In many arenas change is becoming a constant. McKinsey and Company reported that approximately 70% of organizational change initiatives fail (Maurer, 2010). This suggests that due to the myriad of very public changes in the field of healthcare it provides a fertile setting for studying change efforts.
Changes in healthcare are occurring both externally in the form of broad sweeping laws such as the Affordable Health Care Act, payment structures and focused public debate while internal pressures include budget constraints, new technologies, changing ownership and staffing issues. As one healthcare executive involved in this study stated, "Turbulence has been the norm rather than the exception over the years". Hospital leaders today are in a unique predicament, responsible for designing, implementing, as well as, leading their employees through organizational change initiatives. The hospital industry has been struggling to keep up with the rapid-fire changes (CPP, Inc., 2004). It has been very difficult to lead a hospital and pressures on hospitals have worsened over time with no light at the end of the tunnel (2004). Legislative, demographic, and economic pressures have changed the way hospitals do business (2004). Altman and Gurvis (2006) of the Center for Creative Leadership suggested in the case of healthcare:
... leadership is the process by which groups, communities, and organizations accomplish three tasks: setting direction, creating alignment, and gaining commitment. The processes by which these leadership tasks are accomplished take many forms, ranging from individuals stepping into traditional leadership roles to leadership arising as a collective. (p. 21). William Bridges (1980), author of Managing Transitions, says, "It isn't the changes that do you in, it's the transitions" (p. 3). While change is an event (a death, birth, merger, reorganization, new job, or downsizing), the human response to change is a process. Human reactions to change may include excitement, heightened emotions such as anxiety, fear and anger, as well as psychological trauma and confusion. The psychological response is a process of transition over time. People do not typically change their attitudes, beliefs, feelings and allegiances overnight; it happens gradually (Bridges, 1991).
For successful change management, emotions associated with organizational life during times of change must be emphasized rather that the "overly rational portrayal of both change management and managerial activity" (Clarke, Hope-Hailey, & Kelliher, 207, p. 92). The consequence of ignoring the emotions during change is a "one size fits all" management style that really does not facilitate effective change. Understanding the relationship between emotions and the transition can improve leadership during times of transition which translates into less resistance, quicker engagement, and higher commitment. "Implications for successful change management depend as much on the management of the transition period as its strategic formulation" (Clarke et al., 2007, p. 92).
The setting of this study is a hospital that has won many awards during this time period despite the fact that much of this time they were involved in a major change initiative while dealing with a turbulent external environment. This setting identifies the cognitions and emotions of the leaders throughout the change initiatives. Cognitions and emotions are studied through two levels of leaders, executives and directors. Their emotional perspectives during the change initiatives are very important to understand in terms of the impact on the change process and outcomes (Klarner, By, & Diefenbach, 2011). The study captures leader reactions and reflections regarding the organizational change process: beginning, midpoint, and at the twelve year point in time. This longitudinal view of data frames the change as a process "that unfolds repeatedly over time" (Klarner et al., 2011, p. 335). This phase analysis of organizational change may identify emotional patterns different from those obtained in response to a single change initiative (2011).
While significant literature exists on the level of the employees who are actually implementing the changes we were unable to locate a body of literature that deals with the emotions of the leaders of organizations during the change efforts. An over-rational view of both change management and leadership activity exists with little research on the emotional work of the leader within the change context (Clarke et al., 2007). This leads to the following research question:
Research Question: What were the emotions and cognitions that high level healthcare leaders experienced during repeated changes in a turbulent internal and external environment?
Brief History of the Human Aspects of Change
For many years, academics, management and organizational practitioners have hypothesized that organizational transitions follow a series of predictable patterns or stages, which, if understood, could enable leaders to more effectively and efficiently manage organizational change. There are striking similarities in the change models of the past half-century. Each model proposes predictable and sequential stages and phase and cognitive and emotional reactions. There is overlap among the theories regardless of the number of stages described. The stages in each of the models present a common and predictable pattern. Yet successful change management includes the human side, the feelings and emotions, not simply a series of linear and logical processes and activities (Clarke et al., 2007).
Lewin (1951) described the process of change as occurring in three stages: Unfreezing, Moving, and Refreezing, a sequential process through which existing systems are undone rearranged and reconstituted. Lewin's model describes an individual's cognitive and emotional response to change. Initially, individuals must recognize that the old system or "state" is history and reduce their attachment to doing things in a familiar way. This Unfreezing Stage challenges the status quo with different and possibly discomforting information. In the Moving Stage, new ideas, structures and systems are created, tested, and installed to replace those that existed previously. In the Refreezing Stage, new systems are accepted, refined, and operated to produce results.
Elisabeth Kubler-Ross (1969), a Swiss born psychiatrist, published her seminal work on the topic, On Death and Dying, in which she outlined five commonly experienced stages for those facing death or experiencing the death of a loved one. Kubler-Ross's grief model focuses on significant individual loss; it has been applied extensively to work-place losses. These stages include Denial and Isolation, Anger, Bargaining, Depression, and Acceptance. Denial involves activities and rituals that are reflective of life before the change occurred. People in denial refuse to believe what has happened. In Stage Two, anger, denial is replaced by feelings of anger, rage, envy, and resentment. A common question is: "Why me?" In the Bargaining stage, bargains are typically made with God and are attempts to postpone the inevitable. The fourth Stage, Depression, has two aspects; one related to losses in the past and one related to losses in the future. In the final stage of grief, people accept the inevitable. Kubler-Ross describes acceptance by a dying person not as a happy time, but as a time that is almost devoid of feeling. For a survivor, this is the stage in which they realize that life must go on; loss is accepted and attention is turned toward the future.
Bridges (1980) developed a three-stage transition model similar to Lewin's change model. Bridges' stages include Letting Go, the Neutral Zone, and New Beginning. Letting Go recognizes an ending and acknowledges the experience of loss. The Neutral Zone, is described as a "no man's land" that exists between the old and new realities. The Neutral Zone is a broad category incorporating the negative emotions of resistance and the more positive emotions associated with exploration and new possibilities. People operating in this zone feel uncomfortable and emotionally awkward as they confront the unfamiliar and unknown. In this stage both danger and opportunity exist. Some people may persevere and others may abandon the situation. Only after organizations experience Letting Go and the Neutral Zone can they begin the third stage, New Beginnings. Leaders of change seem to forget that through the planning process they have already experienced their own denial and resistance and thus are ahead of the followers in the transition curve. Commitment to new beginnings comes only after they have traveled the transitory path from denial to confusion and resistance, and then to exploration and renewal.