by the external evaluator at the end of the project, students verbalized recognition of the unique educational experiences provided to them as a result of the project. In addition, student journals and course evaluations demonstrated the gerontology curriculum's favorable impact on student perceptions of their clinical competence and commitment to caring for older adults. Additional evidence of achieving the student educational goal were the granting of student awards of excellence by one participating community agency and the initiation of a loan forgiveness program for graduates of the program by another. The evidence also confirmed that faculty felt more prepared to teach undergraduate gerontology content and had greater interest in pursuing projects related to an older adult population (Lange, Wallace, Grossman, Lippman, & Novotny, 2006). Achievement of the project's faculty development goal was demonstrated by the completion of end-of-life training by five faculty, the awarding of faculty fellowships in gerontology to three faculty, the completion of online training in elder care by the learning laboratory director, and faculty attendance and joint presentations at national and international gerontology conferences. Since the initial award, eight faculty have subsequently received funding to support related projects. Evaluation findings also validated the project team's successful management of change according to the framework by Gibson and Barsade (2003). Attention to the alignment of structures, systems, and policies was evident over the course of the 3-year project. Structuralrelated actions included the review of library resources to assure that materials were available to support an increased focus on geriatric content and scholarly productivity. In addition, teaching models, journal subscriptions, and textbooks were added to support the increased attention to this change. Additional systems and structural evidence were noted by the school's allocation of fully developed space to house a geriatric resource center. Moreover, new agency contracts in several facilities and the creation of a community-sponsored award for graduating students gave further evidence of structural changes supportive of the innovation. The effectiveness of the project team's and the School of Nursing's leadership was reflected in descriptors such as “strong leader” and “visionary,” which arose regularly in the focus groups of faculty, students, and community stakeholders at the conclusion of the project. Discussants spoke in particular about the dean's and the
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project director's realization of the project's potential to improve educational opportunities for students and to enhance relationships between the school and the community. Students also remarked about the visible enthusiasm of the project director and the faculty for the care of older adults. Statements such as “stimulating learning environment for students, faculty, and community,” “service to others,” and “building consensus” were evident throughout their discussions. These data reflect the import of committed leadership to the outcomes of this initiative. Active involvement of the advisory board in decision making concerning best approaches for implementing the newly revised curriculum was evident from meeting minutes and summaries that confirmed the revision of the curriculum plan and implementation process based on stakeholder input. The evaluation consultant noted that ongoing involvement of faculty, students, and community stakeholders was apparent throughout the project planning and implementation process. Evidence of consistent communication about the change was found in meeting minutes, reports, articles, presentations, advisory board sessions, and university publications. Interviews with faculty, students, and stakeholders supported their awareness of the goals of the project and the processes used to introduce program components. They also reported satisfaction with the type and amount of communication received. Unanticipated Outcomes. Some of the most educationally and administratively meaningful findings were apparent in the unanticipated as opposed to anticipated findings associated with program objectives. In addition to achieving both project goals, evaluation findings highlighted six major achievements that indicated change in the organizational culture of the School of Nursing. These impacts were evident in written documents, interviews, focus groups, and observations of the ways in which faculty, administrators, and students interacted with one another and with the community as a whole. Most notable among the unanticipated findings were the following: Identification of a vision for the future. The dean, project director, and faculty all reported the influence of this project on the identification of a targeted direction for the future. The project development, implementation, and evaluation processes used by the school have been identified as a model for nursing programs of similar size, mission, and purpose. The administrators and faculty of the school reported that this strategic direction is directly linked to the outcomes accomplished and the knowledge obtained through this project development process. Creation of an environment supportive of innovation. Clearly evident in the evaluation was the impact that this project had on the faculty and on the school as a whole. A number of other initiatives were begun, each of which was linked to the project and each of which benefited from the work that the dean, director, and
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faculty did to make the gerontology education program a success. Faculty and administrators described an unprecedented level of collaboration and synergy across educational programs and research activities and noted the increased connectedness with the community. Community linkages. Members of the advisory board were highly complementary of the dean, director, and faculty of the project. They reported considerable regard for the work underway in the school and described their interactions with faculty and administration as invigorating and rewarding. They stressed the receptivity of faculty and administration to ideas and could not identify any further recommendations for the project. They reported that the project faculty had already addressed their recommendations and that they were wholly satisfied with what had been achieved. This relationship had an added benefit of creating opportunities for additional linkages and program development opportunities for the school and the community. Recruitment of faculty. Several new faculty joined the School of Nursing as a result of this focused initiative. The identification of an area of excellence was seen as a draw for potential additional faculty. The change in organizational culture achieved by this project had the added benefit of recruiting faculty with expertise in the field of geriatric nursing and interest in research activities related to this specialty area. Expansion to an international focus. This outcome was the result of a combination of factors underway in the school. It was identified by several faculty and the dean, however, as a reflection of the work accomplished through the transformation project. Visibility and recognition by other schools of nursing and health care agencies. Presentation and publication opportunities evolved as an outgrowth of the project and its connections with other schools and health care agencies across the state. Initiatives were identified and promoted as a result of the school's exposure and positive work achieved through the project. Faculty from other programs referred to the school as a model for excellence in geriatric education, and its faculty were contacted for assistance with the development of similar programs. The evaluation process also identified several key attributes of project success at the school (Appendix). Each of these was consistent with the characteristics identified by Gibson and Barsade (2003) as essential to organizational culture transformation and highlights the structural and process dimensions necessary for widespread organizational change. The blending of structure, process, and continuous assessment dimensions of this project contributed to its overwhelming success.
Conclusion Curricular innovation can be the impetus for cultural change at universities striving to improve their scholarly productivity in a climate of limited resources. Curricular
innovation also can focus faculty energies toward a common goal that fosters a collaborative spirit and serves as a foundation for future joint ventures. Aligning faculty interests is an effective strategy to improve productivity while conserving resources. The inclusion of community partners adds a competitive edge to grant proposals and provides a foundation for future projects. In summary, five critical elements contributed to the success of this project: (a) visionary leadership; (b) the creative structuring of processes and incentives that had meaning within the existing culture; (c) an enthusiastic champion able to attract wide participation among stakeholders; (d) the establishment of effective mechanisms for continuous communication, evaluation, and the incorporation of feedback; and (e) external collaboration. A visionary leader can recognize opportunities and can articulate potential benefits for purposes of procuring needed resources to support the change. The enthusiasm of a committed champion is infectious to colleagues and students alike and generates the buy-in and the momentum needed for successful change. Partnerships ensure that curricular innovations are timely and realistic. In addition, they often generate new and unanticipated opportunities. External consultants facilitate successful outcomes by offering guidance for structuring implementation and evaluation processes, suggesting approaches to promote faculty support, and proposing solutions to barriers.
Acknowledgments The authors wish to thank the JAHF, in collaboration with the AACN, for funding this project.
Appendix. Sidebar 1: Key attributes of success • Dynamic, goal-directed, visionary, and responsive leaders • Committed and well-qualified faculty • Flexibility and adaptability • Support of senior university administration • Participative decision-making process • Influential and interested advisory board • Receptivity to board members' recommendations • Consistency of program with university and school vision, mission, and values • Use of internal and external evaluation methods with attention to benchmark indicators • Attention to both curricular content and faculty development needs • Cross-fertilization between innovative programs underway in the school • Identification of and connection with local, regional, and national experts to support all aspects of program development, implementation, and evaluation • Responsive, caring, and supportive faculty (Students reported awareness of improvements made in program and responsiveness of faculty to identified needs and concerns. They also described the faculty in highly favorable terms and reported overall satisfaction with the program.)
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References Bolman, L. G. & Deal, T. E. (1997). Reframing organizations: Artistry, choice, and leadership. San Francisco: Jossey-Bass Publishers. Gibson, D. E. & Barsade, S. G. (2003). Managing organizational culture change: The case of long-term care. Journal of Social Work in Long-Term Care, 2, 11–34. Ingersoll, G. L. & Sauter, M. (1998). Integrating accreditation criteria into educational program evaluation. N&HC Perspectives, 19, 224–229. Lange, J. W., Wallace, M., Grossman, S. C., Lippman, D. T., Novotny, J. M. (2006). The journey toward geriatric excellence in a
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non-research-intensive university. Journal of Professional Nursing, 22, 84–90. Larson, E. (2004). Focusing research priorities in schools of nursing. Journal of Professional Nursing, 20, 156–159. Long, K. A. (2004). Preparing nurses for the 21st century: Reenvisioning nursing education and practice. Journal of Professional Nursing, 20, 82–88. Melnyk, B. & Fineout-Overholt, E. (2004). Evidence-based practice in nursing and healthcare: A guide to best practice. New York: Lippincott Williams & Wilkins. Rossi, P. H., Freeman, H. E., Lipsey, M. W. (1999). Evaluation. A systematic approach (6th ed.). Thousand Oaks, CA: SAGE Publications.
AND
This article illustrates how a grant designed to promote new program development provided a vehicle for organizational transformation. The collaboration surrounding this initiative created a common focus within the school that more effectively channeled its resources and resulted in an unprecedented level of scholarly achievement and recognition. Faculty leveraged the success of this initial grant to procure additional funding for related projects. The importance of partnerships and teamwork were two valuable lessons learned. We believe that our experience is replicable in other schools of nursing interested in organizational transformation. Gibson and Barsade's model of managed change guided the project's implementation and evaluation processes. Recommendations for engaging faculty, gaining support, and developing a collaborative network are discussed in the article, with findings from a stakeholder-focused evaluation demonstrating new program goal achievement as well as the transformative changes that occurred in the organizational culture. A focused, theory-derived program plan, with comprehensive process and outcome evaluation components resulted in a major transformation of one school of nursing. Unanticipated outcomes included renewed synergy among faculty; the development of a preferred vision for the future; scholarly collaboration around a central theme that effectively channeled limited resources and dramatically increased productivity; increased regional and national recognition; and the creation of regional, national, and international partnerships. (Index words: Organizational culture; Organizational change; Faculty development; Curricular innovation) J Prof Nurs 24:371–7, 2008. A 2008 Elsevier Inc. All rights reserved.
N
URSING SCHOOLS ARE facing a number of challenges, with increased enrollments and faculty shortages compelling schools to accomplish more with less. At the same time, changing demographic and global climates have redefined what faculty must teach to prepare nurses for entry into today's practice world.
*Associate Professor of Nursing, Fairfield University, Fairfield, CT. †Loretta Ford Professor of Nursing; Director, Clinical Nursing Research Center and Center for Outcomes Measurement and Practice Innovation. University of Rochester, School of Nursing and Department of Nursing Practice, Rochester, NY. ‡Dean and Professor of Nursing, Fairfield University, Fairfield, CT. Address correspondence to Dr. Lange: Fairfield University, 1076 North Benson Road, Fairfield, CT 06824. E-mail: [email protected] 8755-7223/$ - see front matter
Despite this need, most undergraduate programs have failed to implement the substantive changes required to meet the dramatic increase in basic nursing knowledge that has occurred over the past two decades (Long, 2004). Critical to the creation of responsive schools of nursing is the development of a faculty who can keep pace with the wealth of emerging information while also contributing to the translation of research into clinical practice and the dissemination of nursing knowledge. This need is particularly relevant at non-research-intensive universities where teaching quality has traditionally been more critical to faculty promotion than research productivity. This focus is evolving, however, with tenure requirements at many non-research-intensive universities increasingly emphasizing the importance of faculty scholarship and student exposure to evidence-based practice principles. Nursing faculty at such institutions
Journal of Professional Nursing, Vol 24, No 6 (November–December), 2008: pp 371–377 A 2008 Elsevier Inc. All rights reserved.
371 doi:10.1016/j.profnurs.2007.11.002
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LANGE ET AL
are expected to develop new programs of research despite their limited prior experience with proposal writing and grants management or with forging partnerships to support that work. This change in faculty role focus is being driven in many cases by the professional mandate for evidence to guide practice and the imperative for nursing faculty to cultivate new skills and expertise that support this expanded role component (Melnyk & Fineout-Overholt, 2004). Internal resources to promote faculty development are often limited in many nursing departments where budget allocations may not increase in response to rising enrollments. The need for additional funds to secure sufficient clinical faculty and practice sites often preempts funds for faculty scholarship; thus, today's nursing schools face financial constraints that limit their leadership's ability to provide the resources necessary for faculty enrichment. A successful transition to environments supportive of curricular innovation and role change requires the full support of faculty and leadership. Within an environment of scarce resources, nontraditional pathways must be created to acquire faculty buy-in and the means necessary for accomplishing these goals (Larson, 2004). The purpose of this article was to illustrate how curricular initiatives can serve as a pathway to cultural change in schools of nursing that are confronted with similar challenges. The experience of implementing this project resulted in organizational change; stewardship of precious resources; and engagement of most faculty members in activities that support the organization's cultural transformation, university values, and contribution to the profession. The model of organizational change by Gibson and Barsade (2003) provided the framework for this initiative.
A Model for Cultural Change Within Organizations Some would argue that organizations have cultures, whereas others insist that organizations are cultures (Bolman & Deal, 1997). Gibson and Barsade (2003) believed that there are three layers to the culture of an organization. The first layer is composed of the visible aspects of an organization or the attributes that are apparent the minute you walk in the door. The second layer is composed of the norms of behavior that are expected or the boundaries and guidelines prescribed for that behavior. The third layer is constructed of the values, beliefs, and assumptions of how that particular world works. Understanding the complexity of these layers helps explain why making change in an organization is difficult. If change is to be sustained, it must take place at all three levels (Gibson & Barsade). Gibson and Barsade (2003) suggested that the best form of organizational change is through a managed process. According to their framework, five ingredients are essential to manage change that successfully moves an organization to a preferred future state: (a) visionary
leadership; (b) intentionally aligned structures, systems, and policies; (c) stakeholder participation; (d) consistent communication; and (e) ongoing feedback and evaluation about the structure, processes, and outcomes of change. The authors asserted that successful changes alter the organization's culture and lead to a higher level of functioning. These five elements guided this initiative and laid the groundwork for the cultural transformation that resulted.
Visionary Leadership According to Gibson and Barsade (2003), visionary leaders demonstrate their commitment to change through role-modeling behaviors and by allocating resources to support and sustain proposed action. The summer before this project began, a new dean was hired for the Fairfield University School of Nursing. During her assessment of the school's strengths and challenges, the dean recognized that the university had matured into a highly competitive institution capable of attracting the brightest students; however, nursing enrollments were low at the time. Concurrently, the university was expending substantial resources to improve its infrastructure and to expand scholarship opportunities among the faculty. These changes within the university laid the foundation for a major transformational change within the School of Nursing. Attracting highly qualified nursing students meant having accomplished faculty, creative programs, international opportunities, and access to key national leaders that enhance the typical curriculum. Of the 13 nursing faculty at the time, 11 were doctorally prepared. Three had secured prior funding for innovative projects; nonetheless, most had no active program of research. Faculty collectively produced an average of less than 10 publications per year. The school's previous allocation of resources to individual faculty to pursue discrete, unrelated scholarly interests had resulted in a considerable expenditure of resources in comparison with the return. The new dean recognized the need to improve the school's return on investment and that the school's reputation was closely linked to the accomplishments of its faculty. She noted that a dynamic image was needed to remain competitive in recruiting qualified faculty and students. To address these challenges, the dean organized a team composed of four faculty and a representative from the foundation grants office to apply for funding from the John A. Hartford Foundation (JAHF), in collaboration with the American Association of Colleges of Nursing (AACN), which supported programs designed to revamp gerontological content in undergraduate curricula. This initiative had broad support from faculty who recognized the need to more fully integrate gerontologic best practices into the nursing course content. The new dean envisioned this grant as an opportunity to focus faculty energy and to enhance the school's visibility beyond the region. Working within a 4-week time frame, the team defined member roles, expectations, and
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deadlines. Members shared ideas, researched background information, critiqued drafts, and recruited external partners to support the initiative. Three faculty prepared the initial draft; one faculty member incorporated edits into the final proposal. The grants officer and dean prepared the budget. At the time of application, none of the faculty was certified in gerontology; therefore, developing faculty expertise was a critical precursor to successful curricular enhancement. A budget was created to support two primary goals: (a) to assure that the faculty had the necessary expertise and resources needed to provide classroom and clinical learning experiences that engaged the community and stimulated students' interest in working with older adults and (b) to prepare students in the undergraduate program with the knowledge, experience, and commitment to advocate for and address the health needs and quality of life concerns of older adults. The news that the school was selected to receive a 3-year award from the JAHF/AACN set into motion a journey of managed change that would ultimately alter the culture of the school and set the stage for a preferred future. The project team shared a great sense of pride when the grant was awarded, and the entire faculty felt empowered by the knowledge that collaborative teamwork had enabled members to efficiently prepare a competitive application and to cultivate the support of six new community partners. Recognizing the need for faculty leadership of the project, the dean appointed one member of the team to direct its implementation. The project director devised a leadership strategy that embraced three critical elements: (a) engaging all faculty in the project, (b) accessing external experts to facilitate faculty development, and (c) creating mechanisms for collaboration with agency partners.
Intentionally Aligned Structures, Systems, and Policies The project director created an implementation structure guided by three key assumptions: (a) a fully integrated curriculum requires investment by all faculty; (b) faculty participation in the implementation process is essential to achieving their buy-in; and (c) external consultants are critical to broadening faculty perspectives and to contributing a level of expertise not accessible internally. The consultants posed new ideas and solutions to enlarge upon what was deemed possible by the faculty and ultimately enhanced the end product. To fully engage faculty, the director formed a geriatric subcommittee. All faculty were invited to serve on this committee and to undertake the necessary groundwork for the 3-year project (e.g., evaluating existing media and print holdings, visiting partner sites to explore clinical learning opportunities, organizing faculty development workshops, and gathering resources to support the project). The grant funded three nationally renowned gerontological experts to conduct a weeklong faculty workshop. Partners and faculty from other nursing schools in the state were invited to attend the workshop free of charge. This process helped foster good working
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relationships among participants and worked to establish the school's reputation for gerontological excellence. External experts in curriculum development and evaluation also were funded under the grant. A curriculum expert worked with six faculty to sequence content across semesters and to link this work to the objectives outlined in the grant application. An evaluation consultant visited the campus at the outset of the project and at the end of the funding period to review planning documents; to identify appropriate assessment methods for monitoring structure, process, and outcomes components; and to conduct a comprehensive summary assessment at the end of the project period. A critical component of the evaluation plan was the creation of structures to incorporate feedback from all vested parties. To this end, an advisory board representing faculty, community agencies, and lay elders was formed to provide semiannual feedback on the evolving curriculum enhancements. From these outside influences, faculty learned skills that would later transfer to new endeavors; among these were the value in seeking external consultants to enhance project outcomes and the importance of partnering with community stakeholders to ensure sustainability.
Stakeholder Participation Recognition and reward were used by stakeholder groups to promote active participation. Incentives for faculty participation included the opportunity to help shape the project outcomes through active involvement in program planning and public acknowledgment of individual contributions made. Mechanisms for recognition included publication of advisory board members' names on the school's Web site, e-mail updates, and reports at faculty meetings that highlighted the specific contributions of participating faculty. Photographs of participating faculty in a new recruitment brochure that focused on students practicing in older adult environments also recognized faculty involvement. During the second and third years of the project, subcommittee members presented and published their work. In addition, financial incentives were awarded to faculty for attending geriatricrelated conferences, for pursing geriatric certification, or for revising the curriculum. Each of these strategies contributed to an increase in faculty involvement over time. They also rewarded faculty contributors and enhanced the visibility of the project. University and community press releases, likewise, increased the school's visibility and recognition of faculty, partners, and students. Intensive support for the integration of curricular changes included the initiation of individual meetings with faculty to review new course content and to secure media to support the integration. An onsite resource room was created to house the numerous acquisitions obtained, promote easy access to materials, and increase the likelihood of their use. A gerontology expert was recruited for a full-time faculty position to provide additional support to the faculty.
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Participation by community partners was also critical to the success of this project. Incentives for participation included networking at semiannual advisory board meetings, opportunities for collaboration with the school on other joint ventures, free attendance of employees at faculty development workshops, and access to a potential pool of future employees through student clinical placements. Partners were highlighted on the Web site, in press releases, and in professional and lay presentations as well as in the recruitment brochure.
Consistent Communication Ongoing internal communication is crucial to the success of any organizational change initiative. To address this concern, feedback from the advisory board, faculty, and students was sought as part of a continuing process of evaluation and refinement. Regular reports at faculty meetings, e-mail updates, and the distribution of advisory board minutes were designed to maintain project visibility and solicit feedback. Publicized highlights from annual project reports showcased the project team's impressive progress and accomplishments. A survey designed to assess faculty confidence in teaching the geriatric competencies for baccalaureate students served as a basis for planning a second round of faculty development workshops.
Feedback and Evaluation of Structure, Process, and Outcomes Measuring organizational innovation requires attention to the structure, process, and outcomes of the change initiative. As a result, a combination of quantitative and qualitative data collection methods is required. This is particularly true when assessing transformational change in the organization's culture, where multiple initiatives, resources, and responses are likely. In keeping with the cultural change management model proposed by Gibson and Barsade (2003), evaluation activities were directed at determining whether the characteristics required for successful change in organizational culture (structure and process) were evident and how the organizational transformation, if evident, contributed to the educational and organizational outcomes (impact) seen. A stakeholder-focused evaluation approach was used to guide the evaluation process. This evaluation model assures that the needs and opinions of the persons or groups influenced by the program are included in the evaluation process and refinement of program approach. It is also the most useful method for providing relevant information to those who are likely to benefit from or make decisions about the program and its future direction (Ingersoll & Sauter, 1998). Moreover, a stakeholder-focused approach facilitates the assessment of organizational culture and change in values, beliefs, and perceptions over time (Rossi, Freeman, & Lipsey, 1999). In this evaluation method, data collection activities focus on the foundational documents of the program (the stated goals and objectives), the documents created over time (meeting minutes and reports), and the
internal (program planning members and staff) and external (administrators, decision makers, and policymakers) stakeholders who affect and are affected by the change. A review of foundational documents in this project provided the framework and data collection plan for the overall evaluation. Process and outcome objectives were outlined for each of the identified goals, with early activities directed at identifying sources of data to substantiate the achievement of goals and then selecting the most appropriate methods for accurate and consistent measurement of program process and outcome. Because of the potential for additional outcomes beyond those described in planning documents, the evaluation focused on both the intended and unintended outcomes of the project. The evaluator paid particular attention to the words and phrases used by participants during interviews and focus groups to determine whether evidence of change in organizational culture existed. Process evaluation activities were directed at periodic assessments of the extent to which stakeholder groups were involved in program planning and implementation activities and the ways in which program activities were implemented over time. An integral dimension of this assessment component, one that reinforces the flexibility dimension of effective transformation activities, was attention to the faculty's and community stakeholders' willingness to revise and modify program components in response to identified need or preference. Outcome evaluation activities were conducted at the end of the project implementation period and were overseen by an external evaluation consultant who reviewed program-related documents; met with students, advisory board members, dean, and faculty; and compared observations to program objectives and expected outcomes. Documents reviewed during the outcome evaluation segment included the following: program proposal, geriatric content grid for undergraduate curriculum, course descriptions, program progress summary report, list of advisory board members, program flier, evaluation plan, representative student papers and projects, program announcement materials, list of partnering clinical agencies, faculty development plan, benchmark outcome assessment reports, and assessment tools. Summary reviews of annual activities related to project development and implementation were prepared and made available to faculty and community stakeholders. Findings from the evaluation suggested that activities underway during the course of the project planning and implementation processes were consistent with those associated with successful culture change. Clearly apparent were the faculty's consistent efforts to understand students' and stakeholders' response to the change and the faculty's willingness to adapt project plans to fit the needs of the stakeholder groups. Feedback to students was less formal, although students were aware of changes made based on their evaluations of courses and learning activities. Stakeholders and faculty, likewise,
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reported awareness of revisions to the implementation plan based on individual and group feedback. The availability of an external evaluation consultant contributed to the stakeholders' perceptions of the value of the project and the rigor with which it was being assessed. Anticipated Outcomes. The two goals identified for this project were achieved. Quantitative and qualitative evidence supported positive changes in students' knowledge, their commitment to the care of older adults, and their interest in studying the health care concerns of older people. During focused discussions by the external evaluator at the end of the project, students verbalized recognition of the unique educational experiences provided to them as a result of the project. In addition, student journals and course evaluations demonstrated the gerontology curriculum's favorable impact on student perceptions of their clinical competence and commitment to caring for older adults. Additional evidence of achieving the student educational goal were the granting of student awards of excellence by one participating community agency and the initiation of a loan forgiveness program for graduates of the program by another. The evidence also confirmed that faculty felt more prepared to teach undergraduate gerontology content and had greater interest in pursuing projects related to an older adult population (Lange, Wallace, Grossman, Lippman, & Novotny, 2006). Achievement of the project's faculty development goal was demonstrated by the completion of end-of-life training by five faculty, the awarding of faculty fellowships in gerontology to three faculty, the completion of online training in elder care by the learning laboratory director, and faculty attendance and joint presentations at national and international gerontology conferences. Since the initial award, eight faculty have subsequently received funding to support related projects. Evaluation findings also validated the project team's successful management of change according to the framework by Gibson and Barsade (2003). Attention to the alignment of structures, systems, and policies was evident over the course of the 3-year project. Structuralrelated actions included the review of library resources to assure that materials were available to support an increased focus on geriatric content and scholarly productivity. In addition, teaching models, journal subscriptions, and textbooks were added to support the increased attention to this change. Additional systems and structural evidence were noted by the school's allocation of fully developed space to house a geriatric resource center. Moreover, new agency contracts in several facilities and the creation of a community-sponsored award for graduating students gave further evidence of structural changes supportive of the innovation. The effectiveness of the project team's and the School of Nursing's leadership was reflected in descriptors such as “strong leader” and “visionary,” which arose regularly in the focus groups of faculty, students, and community stakeholders at the conclusion of the project. Discussants spoke in particular about the dean's and the
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project director's realization of the project's potential to improve educational opportunities for students and to enhance relationships between the school and the community. Students also remarked about the visible enthusiasm of the project director and the faculty for the care of older adults. Statements such as “stimulating learning environment for students, faculty, and community,” “service to others,” and “building consensus” were evident throughout their discussions. These data reflect the import of committed leadership to the outcomes of this initiative. Active involvement of the advisory board in decision making concerning best approaches for implementing the newly revised curriculum was evident from meeting minutes and summaries that confirmed the revision of the curriculum plan and implementation process based on stakeholder input. The evaluation consultant noted that ongoing involvement of faculty, students, and community stakeholders was apparent throughout the project planning and implementation process. Evidence of consistent communication about the change was found in meeting minutes, reports, articles, presentations, advisory board sessions, and university publications. Interviews with faculty, students, and stakeholders supported their awareness of the goals of the project and the processes used to introduce program components. They also reported satisfaction with the type and amount of communication received. Unanticipated Outcomes. Some of the most educationally and administratively meaningful findings were apparent in the unanticipated as opposed to anticipated findings associated with program objectives. In addition to achieving both project goals, evaluation findings highlighted six major achievements that indicated change in the organizational culture of the School of Nursing. These impacts were evident in written documents, interviews, focus groups, and observations of the ways in which faculty, administrators, and students interacted with one another and with the community as a whole. Most notable among the unanticipated findings were the following: Identification of a vision for the future. The dean, project director, and faculty all reported the influence of this project on the identification of a targeted direction for the future. The project development, implementation, and evaluation processes used by the school have been identified as a model for nursing programs of similar size, mission, and purpose. The administrators and faculty of the school reported that this strategic direction is directly linked to the outcomes accomplished and the knowledge obtained through this project development process. Creation of an environment supportive of innovation. Clearly evident in the evaluation was the impact that this project had on the faculty and on the school as a whole. A number of other initiatives were begun, each of which was linked to the project and each of which benefited from the work that the dean, director, and
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faculty did to make the gerontology education program a success. Faculty and administrators described an unprecedented level of collaboration and synergy across educational programs and research activities and noted the increased connectedness with the community. Community linkages. Members of the advisory board were highly complementary of the dean, director, and faculty of the project. They reported considerable regard for the work underway in the school and described their interactions with faculty and administration as invigorating and rewarding. They stressed the receptivity of faculty and administration to ideas and could not identify any further recommendations for the project. They reported that the project faculty had already addressed their recommendations and that they were wholly satisfied with what had been achieved. This relationship had an added benefit of creating opportunities for additional linkages and program development opportunities for the school and the community. Recruitment of faculty. Several new faculty joined the School of Nursing as a result of this focused initiative. The identification of an area of excellence was seen as a draw for potential additional faculty. The change in organizational culture achieved by this project had the added benefit of recruiting faculty with expertise in the field of geriatric nursing and interest in research activities related to this specialty area. Expansion to an international focus. This outcome was the result of a combination of factors underway in the school. It was identified by several faculty and the dean, however, as a reflection of the work accomplished through the transformation project. Visibility and recognition by other schools of nursing and health care agencies. Presentation and publication opportunities evolved as an outgrowth of the project and its connections with other schools and health care agencies across the state. Initiatives were identified and promoted as a result of the school's exposure and positive work achieved through the project. Faculty from other programs referred to the school as a model for excellence in geriatric education, and its faculty were contacted for assistance with the development of similar programs. The evaluation process also identified several key attributes of project success at the school (Appendix). Each of these was consistent with the characteristics identified by Gibson and Barsade (2003) as essential to organizational culture transformation and highlights the structural and process dimensions necessary for widespread organizational change. The blending of structure, process, and continuous assessment dimensions of this project contributed to its overwhelming success.
Conclusion Curricular innovation can be the impetus for cultural change at universities striving to improve their scholarly productivity in a climate of limited resources. Curricular
innovation also can focus faculty energies toward a common goal that fosters a collaborative spirit and serves as a foundation for future joint ventures. Aligning faculty interests is an effective strategy to improve productivity while conserving resources. The inclusion of community partners adds a competitive edge to grant proposals and provides a foundation for future projects. In summary, five critical elements contributed to the success of this project: (a) visionary leadership; (b) the creative structuring of processes and incentives that had meaning within the existing culture; (c) an enthusiastic champion able to attract wide participation among stakeholders; (d) the establishment of effective mechanisms for continuous communication, evaluation, and the incorporation of feedback; and (e) external collaboration. A visionary leader can recognize opportunities and can articulate potential benefits for purposes of procuring needed resources to support the change. The enthusiasm of a committed champion is infectious to colleagues and students alike and generates the buy-in and the momentum needed for successful change. Partnerships ensure that curricular innovations are timely and realistic. In addition, they often generate new and unanticipated opportunities. External consultants facilitate successful outcomes by offering guidance for structuring implementation and evaluation processes, suggesting approaches to promote faculty support, and proposing solutions to barriers.
Acknowledgments The authors wish to thank the JAHF, in collaboration with the AACN, for funding this project.
Appendix. Sidebar 1: Key attributes of success • Dynamic, goal-directed, visionary, and responsive leaders • Committed and well-qualified faculty • Flexibility and adaptability • Support of senior university administration • Participative decision-making process • Influential and interested advisory board • Receptivity to board members' recommendations • Consistency of program with university and school vision, mission, and values • Use of internal and external evaluation methods with attention to benchmark indicators • Attention to both curricular content and faculty development needs • Cross-fertilization between innovative programs underway in the school • Identification of and connection with local, regional, and national experts to support all aspects of program development, implementation, and evaluation • Responsive, caring, and supportive faculty (Students reported awareness of improvements made in program and responsiveness of faculty to identified needs and concerns. They also described the faculty in highly favorable terms and reported overall satisfaction with the program.)
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