DNP 835 Module 1 Systems Theory and Resistance to Change Example

Good Evidence, No Adoption: Using Systems and Organizational Theory to Explain Why a Hospital Resists an Acute Care for Elders Unit

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Doctor of Nursing Practice Program, Aspen University

DNP 835: Strategic Leadership and Business Management

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Good Evidence, No Adoption: Using Systems and Organizational Theory to Explain Why a Hospital Resists an Acute Care for Elders Unit

Health care leaders are often puzzled when a change with strong evidence is not adopted. The usual explanations, resistance to change, lack of awareness or poor communication, rarely capture what is happening. Systems and organizational theories offer better explanations by showing how structures, incentives, relationships and norms produce the behavior leaders observe. This paper applies those theories to a composite 300-bed community hospital that has twice shelved a proposal to open an acute care for elders unit, a medical unit designed around the needs of hospitalized older adults, and identifies where a doctoral nurse leader could intervene.

The Evidence the Hospital Set Aside

Acute care for elders units combine a prepared environment, patient-centered nursing protocols to maintain function, early discharge planning, medical care review to avoid harmful medications and procedures, and interdisciplinary rounds. A randomized trial in a community hospital found that, although self-reported function at discharge did not differ, the composite of decline in daily activities or nursing home placement was less frequent with the model, 34% versus 40%, without increasing length of stay or costs; nursing care plans promoting independence were used more often, restraints less often, and patients, families, physicians and nurses were more satisfied (Counsell et al., 2000). A later meta-analysis of acute geriatric unit care using components of the model found fewer falls, risk ratio 0.51, less delirium, less functional decline from baseline before admission, shorter stays, fewer discharges to nursing homes, more discharges home and lower costs, although mortality and readmissions did not differ (Fox et al., 2012). The evidence is not uniform across outcomes, but it consistently points to benefit without added cost.

A Complexity Lens

Complexity theory describes health care organizations as complex adaptive systems: collections of individuals and groups who act according to their own internal rules, whose actions are interconnected, and whose behavior produces patterns that no one designed. In such systems, small changes can have large effects, large efforts can produce little change, and outcomes emerge from relationships rather than from plans imposed from the top (Plsek & Greenhalgh, 2001). Seen this way, the hospital's two decisions to shelve the unit were not single decisions but the result of many local rules interacting: how beds are counted, how physicians are paid, how nurses' roles are defined and how beds are assigned.

It also explains why a better presentation of the same proposal is unlikely to succeed on its own.

Structure and Incentives

Several structural features push against the unit. The hospital's bed management system assigns patients to whichever medical bed is open, and a unit reserved for older adults would reduce flexibility during crowded periods, a concern the bed management office raised both times. The hospital is organized by physical units with separate budgets, so the costs of the model, such as a geriatric nurse specialist, pharmacist time for medication review and physical therapy, fall on one unit's budget, while savings from fewer falls, shorter stays and fewer nursing home placements appear elsewhere or go unmeasured. Performance measures reward throughput and occupancy rather than preserved function. In systems terms, the hospital performs exactly as its structure and incentives design it to perform.

Professional Norms and Identity

Organizational theory also emphasizes norms and identities. Hospitalists may see a specialized unit as limiting their autonomy or adding meetings, and some nurses may worry that caring only for older adults would be seen as less prestigious than other assignments or would increase workload. Managers of other medical units may fear losing experienced nurses or the patients who fill their beds. These concerns are not irrational, but combined with the structural disincentives, they make shelving the proposal the easiest path, even when evidence suggests benefit.

Points of Influence for a Nurse Leader

Complexity theory suggests that change is more likely through a few well-chosen changes to relationships and rules than through a grand plan. A doctoral nurse leader could focus on several points of influence. First, change the question: rather than proposing a dedicated unit, propose applying the model's core components on one existing medical unit for older patients, with bed assignment rules that prioritize but do not reserve beds, which answers the bed management concern. Second, make costs and savings visible together: build a shared ledger that credits the unit with avoided falls, shorter stays and avoided nursing home placements. Third, involve hospitalists in designing interdisciplinary rounds that save rather than add time. Fourth, create a professional identity for nurses on the unit, through geriatric nursing certification and recognition, so that the assignment is seen as expertise. Fifth, measure what matters to each group, including falls, delirium, function, length of stay, discharge destination and staff experience, and share them openly.

Testing the Explanation

A theory-based explanation is itself a hypothesis. Before proposing a new plan, the nurse leader would test it by interviewing the people involved in the two earlier decisions: the bed management director, the chief financial officer's analyst, hospitalist leaders, nurse managers of the medical units and frontline nurses. If the interviews confirm that bed flexibility and budget attribution were decisive, the component-based approach and shared ledger address the real obstacles. If they reveal something else, such as a past failed project that left mistrust, the plan must change. This step also builds relationships with the people whose support the next proposal will need, which complexity theory suggests matters as much as the proposal's content.

Conclusion

The composite hospital's decision to shelve an acute care for elders unit, despite evidence of fewer falls, less delirium and lower costs, is better explained by systems and organizational theory than by simple resistance. As a complex adaptive system, the hospital responds to its bed management rules, unit budgets, performance measures and professional norms, all of which favor the status quo. A nurse leader who understands these forces can target points of influence, a component-based start, a shared ledger of costs and savings, hospitalist engagement, professional identity for nurses and transparent measurement, that make adoption the easier path.

References

Counsell, S. R., Holder, C. M., Liebenauer, L. L., Palmer, R. M., Fortinsky, R. H., Kresevic, D. M., Quinn, L. M., Allen, K. R., Covinsky, K. E., & Landefeld, C. S. (2000). Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: A randomized controlled trial of Acute Care for Elders (ACE) in a community hospital. Journal of the American Geriatrics Society, 48(12), 1572-1581. https://doi.org/10.1111/j.1532-5415.2000.tb03866.x

Fox, M. T., Persaud, M., Maimets, I., O'Brien, K., Brooks, D., Tregunno, D., & Schraa, E. (2012). Effectiveness of acute geriatric unit care using acute care for elders components: A systematic review and meta-analysis. Journal of the American Geriatrics Society, 60(12), 2237-2245. https://doi.org/10.1111/jgs.12028

Plsek, P. E., & Greenhalgh, T. (2001). The challenge of complexity in health care. BMJ, 323(7313), 625-628. https://doi.org/10.1136/bmj.323.7313.625