Recommendations for Overcoming Resistance to Culture Change
In seminal work on employee resistance to change conducted shortly after World War II, Coch and French [45] challenged the concept that resistance to change was the result of flaws or inadequacies on the part of staff, which would make addressing resistance difficult. Instead, they proposed, and proved through experimental methods, that resistance arose primarily from the context within which the changes were taking place. In other words, they found that managers could ameliorate resistance to change through changes to management and leadership practices. In their experiment, resistance to change in a manufacturing plant was overcome when management effectively communicated to staff the reasons for the change and engaged staff in planning for the desired changes. Studies on the barriers and facilitators of culture change implementation in nursing facilities have similarly found that facility leaders can take steps to address, or even avoid, staff resistance to change.
In our own research, we have found that resistance to change is a common barrier faced by facility leaders. We also found that resistance to change was unique among barriers in that, although strategies used to address other types of barriers varied widely, administrators consistently reported using the same strategies to address and overcome resistance to change. These strategies all involved management and leadership activities, including education and training and improved communication. In addition, administrators discussed in detail the ways they tailored education and communication to their facility’s unique needs. They also indicated that these efforts should be ongoing, communication should be two-way, and that all staff should be included [43].
Good Communication
One important tool for avoiding or overcoming resistance to culture change that facility administrators reported was good communication. They reported that open and bidirectional communication fostered feedback about ongoing culture change efforts and encouraged engagement and buy-in from staff. They also suggested that it is important that this type of communication be ongoing. Good communication about culture change, in particular, included providing a strong rationale for the changes and involved getting input from staff before and during implementation [43].
These findings are similar to other studies of culture change which have found that culture change implementation should involve staff at all levels [37] and that facility leaders should follow through on the plans that have been communicated [39]. Interestingly, the importance of good and open communication has also been identified as important to other forms of nursing facility quality improvement [46].
Training and Education
The facility administrators we interviewed also reported providing education and training for staff about culture change in a variety of ways, including as part of regular in-service training and as a component of new employee orientation. The training materials used were often obtained from the leading culture change organizations. However, importantly, administrators reported tailoring these trainings to the specific needs of their employees or unique context of their facility. For example, administrators reported breaking up long training sessions into shorter segments provided over a longer period of time or organizing trainings to be provided to small groups on the units rather than in more didactic conference-style settings [43]. Administrators explained that providing training in this way was more palatable to staff and helped incorporate learning into everyday care.
Other studies of nursing home culture change have also found training and education to be important to implementation. For example, in a study of a labor-management partnership for culture change implementation, Leutz and colleagues [47] found training of staff from all disciplines by culture change experts to be an important element of successful implementation. Training topics included those that were very general, such as gerontology, and very specific, including person-centered care. Staff were paid for their time participating in training, which took place at their facilities to make participation easier. The trainings were also staggered over the course of several months, so that staff had time to use what they had learned between sessions and could discuss their experiences at the later sessions.
Munroe and colleagues [40] conducted a study of culture change training using pre-post test survey methods and found that formal training had more of an effect on staff than informal training. In the study, staff at 2 facilities received formal education from a consulting group while staff at 2 other facilities then received informal training from the staff of one of the formally trained facilities. An important conclusion of the authors was that the formal training did a better job than the informal training of helping facility leaders and managers view their relationships with staff differently. This suggests that facility leaders and managers may have to alter their management styles to create the supportive context within which culture change efforts can succeed [48].