Organisational Development in the Nursing Field

Organisational development (OD) is widely documented in a plethora of literature many theorists suggest that OD is science based and its topics are rooted in behavioural sciences. OD emerged in the 1960s in

order to support organisations with incremental changes which appeared very topical at the time. Paton et al (2005) suggests the prevailing emphasis of OD is on incremental change however OD originated in developing gradual or first order change within existing and established frameworks. In more recent times OD is required to respond to transformational change (Burns 1978, Bennis & Nanus 1985, Marriner-Torney 1993). This form of change involves changing existing frameworks including attitudes, beliefs and cultural values. A commonality of both these types of change is that they require top down support towards strategy. However from reading a plethora of literature on OD an evident weakness is that not all change is instigated top down, ideas for change can and do come from any level within an organisation and sometimes pressures for change can be bottom up. Bottom up change lacks power and consequencely this could have a negative effect on the OD process.

OD focuses on the process of change rather than the task and is linked to “soft data” (Peters & Waterman 1982). There are numerous topics associated with OD including organisational climate, conflict, culture, management development, employee commitment all according to Mullins (1994) improve organisational performance. Mullins (1994) suggests all topics have to be interlinked or interdependable of each other to gain improved organisational performance. However it could be argued how the accuracy of outcomes are measured or quantified. As changing the interlinked topics may or may not increase outcomes, profits/performance could be increased by external changes and may not always be related to topics involved.

Many Authors have tried to define/suggest a purpose of OD including (Beckhard &Pritchard 1992, Schein 1985, Boddy & Buchanan 1992). The literature suggests OD lacks a commonly agreed definition that is accepted as capturing its nature, principle and extent (Paton et al 2005). The emerging themes from the literature suggests OD applies behavioural science to achieve planned change. Goals include improved organisational effectiveness through using systems theory to analyse organisational issues (Ludwig Van Bertalanffy 1968.)

OD appears to be a management discipline of significance to the settings approach in the workplace it creates an enabling workplace where people work effectively towards strategic goals aligning leadership, structure, relationships and learning towards goal attainment. A key theme of OD is improving organisational efficiency in conjunction with improving the quality of employees working lives (Brauche 2001, Saunders & Barker 2001). This relates to the art and practice of linking people with purpose to reach and achieve strategic goal and is very much people focused.

For the purpose of this paper I shall be critically evaluating OD processes and frameworks in line with current literature and applying these processes to current OD practices within the National Health Service (NHS) and more specifically to the Primary Care Trust (PCT) in which I work. I shall be producing the following OD strategy “Developing skill mix into the Evening District Nursing Team to provide service delivery in a more efficient and effective manner”. (See Appendix A outlining strategy). I will discuss the OD process used to formulate the strategy and plan the change and critically analyse this process. I will focus on the formulation of the change situation within the PCT and discuss common elements of change and how these elements proactively bring about change within the organisation. I shall evaluate the potential effectiveness of the strategy and the potential impact it may have on the organisation.

In order to provide the contextual setting for this project it is important to briefly outline my role within the NHS and examine the changes in the NHS during the recent years. The NHS is a large organisation employing people with a wide range of talents, one of the smaller parts being the Primary Care Trust (PCT) for who I work. My role within the PCT is a clinical/operational management role integrated into a senior nursing role. I manage six District Nursing teams including the evening nursing service and work half time as a District Nurse. I report directly to a Performance/Service Development Manager who in turn reports to the Associate Director.

The PCT employees approximately 1150 staff the majority are clinical staff providing community services. The past structure of the NHS has been embedded in a hierarchical “top down” controlling system styles, yet with the “Modern NHS” this culture is changing (Lucus 2005, Zimmerman et al 1998). The Government White Papers and National Health Service (NHS) Policy documents (DoH 1997, 1998a 1999, 2001, 2002) reflects plans for a modern NHS and outlines the Government plans for 2000 – 2010; These White Papers build a tangible base on which change for the NHS is based, providing anchoring points for the change on an incremental basis. Smith (2005) discusses how incremental change increases employees readiness to change this is very much evident in the aims and objectives of the PCT.

The evening nursing service consists of 34 staff which equates to 6.79 whole time equivalent staff (see Appendix C) the staff all work part time and the majority have more than 10 years service. A service review reported some team members were not working to their grade and there was a need for skill mix within the team to meet the complex care needs of patients on their caseload. This review highlighted highly trained staff undertake clerical duties and simple tasks due too lack of appropriate grade of staff within the team. Community nursing has had to respond to changes from the Government and to the additional pressures including an increase in workload both on day time Community Nursing services but also on the ENS. These pressures are influenced by increasing numbers in the client group District Nurses visit, and the frailty/dependency of these clients. Demographic changes identify that the number of the elderly will increase with a dramatic rise amongst those aged 85 and over adding to District Nursing caseloads in the future. As more people are nursed in primary care the demand for out of hours community based nursing services such as the ENS has steadily risen. The care these clients receive has increased in complexity with the influx of continuing care clients and Active Case Management clients into the service. However despite all of the above the skill mix within the team has remained stagnant.


Many authors discuss approaches to OD what it is and how it is used within organisations, however in practice OD never neatly fits into one approach as change can be chaotic with unexpected combinations and outcomes (Iles &Sutherland 2001).

Themes/Approaches to OD

The OD processes for developing plans for change are based on an ideology of planned participation and democracy (Stacey 1996). These processes rely on change agents facilitating change rather than imposing change. Action Research is one intervention which helps to define a problem and participants then have ownership of that problem (Darwin et al 2002).

Action Research

The concept of Action Research is traced back to Lewin in the 1940s (Darwin et al 2002). Lewin argued in order to understand change and certain social practices social scientists must include practitioners from the real work in all phases of the inquiry (McKernan 1991). Lewin drew on theories of progressive education of the educational philosopher John Dewey. Carr & Kemmis (1986) were critical of Lewins work around Action Research suggesting that democracy and group decision making were viewed as a technique to again the cooperation of workers rather than a fundamental principle for social action and in practice I feel this sometimes happens.

Action Research is often referred to as a management tool for the introduction of change and the strength of Action Research lies in the coupling of participants and research to action and change. This type of change process reflects change in practice as a change agent in this process you need to be part of the change process to understand and empathise with the journey of the change and the people involved. As we know from practice change never runs smoothly, and at times unless you are personally involved in the change you can struggle with the emotions from staff affected from the change.

Action Research creates spiral steps composing of planning, action and evaluation – the evaluation element being the results of the action (Kemmis & McTaggert 1990). Action Research is a rigorous and systemic approach toward OD which uses scientific methods to initiate the change it uses research to enhance practice at a practical level. This type of OD is used in the NHS where care is evidence and researched based. It does require expertise and discipline to use it efficiently and effectively. The change agent requires knowledge and understanding of the Action Research process and knowledge of the validity of research, and the ability to think analytically around evidence and research before putting it into practice.

There are 3 types of Action Research: Technical, Practical, and Emancipatory (Darwin et al 2002). The type more commonly used is practical where the researcher and practitioner comes together to identify a potential problem, it gives joint ownership of the problem associated with the change. The practical type gives more flexibility than the technical approach as it allows participants to problem solve as they move through the change which in turn can give multiple perspectives of the problem.

This type of Action Research fits well into the ethos of the NHS and the principles that problem solving complex health and social problems lies beyond the ability of any one professional/team and large group intervention is required supported by a change agent to constantly monitor evidence and research to ensure practitioners constantly deliver evidence based. However a criticism of Action Research is that in a hierarchical organisation the empowering element of Action Research is often difficult to achieve due too the power structure involved within the organisation.

The cultures in the NHS have changed people now constantly question practice and engage in new enquiry. Staff are actively encouraged to problem solve at shop floor level and Action Research would help staff to perform this. Specifically the methodology used in Action Research has the potential to be useful in areas such as developing innovations, improving healthcare and developing knowledge. Whitehead (2005) discusses how Action Research is gaining acceptance in healthcare management however examples of this in the literature are limited (Waterson 2000, Harrison 2000). Unfortunately Action Research has yet to gain widespread acceptance in the Health Service despite the fact clinicians in the NHS use evidence and research on daily basis.

Action Learning

Action Learning is an approach to OD which involves the development of people in organisations which takes the task as the vehicle for learning (Pedler 1991). Action Learning is learning from what is happening in the workplace opposed to acquiring new knowledge, although programme knowledge can be introduced into an Action Learning programme as it can give a conceptualised framework to the programme.

Many Authors suggest that OD cannot be undertaken on an individual basis as it requires a group to formulate the process and Action Learning brings about changes in people via group work because individuals within the group influence each other and this can be an excellent way to change culture within organisations.

Action Learning is a way of learning from Actions and there are 2 important elements to Action Learning:
· Group work: people who work together on their “doing” and their “Learning”
· Regular meetings: to allow time for questioning, understanding and reflecting (Weinstein 1999).

The involvement of groups in Action Learning makes it effective for introducing change into an organisation and most importantly culture change (Weinstein 1999). Culture change can be difficult to change within organisations as attitudes are not born in us they are formed in groups for example family or work groups and these groups are instrumental in changing our attitudes and beliefs. Group work enables attitudes to change over a period of time and Action Learning enable this process. Changes in people comes about in groups because individuals influence each other and Action Learning sets out principles to challenge people in a group setting, which in the long term will help staff to address change in the workplace.

Action Learning is embedded in the theories of Reg Revans (1983, 1982, 1998) but uses the Kolb & Revans learning cycles which involves learning from our actions and suggests there can be no learning without action. Action Learning promotes the creative integration of thinking and doing to form learning.

The theory of Action Learning consists of a number of elements:
· Programmed Knowledge
· Questioning
· Action
· Reflection

Learning should also be greater than the change, thus programmed knowledge and questioning must be learnt faster than change to avoid becoming dated.

Action Learning helps to conceptualise a problem the Action Learning set works through the symptoms of the problem narrowing the symptoms down to fine detail in order to get to the exact root of the problem this in itself can be challenging. Action Learning is used as a diagnostic at the implementation stage of a change to diagnosis a problem and it uses tactic knowledge for problem identification (Weinstein 1991).

Several Authors suggest Action Learning produces slow results and can take time for people to develop their skills in order to gain full benefits from the set. People can struggle with the balance between accomplishing their task and learning from it and embracing the challenge of the group dynamics. For organisations that prefer quick results Action Learning may not be the appropriate approach to use. Action Learning requires commitment from employers through time and personal development. Sets can work on a task for a period of 6 – 12 months before producing results within an organisation. Employers need to understand this prior to committing their staff to the set. Long term outcomes from Action Learning can be measured in the form of professional development and organisational outcomes but it takes time to measure. Not all employers are able to commit this time and expense. Another common psychological barrier to Action Learning is the perception by the employees that they neither have the time or inclination to learn (Peters & Smith 1996). However a counter argument to this is that Action Learning can develop an inclination for employees to become lifelong learners not only developing a learning organisation but a learning society (Koo 1999).

Deloo & Verstegen (2001) suggest that Action Learning may lead to personal growth but lacks results in organisational growth. Zuber-Skerritt (2002) challenges this suggestion by stating the Authors have not conducted successful Action Learning programmes themselves and show poor understanding of the theoretical concepts that is a pre-condition for successful Action Learning programmes.

Whilst there are clearly benefits gained from Action Learning programmes both at a personal and professional level the financial benefits of such programme have never been quantified. One could argue that some organisations may not want employees developed so they constantly question and challenge and equally some employees would not want this either. However these organisations and employees would be left behind in a rapidly changing environment where people and organisations are facing uncertainties and challenges on a daily basis.

Action Learning is a powerful tool in enabling managers to recognise and deal with ambiguity and anxiety and develop strategies for group learning. This learning group can be a microcosm of the organisation.

The Action Learning model is an example of a powerful organisational intervention and can appeal to managers who may be unwilling to engage in a more traditional intervention, but yet Action Learning fits well in with today’s transformational management style. Action Learning sets in practice appears to contribute to and support transformational change in practice (McNamara 2006).


Clinical performance indicators are powerful tools by which the quality and effectiveness of Health Care can be monitored and measured (Harvey 2004). Information gained from these indicators can assist in the restructuring and the redesign of care delivery. Community Nursing Services uses clinical performance indicators in the form of caseload profiling and caseload analysis to monitor the effectiveness of District Nursing Services. These clinical performance indicators are not deemed to be exact standards rather they are designed to be flags which alert the organisation to possible problems and or opportunities for improvement.

A recent performance indicator highlighted that the Evening Nursing Service (ENS) lacked skill mix within the team resulting in highly trained staff performing task orientated skills and clerical work. DOH (2001) The NHS Plan documents strategies to ensure the right mix and numbers of professionals employed are in the right place at the right time. These documents supported the performance indicator by highlighting the need to analysis and optimize the ENS service. The skill mix within the team is highlighted in Appendix C and the staff work in pairs in the evening.

I as the manager of the ENS was assigned the task of working with the team to plan a strategy for change to restructure the skill mix within the ENS service using the must appropriate OD intervention.

The ENS team is a well established team and the skill mix within the team was stagnant, staff had been in post for many years, therefore the ENS has developed its own culture over the years and I was aware this culture would be hard to challenge and change.

Culture can be an important enabler or inhibitor of change and understanding the role of organisational and professional culture is important (Davies et al 2001). Culture is often strong which means it can have a powerful impact on an organisation but it is not always positive and I felt this reflected the ENS team. The NHS echoes the words of culture “The way we do things around here” (Lundy & Cauling 1996). This type of culture is classed at level three of Scheins1988 model of culture defined as the truest level of culture within an organisation – the taken for granted or invisible culture and this is was reflected in the ENS team. This strong culture can inhibit change especially when new strategies are implemented that go against the entrenched culture and basic norms as the change agent you can then become face to face with the power of culture. I was very aware that the power of the culture within the ENS was going to be difficult to change therefore I decided to use an approach by Gagliardi (1986) “Cultural incrementailism” which incorporates new cultures alongside old ones until the new cultures overtake and become embedded. This type of culture change does take more time to happen but I felt if I was going to change the skill mix in the team I could not change it overnight, new staff would have to work alongside old staff hopefully binging in modern views helping to change the culture in a gradual manner.

I was aware from Waldersee & Griffiths (2003) that the weakness of many change interventions is often attributed to failures in the implementation process rather than the strategy itself. Participative approach toward change appears to be a more conducive approach to use as its methods include support for the change from the work force. Spreitzer (1996) relates participative approaches to empowerment were employees believe they are important assets in the organisation and whilst this may true theoretically it is worth noting that there will always be employees who will resist change and clearly allowing them to participate in the change programme can increase the resisting factors of the change (Lewin model 1951).

The clinical performance indicators which initiated this change were higher management led, which is indicative of OD. Therefore this change strategy involved using a three way approach:

Ø Rational – Empirical approach Chinn & Benn (1996), Nickols (2003)
Ø Participatory approach – See Appendix
Ø Action Research using the Practical Interest model incorporating Kurt Lewin (1951) model of change.

The aim of this approach was to allow the ENS team to perceive and understand the need for the change and then assist them as the change agent to develop responses through team participation (Stacey 2000). The Action Research element of the strategy would allow the team to have ownership of the change by building on the past but using research and evidence to move forward. Whitehead (2005) suggests post modern Action Research represents a much better fit for today’s modern NHS in line with current reforms in the Health Service Agendas, as the Action Research approach focuses on inclusion and participation as a means to transform and restructure organisations. From the literature I feel Action Research represents “best practice” for achieving organisational change and this underpins my choice of OD intervention (Zuber-Skerritt 1996).

The Practical model of Action Learning would allow myself as an internal change agent and the team to work together to improve practice through the application of personal experience of the group (Grundy 1982).

The Rational – Empirical approach (Chinn & Benne 1996) fits into a top down approach of change which makes explicit which changes are necessary and targets the organisational elements assuming that staff will change to accommodate the change that people are rational beings and will follow their self interest. But a negative aspect of this approach is that note everyone is rational in a change situation either overtly or covertly and therefore this approach should be used with caution.

The Participatory Approach would encourage all team members to get involved in the change and make democratic team decisions, employees who are involved in change develop an ownership for the change which can translate into commitment and motivation (Emery & Emery 1993). A key mechanism of attitude change in a participatory approach is the generation of support for change among the workforce, without this support the change can be viewed as unlikely to succeed (Waldersee & Griffiths 2003). Whitehead (2005) echoes my thoughts about using a participatory approach as it makes change easier to achieve when those affected by the change are involved in each cycle and therefore own the change.


The first meeting with the ENS team was to “Diagnosis” the need for the change (Whitehead et al 2003). I was the “internal” change agent due too my detailed knowledge of the service this knowledge included actual work on the service, and felt this would give me credibility from the team members. As a team we looked at and analysed the caseload profiling and workload review of the ENS team, alongside reviewing associated literature on up-to-date evidence based on caseload profiling of an ENS service in a neighbouring PCT and then compared and contrasted the results. This relates to the Action Research element of the strategy. I also asked all team members to forward think prior to the first meeting and bring ideas with them of how they would like the service structured with rationales for their decisions. I felt this would encourage a participatory approach towards the strategy and forge constructive relationships with all team members (Whitehead et al 2003). My intension was to give the team members ownership of the change and in return for them to give commitment to any choices which may be made (Arygris & Schon 1978). My hope was these interventions working jointly would lead to a cultural change within the team. By the end of the first meeting the majority of staff did agree that the skill mix within the team was inappropriate and therefore the problem was “Diagnosed”. Everyone went away to think about their “Ideal” team and bring their ideas to the next meeting.

The second meeting fostered a field force analysis (Lewin 1958) (see Appendix C). This became the unfreezing process (Lewin 1958). One of the aims of the meeting was to create the conditions necessary for a successful change (Burnes 1992). We focused on problems and opportunities which were identified and I as the change agent tried to increase the driving forces to make the meeting positive and productive. As a group we also undertook a SWOT analysis to highlight strengths and weaknesses which allowed us to devised a plan of “where we are now and where we go from here” with a time frame. Again this group work was creating the spiral steps of Action Research (Kemmis & McTaggert 1991). I was aware at this meeting of the criticisms made by Carr & Kemmis (1986) as previously discussed and my aim was for the group to have a social action opposed to me as the internal change agent gaining cooperation of the workers, therefore I undertook a more facilitator role within the group to remove any power status the staff viewed of me. I also wanted the individuals within the group not only to learn the task (what the group is working on) but also I wanted the group members to equally focus on the process (how the group is going about the change) to enable them to conceptualise the whole process. This conceptualising would allow the group to use a deeper level of OD intervention where activities involved in the change process are geared to helping individuals discover hidden aspects of their personalities and relationships within the group, which could help to change the culture within the group.

One of the key issues identified from this meeting was the need to bring into the team a lower grade of untrained staff to address clerical issues within the team, a task presently undertaken by anyone in the team including highly trained staff, and also to lower the grade of the present team leader post of the team (which was vacant) in order to give the post more hours. This relates to Arnold et al (1998) when he talks about job redesign, where a job is re configured to give greater variety in the workplace in order to motivate people and to give more autonomy to empower people. This was the aim of the team discussion around the introduction of new grades within the team. This new design would ultimately improve the teams quality of working and the main drivers for this redesign were the present inappropriate use of skills.

The meeting concluded by staff being asked to scan the literature around job redesign and skill mix, and to bring their findings to the next meeting. Individuals within the team volunteered themselves to write the lower grade job description for discussion at the next meeting. This meeting had an overall positive feel and ownership of the change did emerge from everyone present. This reflected the “practical” approach of Action Research – problem solving. This meeting concluded with change targets and outcomes agreed and formal systems appertaining the change were formalised.

As the internal change agent working with the team it was interesting to note the type of players within the team shapers, finishers and plants (Belbin 1981). I was aware had all the players in the team been the same type of players then dynamics of the group could have been very different, giving different results to the change process. Schein (1992) suggests the concept of culture has its roots in theories of group dynamics and growth understanding, the dynamics can help develops strategies for change and organisational culture relating to team work or indeed can inhibit the change process.

The third meeting was a brief meeting to discuss the job redesign and complete the new job descriptions. At this meeting senior staff were asked to be on the interview panel for the new posts alongside myself. This inspired the team as they had never been invited to sit on an interview panel before. I felt this learning opportunity really gave the team empowerment and ownership of the change in action. Although this change process was initiated” top down” this really gave the change a “bottom up” feel. My transformation leadership style (Patton 1990, Burns 1978) allowed me to see and share my knowledge around recruitment with the team, this systems approach to learning allowed me to combine formal training with on the job coaching to the team around the recruitment process. My aim was to develop the team to use double loop learning while they are in the change mode, encouraging them to question taken for granted beliefs (Argyis & Schon 1978). However for double loop learning to occur the team needed to continue to develop a culture that supported change and risk taking and this included having an openness that encourages dialogue and expression of conflicting points of view.

The refreezing process was when the new lower grade staff were in post. These were Band 2 and Band 6 staff. As a team we reviewed the whole change process four months after the new staff were in post. This evaluation monitored and established the effectiveness of the action taken during the Action Research process. We measured the effectives of the change by previously agreed outcomes and targets. These outcomes included:
· Less Bank nurse useage
· More staff on duty each evening – allowing appropriate grades of staff to undertake appropriate roles
· Moral of team improved
· Less sickness within the team

The team agreed that all outcomes had been achieved and all team members felt more supported and happier in their role. This outcome supported the literature from Brache (2001) and Saunders& Barker (2001) who both suggest the purposes of OD is to improve organisational effectiveness but also improve organisational health and quality of working lives.


The NHS culture has been created and sustained by its history, plurality of purpose, structures, uses and pro values and these are difficult to change in any change processes.

Achieving and sustaining effective organisational change and renewal is imperative in any organisation. The people in an organisation can be either the key to achieving effective change or the biggest obstacle to success, and this can largely depend on the appropriateness of the OD intervention used. The price of failed change efforts can be high including loss of credibility on parts of leaders/managers. Leaders need to create a readiness for change at both at an individual and employee level and the NHS is no exception.

However this change will depend on how leaders initiate the change and on which OD intervention they use to carry out the change. OD has been used many times in years gone by and to some degree OD is currently in a state of evolution as OD practices and techniques have become mainstream into the basics of management principles (Wooten & White 1999).

I felt using Action Research to initiate and facilitate my strategy for change worked positively in conjunction with my transformational leadership type. My understanding is that the best people to bring about change are those involved in it and who understand it best. Using Action Research as an OD intervention did involve all the team members in the whole change process and it brought about new learning and experiences for the team members and ultimately jelled them together as a team more cohesively. Using Action Research allowed the team to determine the conditions of their own lives at work, improving their working lives and conditions of work which in turn allows them to work more effectively.

This strategy of change is a micro change within the PCT but has achieved macro results. As a manager I am aware that as a team we do not want to refreeze permanently in this new state, we need to view this as a transactional change where change occurs continuously to improve efficiency and effectiveness within the work place.

Ambitious goals such as the achievement of the NHS plan will require that the NHS becomes an organisation able to embrace continuous, emergent change but will depend on the people in the NHS becoming more skilled in handling change and the use of OD interventions in a complex environment with multiple stakeholders, conflicting objectives and considerable constraints (Iles &Sutherland 2001).