Managing healthcare changes using the VUCA 2.0 framework

FigureThe Greek philosopher Heraclitus is credited with the idea that change is the only constant in life. There's no more apt description for today's practice environments, which require that nursing leaders focus their efforts on retention and preventing staff burnout, ensuring staff and patient safety, and confronting resource and financial pressures.1,2 Nursing practice environments that can embrace change maintain higher levels of employee engagement, and ultimately, provide higher quality care.3 In a changing environment, nurse managers must be attuned to, and act on, what's important to their staff, including the allocation of discretionary resources. These demands require that they have a variety of strategies in their management toolbox. This article discusses one such strategy that's useful in managing change in complex and unprecedented times. The acronym VUCA was initially used to describe periods of time filled with volatility, uncertainty, complexity, and ambiguity.4 VUCA 2.0 builds on earlier work and offers a useful framework for strategizing and implementing change during these uncertain and complex times.5 Here, we present how the leadership theories underlying VUCA 2.0 were used to negotiate resource allocation specific to conference attendance reimbursement at our organization. SITUATION OVERVIEW Our facility, a quaternary children's hospital, has been Magnet®-recognized since 2008. The Magnet® model's five components (transformational leadership, structural empowerment, exemplary professional practice, new knowledge/innovation, and empirical outcomes) are now part of the institution's DNA. Administrative nursing practice decisions are grounded in these core principles. Robust support for ongoing education and professional development are long-standing organizational hallmarks; a conscious effort is employed to ensure that organizational units have the requisite resources needed to foster activities that address these components. This commitment is viewed by many as an indication of the organization's commitment to clinical inquiry and staff satisfaction. Like many organizations, however, the post-COVID era has created new stressors specific to nursing retention and fiscal demands. Within our division, there arose a need to reexamine the programmatic guidelines related to the distribution of resources specific to attendance at professional conferences. In contemplating the impact of a potential change, we conducted a literature review on the value of professional conferences, as well as leadership and change management principles. BACKGROUND The importance of professional conferences Understanding the importance of nursing conferences to both the practice unit and the individual nurse, and balancing the cost and outcomes, are paramount to developing the right guidelines.6 A review of the literature found that conference attendance for nurses offers many benefits. For more experienced nurses, conference attendance provides a mechanism to address their desire for professional development around emerging technologies and clinical skills.7 Conferences can also provide inspiration and reenergize the nurse's passion for learning and the profession.8 For professionally younger nurses, attendance has been shown to offer networking opportunities and to strengthen a sense of professional belonging and engagement; it also leads to an increased feeling of empowerment, intention to stay, and ability to achieve personal and professional goals.9,10 Regardless of experience level, other benefits include exposure to cutting-edge knowledge and motivation to adopt new practice changes or to become involved with a professional organization.6 Although it can be challenging to calculate an immediate benefit from conference attendance, available evidence substantiates conferences' usefulness in building a positive practice environment by supporting staff with their scholarly endeavors, preparing for professional certification, and developing leadership skills.11 All of these factors have been associated with improved nurse retention and quality care.8,11,12 Preconference planning furthers the return on conference attendance. Managers meeting with attendees in advance of the conference offers an opportunity to ensure that individual and department goals are met.6 There should be alignment with the individual's clinical ladder progression or other professional goals, as well as advancing unit-based strategic initiatives. Examples include requiring attendees to: 1) attend educational sessions specific to clinical practice, patient safety, or creating healthy work environments; 2) formally share new knowledge and best practices with peers; 3) visit exhibit halls and poster presentations to dialogue about new medications, technologies, and clinical practices, while enhancing critical-thinking skills and considering potential adoption; and 4) participate in simulations with new practices or technology.6,9 In sum, professional conference attendance is a multifaceted asset to sustaining professional nursing practice, underscoring the need for nursing management's support. Nursing leadership styles and the impact on change management The American Nurses Credentialing Center (ANCC) describes transformational leaders as those who can lead people through change and meet the demands of the future.13 Transformational leaders are inspirational, innovative, collaborative in decision-making, and able to create a vision and lead for change.13 This relational leadership style has also been shown to strengthen trust, boost staff empowerment, and improve the quality of care.3 When transformational leadership is embedded at the unit level there's improved job satisfaction and organizational commitment.14 It's essential for today's nursing leaders to manage change, build team confidence, and lead during times of increased stress and uncertainty. Nurse managers are influential in building a sense of community by leading and empowering professionals with transparency and integrity.15 Nursing leaders who are visible, accessible, and confident and collaborative in their decision-making, and who can effectively and empathically communicate with staff, are well-positioned to champion necessary change.12 Informed nursing leaders acknowledge that a myriad of factors enhance the practice environment and contribute to nurse loyalty and workplace satisfaction.16 Beyond salary and proximity to work, these factors include autonomy, team collaboration, sufficient resources, equitable opportunities for personal career development, and leaders who build meaningful and respectful relationships with staff.16-19 When these factors align, there's increased faith in leadership, improved nursing staff retention, and higher quality care.3,20 Wisely employing human resource management strategies has also been found to be highly effective in managing change, increasing job satisfaction and decreasing burnout.17,21 Although many human resource functions are legally mandated (for example, the Family and Medical Leave Act), or standard organizational benefits (such as dental insurance), other more discretionary offerings fall more directly under the purview of the nurse manager. Matsumoto found a positive relationship between human resource management practices implemented by nurse managers, including those associated with supporting personal career development, and a perceived improved nursing practice environment.17 A framework for change In addition to transformational leadership skills and knowledge about building trust and engagement, an option for nurse managers, when faced with the need to facilitate change, especially in unpredictable times, is to use the VUCA model. This conceptual model, which the US Army War College introduced in 1987, is based on the leadership theories of Warren Bennis and Burt Nanus.4 The acronym VUCA was initially coined to capture the volatility, uncertainty, complexity, and ambiguity of the post-Cold War era. Since then, the concept has been modified to support decision-making and strategizing in a variety of industries.22,23 The premise of this model is that having a solid understanding of the implications of an unstable environment, and knowing how to strategize to mitigate these challenges, will lead to better decisions and outcomes. Leadership and business strategists have continued to build on this concept. In 2017, Bill George, a Harvard Business School professor, proposed an adaptive and strategic leadership approach, which he called VUCA 2.0, to lead in rapidly changing environments.5 This time the acronym stood for vision, understanding, courage, and adaptability. George's strategic leadership approach to a VUCA environment was to establish a clear vision, ensure a deep and clear understanding of the organization's strengths and culture, show courage by challenging the status quo, and be adaptable.5 In 2019, Pamela Meyer, a leadership expert and consultant, proposed that when leading during VUCA times, the first step is identifying which of the four elements is most relevant to the situation, and then the barriers and opportunities; from there, the ideal approach can be identified.23 For example, if ambiguity is the biggest concern, the strategy should include a continued and clarified focus on vision and purpose. When complexity is the biggest challenge, best practices include improved communication and collaboration.23 A comparison of these iterations can be found in Table 1. The application of VUCA 2.0 is described in the following case study. TABLE 1: - VUCA components VUCA: Understanding the issue22 VUCA: Actions for leading23 VUCA 2.0: Planning the change5 Volatility: Rapid rate and unpredictable nature of change Volatility: React quickly and thoughtfully Build in redundancies Ensure continuous communication Vision: To see through the chaos; ability to define mission and values Uncertainty: Lack of predictability; some key information isn't readily available in real time Uncertainty: Fully understand the scope of the issue and from multiple points of view Take action with certainty Understanding: The organization's capabilities and strategies Complexity: Dynamic environment, often overwhelming in scope Complexity: Improve communication, collaboration, and coordination Adapt organizational structure to match complexity Courage: Make audacious decisions that embody risks Ambiguity: Multiple cause-and-effect possibilities, mixed messages, haziness of reality Ambiguity: Communicate with clarity Recommit to vision and purpose Set priorities Adaptability: Using flexible tactics while staying on a strategic course A CASE STUDY The problem Within our nursing division, there was an immediate need to reexamine the distribution of resources specific to expenses associated with nursing attendance at professional conferences. Leadership's ability to manage change can impact staff satisfaction, engagement, and ultimately, quality of care.3,14,19 Our aim was to manage potential change associated with the programmatic guidelines related to conference attendance, while ensuring a commitment to organizational values. The challenges faced in drafting new guidelines, however, included a short timeline and insufficient historical data, issues that were complicated by the need to develop guidance that remained true to our institution's values and the Magnet® vision. The approach A committee was formed that included nursing directors, a clinical coordinator, nurse scientists, and business administrators. The committee faced a tight timeline, uncertainty surrounding the number of staff who had taken advantage of conference reimbursement in the past, and complexity related to multiple stakeholders with varying opinions and priorities. Foundational to our process was the adoption of those components that George and Meyers described in their work on strategizing in VUCA environments. Vision. The committee's initial discussions ranged from sublime reflections on organizational commitment to the Magnet® model ideals, to pragmatic considerations, such as which types of transportation and hotel accommodations would be supported. The group quickly decided that we needed to have a clear vision of our values, and from there establish a set of guiding principles on how to distribute the funds. This vision needed to align with the organization's vision and culture. Having a clear vision related to our mission, values, and strategy would help the committee members to “see through the chaos.”5 An early question the committee faced was if requests for reimbursement from staff who had been accepted to present at a conference should be given priority. For more experienced staff, conferences, in addition to offering a platform for disseminating work, provide opportunities to keep abreast of changes and develop leadership skills. There was also strong support among the group for sending staff earlier in their careers to conferences. The group considered that professionally younger staff would benefit from conference attendance because it stimulates enthusiasm for and commitment to the profession and helps them develop skills and prepare for more advanced learning and clinical inquiry; further, it was felt that conference attendance improves retention.9,12 Additional evidence to support these positions was sought through a review of the literature. Ultimately, the committee decided that conference attendance at every level of professional experience offers important benefits and that equity would be one of our guiding principles. No one group would be prioritized over another based on job title, seniority, or role at the conference. Another topic of discussion was related to the agenda and value of the conference. In part, this value was discerned by initially reflecting on specific organization-wide and departmental goals. Because we were concerned that we might not have enough funds to cover all the requests, the committee proposed supporting attendance at conferences that were in alignment with organizational and/or departmental goals. This determination would be managed by local nursing director review and approval, as appropriate. The group also discussed the value of supporting the individual staff person's personal professional goals. Encouraging autonomy and ongoing professional development and fostering the development of leadership skills have been associated with a more positive practice environment.17,19 High-quality practice environments, in turn, have been associated with improved retention, patient satisfaction, and health outcomes.12 Conference attendance is one conduit for accomplishing these objectives. The final decision was that conference reimbursement would be approved for staff if attendance at the conference supported the staff member's personal professional goals. The last component of our vision was that the criteria and process for conference reimbursement approval needed to be simple, clear, and transparent. We needed to find a manageable way to move forward in the current fiscal year. Wide dissemination of the guidelines and supportive tools, such as checklists, were proposed (see Table 2). The vision and guiding principles that the committee ultimately agreed upon were to ensure conference reimbursement programmatic guidelines were equitable, aligned with organizational and departmental goals, supported personal professional goals, and outlined a simple, clear, and transparent process. TABLE 2: - Checklist for distribution of travel monies Guiding principles: Equity, in alignment with organizational and departmental goals, supported personal professional goals Eligibility for consideration Item Yes No ? N/A Notes Staff must be a permanent employee Employed for at least 12 months Conference content aligns with personal-professional goals Conference content aligns with unit-based strategic objectives Has attendee received conference monies during the past year? Have other funding sources been considered? Previous conference attendance has helped advance unit or organizational strategic initiatives? Conference characteristics Professional organizational affiliation: Nursing organization Interdisciplinary organization Medical organization None or Other Scope: International National Regional/Local Virtual Understanding. Understanding is the process of knowing an organization's culture and capabilities, and playing to its strengths, especially during times of. rapid change. This process is accomplished at least in part by seeking out multiple viewpoints.5 The committee started the process of ensuring broader understanding, and capturing multiple viewpoints, by including members from different departments and roles. As the committee progressed through its work, the proposed guiding principles, potential changes, and draft versions were shared outside the committee with other departmental leadership. These included the Associate CNO, additional senior directors, and clinical coordinators. These individuals offered varying viewpoints and perspectives based on their administrative scope, unit, specialty, and engagement with nursing staff. One nurse scientist also took the lead to search for literature on the value of conference attendance in supporting professional advancement and nursing retention to ensure we included any available evidence on these topics. In addition, the committee sought out data on the amount of funds approved and the number of staff who benefited from conference attendance in recent years. The organizational culture factored significantly into clarifying the vision. For example, one of our organization's strengths is in the nursing department's long-term commitment to a culture that supports clinical inquiry and professional advancement. This commitment has had a demonstrated positive impact on the quality of care, staff satisfaction, and retention. It also weighed heavily in the discussions and was instrumental in the final decision not to prioritize funding based on seniority or role at the conference. Courage. There was a recognized risk in this work. In complex environments, it's never possible to satisfy everyone's requests, and we recognized the potential for some disgruntlement with any final proposed changes. With that in mind, the committee members agreed to stay true to the vision and guiding principles. 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