The Labour government acknowledged that the physical health needs of people with mental health problems had been neglected and that this group need support to access appropriate healthcare and health promotion services (Department of Health, 2009). Over the last ten years there has been progress made regarding the use of exercise in mental health services. In 2004 a research team asked GPs if they would consider prescribing exercise instead of antidepressants for low mood. Only 5% said they would.
In a recent follow-up survey in June 2011, the proportion of those willing to prescribe it had risen to 22 %, reflecting a clear shift in attitudes and beliefs (Baker 2001) . However, I personally do not feel this is a large enough rise. From my experience in working in psychiatric wards at this hospital I have observed that exercise is much underused. For example there are no gym facilities and no exercise groups at all. I propose that all psychiatric inpatients should have access to and encouragement to attend physical exercise facilities.
This is despite a large body of evidenced based research that has proven exercise can be an intervention to prevent and alleviate mental illnesses. For example, one study of the effects of physical exercise on depression concluded that after sixteen weeks exercise was just as effective as SSRI’s but without any of the side effects. Physical exercise also had the benefit of improving physical health and improving self-esteem through socialising (Craft et al 1997).
In order to do this I will need to use change management theory and leadership theory. Change management is a structured approach to shifting or transitioning individuals, teams, and organizations from a current state to a desired future state. It is an organizational process aimed at helping employees to accept and embrace changes in their current business environment In order to implement my change there would be a number of things I would need to consider. Firstly, I would need to consider how my change will be implemented.
Ackerman (1997) has distinguished between three types of change: developmental, transitional and transformational. I would need to decide which strategy of change would best suit my vision. I feel it would be best to attempt to carry out a planned transitional change. This is an implementation of a known new state; involving the management of the interim transition state over a controlled period of time. My interim transition stage would be the process of building gym and exercise facilities while training staff capable to work in both psychiatric and exercise fields.
This stage would also involve negotiating and finding a way around the administrative, health and safety and policy barriers which I estimate would be the biggest difficulty. My known new state would be encouraging psychiatrists to prescribe exercise and encouraging the service users to make use of the exercise facilities during their time as inpatients. I would define my change as episodic rather than continuous. Episodic can be defined as ‘infrequent, discontinuous and intentional’ (Weick and Quinn 1999).
Sometimes termed ‘radical’ or ‘second order’ change, episodic change often involves replacement of one strategy or programme with another. However, once my intervention of exercise has been established I plan to make continuous change to it so as to make incremental improvements to ensure it is as an effective intervention as possible. Another, reason why I plan to use Ackmann’s transitional strategy as a basis for my change is because it has its foundations in the work of Lewin who conceptualised change as a three-stage process which I will explore later (Lewin 1951).
When planning a change in the NHS such as this it is necessary to look at change theory models. These will be very relevant when implementing my change. The majority of contemporary research originates from the work of social psychologist Kurt Lewin in the mid-twentieth century. Lewin identifies three stages through which change must proceed before any planned change will become embedded in an organisation or system of working. These are unfreezing, movement and refreezing. I will base my change upon this model. Unfreezing is when I as a change agent proposes a plan for change to the team or organisation.
During this stage I will attempt to win over team members who are not keen on my change, I will aim to resolve any anxieties or concerns regarding the change. Cummings and McLennan (2005) claim that an essential leadership role is to understand the different perspectives of individuals and stakeholders and to ‘align the changes to be meaningful for them’. During this stage I will attempt to access the relative merits of the forces for against change such as extent of the proposed change, nature and depth of motivation of stakeholders, and the environment in which change will occur.
It is necessary for the driving forces for change to exceed the opposing forces for change, this is essential for change to be successful. As part of this stage it is considered necessary to conduct a force field analysis which I include in my appendices. In summary, I had several large forces for change. One being that exercise in alleviating the symptoms of mental health is supported by a large amount of evidence based research. Another large force for change is that people in mental health services suffer far worse physical health problems than members of the general population.
I believe that my planned change or intervention will improve the physical health of this group. In my opinion the biggest force for change is that in times where health care cost demands are outpacing any rise in healthcare budgets, exercise is an intervention that can reduce the demands on the budget. After researching the topic I have concluded that the biggest force against this change would be the set up costs in terms of building facilities and training staff.
Provision of physical activity also requires trained and qualified personnel; there is no data on availability, skills and training of staff with competence as exercise specialists and the expertise to treat people with a multitude of mental and physical problems as well as the skills to work in psychiatric settings. (Jones et al 2004). Another force against change would be navigating around administrative and policy rules. In the present culture of our society, procedures including health and safety, liability, manual handling and risk assessments may not allow ‘hospitals’ and ‘on site exercise facilities’ to be compatible.
However, despite these concerns I believe I would be able to build up a good degree of teamwork within my team as I believe those I would be leading would be enthusiastic and motivated to make this change a reality. I will also conduct a SWOT analysis as part of this stage. This involves thinking about an organisation’s strengths, weaknesses, opportunities and threats, and using the result to identify priorities for action (Ansoff, 1965). SWOT analysis is a ubiquitous feature of business strategy texts and courses.
In a survey of 113 UK companies, Glaister and Falshaw (1999) found that SWOT was one of the most widely used strategic planning tools in current use across a range of sectors. The basic theory of using a SWOT analysis is because it helps an organisation to think about the reasons why they may need a change. I have included a SWOT analysis in my appendices. As part of this initial ‘unfreezing’ stage I will need to be able to gain support of the workforce to make my change successfully, I will need to gain and maintain this support through a mixture of good communication, good interpersonal skills and developing a sense of achievement.
Scholtes, (1998) in his trust, respect and affection model identifies trust as arising out of the feeling that leaders or managers both care for their staff and are capable of doing the job. At this unfreezing stage it will my job as leader to help those team members who are not keen on the change to resolve their anxieties or concerns so that they become committed team members. Senge in ‘The Fifth Discipline’ (1990) talks of the difference between commitment, enrolment and compliance, suggesting that while it is more pleasant (and reassuring) to have considerable commitment, it is not necessary for everyone to be as fully signed-up as this.
There exist a number of positions along a continuum, along which players may position themselves in response to proposed action and change. These are, in reducing order; commitment, enrolment, genuine compliance, formal compliance, grudging compliance, non-compliance and apathy. Senge suggests analysing what level of support is required from each of the players and directing energy to achieve that, rather than at trying to persuade everybody to ‘commit’ The second stage is movement; this is movement towards accepting the change.
At this point I will need to formulate a plan of action and implementation. I would use a Gantt chart to effectively communicate my change management plan. A Gantt chart is a type of bar chart that illustrates a project schedule. Gantt charts illustrate the start and finish dates of the terminal elements and summary elements of a project (Gantt 1910). Terminal elements and summary elements comprise the work breakdown structure of the project. I would also set up a small project or reference group to help manage the project with me.
I will aim to include everybody whom would be affected by the change in the planning. I will set goals and objectives and set target dates and timelines. I will also be available to support others and offer encouragement throughout the change process. I believe that the multidisciplinary team work and layers of management, already established in the NHS will be an important lever to help implement and embed the change. Throughout this process, I will be constantly evaluating the changes and making modifications if necessary. The third and final stage is refreezing.
This stage involves supporting others so that the change is sustainable and remains in place to achieve improved outcomes. My role as leader will be to help the continued integration of the change into practice to ensure refreezing-that is, the change becoming part of normal practice; if this does not occur the previous behaviours will occur. There are a wide range of different theories of motivation in business management. These are of importance because the style of management theory adopted could potentially make the process of change a smoother transition.
The core models are McGregor’s Theory X and Theory Y model, Maslow’s hierarchy of needs model, Herzberg’s Motivation – Hygiene theory, Taylor’s scientific model and Mayo’s Human Relation model (Maslow 1970): (Herzberg 1966); (Taylor 1911); (Mayo 1933). Attempting change management under one of the more autocratic management models such as Taylor’s or McGregor’s Theory X model would have very different consequences when compared to Mayo’s or McGregor’s Theory Y model. Under Taylor’s model the workforce may resist change.
This is because in such a work environment theory managers will make all of the decisions and simply give orders to the employees below them. In this working environment change would not be a smooth transition as there would be a barrier between management and workers, change occurs smoothly when the workforce work together to lead change. These models would not create motivation amongst the workforce. Alternatively, change may be more successful in an organisation culture based upon Maslow’s hierarchy of needs (Maslow 1970).
Maslow put forward a theory that there are five levels of human needs which employees need to have fulfilled at work. All of the needs are structured into a hierarchy, and only once a lower level of need has been fully met, would a worker be motivated by the opportunity of having the next need up in the hierarchy satisfied. A business should therefore offer different incentives to workers in order to help them fulfill each need in turn and progress up the hierarchy. Therefore to implement my change and to e successful at doing so this model suggests I should delegate responsibility to employees to ensure they achieve self actualisation in the workplace. This could potentially ensure a smooth transition of change. However, there are problems with looking at management models when implementing changes. Every workplace, particularly the NHS is very complex and has a range of different management styles within each workforce. To state that management should use Maslow’s hierarchy of change to ensure a smooth transition of change is too simplistic.
Although in theory it appears to be a solution, in reality there are lots of faults of this model in the workplace place. The theory makes crude assumptions that simply don’t apply to everyone. Most importantly Maslow states people attend to basic needs first and progressively deal with more complex matters until they reach a point he calls self-actualisation at the top of the hierarchy’s pyramid. However in reality not everybody gets that far. This criticism is especially relevant in the practice I wish to change.
In the NHS it is widespread knowledge that there are a large number of managerial positions, but to implement my change once exercise facilities are available I would need the support of the nurses and support staff to actualise my change. My point being that not everybody involved in my change would be able to reach self actualisation in their particular job or role. Another criticism of Maslow’s theory which equally applies to all of the theories is that Maslow’s idea belongs to a time and place. Maslow was American and he first suggested the hierarchy in the 1940s.
It’s highly specific to America’s individualist culture where middle-class people worry about their personal needs rather than any collective needs. This may not be so relevant in a less right ring country with public health care and with a workforce with such diverse ethnicities and cultural heritage as is in the United Kingdom. However, despite the criticisms that are directed at theories of motivation it will be important for me as a leader to have the knowledge regarding how to motivate my workforce.
When thinking about how I as a manager would go about implementing this change I feel it is important to consider what type of leader I would be. Leadership will be very important if I am to be able to work with conflicting views to build up trust in the change proposal’s worth and the value of putting effort into my proposed change. House (2004) describes leadership as the ability to motivate and enable other people to achieve the goals of the organisation they work for. There are many different theories of leadership styles, the two main ones being transactional and transformational leadership.
Transactional leadership is leadership at its most basic. The followers do what the leader asks of them in return for a reward. The role of the leader in this model is to state what needs to be done and who will do it and then allow them to get the job done, hence it focuses on getting a task done rather than on the person undertaking a task. In nursing this approach was traditionally used in previous years when task allocation was the role of the ward manager when patient care was perhaps less holistic than it is today.
When implementing my change I aim to be a transformational leader. This will involve being able to share and communicate my vision of change effectively to others. Transformational leadership theory suggests there needs to be a relationship of trust between the leader and the follower. Bass (1985) suggested four essential components of effective transformational leadership. First, leaders must provide intellectual stimulation, challenging the way things are and encouraging creativity among the team.
Second, they must demonstrate individualised consideration and by using good communication skills make followers feel able to share ideas and gain direct recognition for their unique contributions. Third, they need to demonstrate inspirational motivation which enables followers to experience the same passion and motivation as the leader to meet the team goals. Fourth, they need to have idealised influence; that is, they must act as a role model who followers wish to emulate whole taking on the values of the leader. As a leader I will also need to possess emotional intelligence.
This refers to the ability of the leader or manager to understand the role that their emotions play in their decision making and the ability to recognise the emotions of the individuals within the team and how this affects the work they do (Goleman, 1996). Goleman’s emotional intelligence framework comprises five elements: self-awareness, motivation, self-regulation, empathy and social skills. Possessing emotional intelligence will be important if I am to be able to work with conflicting views to build up trust in my change proposal’s worth and the value of putting effort into my proposed change.
As a leader I will also need to be assertive. This is as opposed to being submissive or aggressive. Assertiveness can be defined as ‘expressing opinions or desires strongly and with confidence so that people take notice’. (Oxford Advanced Learners Dictionary). Ruiz, M. (2004) The Voice of Knowledge argued that there were four factors involved in being assertive. These were to be impeccable with your word, not to take anything personally, not to make assumptions and for a person always to do their best. In conclusion in order to make my change successful there are many things I will need to do.
Firstly, I will need to use theories of motivation to ensure I am able to motivate my workforce so that teamwork will be successful. I will then need to use Levin’s change theory model to ensure that I can gain support from my colleagues and to accurately plan my change. During my freezing, movement and refreezing stages there are lots of qualities I will need to display as a leader. I have identified I would consider it must appropriate to be a transformational leader as identified by Bass (1985). As a leader it would also be vital for me to display emotional intelligence and to be assertive.
What I have learned from this module is that the business management theory behind making and implementing a change can be as important as the actual subject of change itself.