i FACILITATOR’S GUIDE i i FACILITATOR’S GUIDE i i i FACILITATOR’S GUIDE CONTENTS MODULE 6: MONITORING AND EVALUATING THE PROJECT Objectives 1 Session 9 2 The monitoring and evaluation process 2 Monitoring 2 Elements of monitoring 3 Planning a monitoring system 3 Evaluation 5 Preparing for evaluation 6 Planning for evaluation 6 References 8 Information sheet 6.1 - Monitoring 9 Information sheet 6.2 - Formal surveys/ 11 Questionnaires Facilitator’s guide - Monitoring and evaluation 13 Exercise sheet 6.1 - Monitoring plan assessment 14 tool Exercise sheet 6.2 - Monitoring and evaluation 16 plan i v FACILITATOR’S GUIDE 1 MODULE 6: Monitoring and evaluating the project MODULE 6 MONITORING AND EVALUATING THE PROJECT Objectives Upon completing this session, the reader should be able to: Describe the elements and functions of monitoring and evaluation Apply the planning and implementation principles of monitoring and evaluation Apply the findings of monitoring and evaluation 5 5 5 MODULE 2 Identifying and Analysing the Stakeholders and Networks MODULE 5 Managing Communication and the Change Process MODULE 3 Understanding the Contextual Environment MODULE 1 Identifying the Problem and the Desired Outcome MODULE 6 Monitoring and Evaluating the Project MODULE 4 Understanding the Policy, Political and Decision- Making Processes T T T T T T 2 MODULE 6: Monitoring and evaluating the project Session 9 The monitoring and evaluation process In the previous session you developed an understanding of the management of change. But to ensure that change is implemented in an effective and efficient way there is a need to monitor progress and evaluate the process, output and outcomes of your project, program or initiative. This session will introduce you to the principles and processes of monitoring and evaluation. Monitoring progress and evaluating results are key functions to improve the performance of those responsible for implementing programs/projects. It therefore follows that it is an essential part of the advocate’s collection of skills. Close communication and negotiation are necessary while planning and carrying out monitoring and evaluation processes. Monitoring Monitoring is a management tool that contributes to effective and efficient implementation. Those responsible for monitoring should be open to modifying original plans during implementation, if such action seems warranted. By comparing what has been accomplished to targets set up in advance for a given time period, monitoring identifies shortcomings before it is too late. It also provides elements of analysis as to why progress fell short of expectations, identifying constraints and pointing the way towards measures to overcome them. Monitoring may be used to adjust specific objectives and revise the work plan. This does not mean that objectives should be changed lightly. But when monitoring signals that something is off course, a careful review of the situation should be undertaken to assess if a modification of objectives is merited. For further information on monitoring, please refer to Information Sheet 6.1. 3 MODULE 6: Monitoring and evaluating the project Elements of monitoring Routine reporting, field visits, detailed activity plans and timetables provide a monitoring framework. Baseline data describe the problem or situation before the service, program or project begins (or begins another phase) and identify a point from which to measure progress. Often it is not desirable to delay the start of an activity while comprehensive baseline data are being gathered. In that case data should be gathered in association with the early phase of the activity, before it has had time to have an impact. At the beginning of implementation, or immediately prior to it, those responsible for carrying out a programme should review the plan of action and confirm or refine objectives, activities, time frame, resources, baseline data, and monitoring plan. Planning a monitoring system What should be monitored? Select indicators for monitoring. An indicator answers the question: “what is going to show that we have accomplished our objective?” To decide on an indicator, recall the objective of an activity and the targeted audience: what is the expected result of the effort and who is the intended user of the service? Although many indicators can usually be established for each objective, it is important to select one or a limited number of key indicators that will best demonstrate you accomplished your purpose. There is no standard list. Good indicators limit and focus data collection. The basic principles are: • keep the information requirements to a bare minimum; • collect the information that will be most helpful to those who will use it. The most common problem is that too much data is being collected, of poor quality, that is not being analysed or used, expending resources that could be better used. How should it be monitored? Select methods to track indicators and report on progress. Many methods may be used: observation, interviews, routine reporting. Piggyback on existing data collection systems whenever possible. Both formal and informal, quantitative and qualitative methods can be used to check periodically on certain programme aspects. Decide how information will be recorded systematically and reported clearly. 4 MODULE 6: Monitoring and evaluating the project The monitoring plan should also identify who will be involved in reviewing progress and providing feedback on a regular basis. What reports should contain? The major components of progress reports are fairly standard and include: • a list of specific objectives and activities that were to be accomplished during the quarter (or six month period); • the degree to which each was completed, with numbers; • identification of constraints or obstacles that explain why certain objectives/activities were not completed as planned (if applicable); • identification of additional resources, training, etc., needed to help overcome these constraints; • updated list of objectives/activities planned for the next period; and • financial accounting: what was budgeted and spent during the report period and any proposed changes for the next period. (See Exercise Sheet 6.1) Example Data Data Monitor Don’t Comments available not Monitor available Inputs √ √ The resources required to advocate have been listed and can be monitored. Processes √ √ An implementation plan was developed therefore the process can be monitored. Outputs √ There is no specific product, therefore need to focus on outcomes rather than outputs. Efficiency √ √ Monitoring the contribution of the human but resources employed could monitor difficult efficiency of effort. But this may not be to worth the effort required. monitor Effectiveness √ √ The objectives have been set but the outcomes will need to be monitored. Reporting mechanisms will need to be put in place. Outcomes √ √ The objectives have been set but monitoring of progress will need reporting mechanisms put in place. 5 MODULE 6: Monitoring and evaluating the project Having completed this assessment a monitoring plan can be developed. The plan will include the: • aspects of the project to be monitored; • data sources available and to be developed; • the timeframes and • the resources required. Exercise Using the Monitoring Plan Assessment Tool (Exercise Sheet 6.1), develop a monitoring plan for your project. Evaluation Evaluation examines changes and their significance in relation to one or more of the following issues: relevance, effectiveness, efficiency, impact and sustainability. Generally there are three points at which evaluation is carried out: • Prospective appraisals, sometimes called ex ante evaluations, are carried out before a programme or project is started. An appraisal is the critical assessment of the relevance, feasibility (political, technical, financial and institutional), and socio-economic profitability of an activity before a decision is made to undertake that activity, or approve funding for it. Baseline surveys, field studies and situation analyses may provide elements of appraisal. • Ongoing evaluation is the analysis during the implementation phase of the continuing relevance, outputs, effectiveness and impact of an activity. It is closely linked to monitoring and is used to alert managers to problems so that corrective action can be taken. Informal observation usually plays an important role. Mid- term evaluations are also carried out during implementation. The results of either may lead to mid- course corrections. • Retrospective evaluations, also called ex-post evaluations, analyse relevance, effectiveness and impact after the completion of an activity. Lessons learned can be used as input for future planning and funding decisions. Successful advocacy for change is dependent on process, hence monitoring of the process is critical. Ongoing evaluation is therefore preferred in this case. EVALUATION can be defined as an analytical process involving the collection and reduction of data of all (or some) phases of the instructional process and culminating in the synthesis of a report containing recommenda- tions about the instruc- tional programme being evaluated. 6 MODULE 6: Monitoring and evaluating the project Preparing for evaluation Objectives should be drafted sufficiently clearly in the plan of operations to make evaluation possible; often they will contain the indicators on which the success of the program or service is to be judged. The plan should include provision for monitoring and evaluation. It should designate a person who will be responsible for evaluation. Unless the base-line data have been gathered during the situation analysis, arrangements should be included for it to be gathered as the process starts up. (See Sessions 1 and 2) Planning for evaluation The best way to decide on the purpose of an evaluation is to identify all who might use the evaluation and then discuss with them what they want the evaluation to do and how they would use its results, what difference the information would make - that it would be possible to do something about the problems disclosed. What resources are needed and available for evaluation? Early in planning an evaluation make an estimate of its costs. Costs depend on the nature and size of the project and design of the evaluation. Also, you should consider the non- financial or indirect costs of the evaluation, the time and effort that people involved must contribute, when away from their regular work. Formulating findings Findings answer the evaluation questions. They describe the situation, compare it to what was expected, explain the reasons for the situation and its consequences for achieving programme goals. For findings to be credible and persuasive, they must flow from the data gathered and be backed up by the evidence collected. Focus the findings on issues related to the purposes of the evaluation and select the most important and interesting ones. Using evaluation results Evaluation results should be used to: • improve future planning; • assist decision-making; • indicate where further action might be needed; and • indicate where further research is needed. 7 MODULE 6: Monitoring and evaluating the project The monitoring and evaluation plan should contain the following • The purposes of the monitoring and evaluation (who can/ will use the results) • The timing of monitoring and evaluation in the project/ program cycle • Aspects of the project to be monitored • Who will be responsible for managing and carrying out the plan • What methods of gathering data will be used • Resources the supplies and materials, infrastructure and logistics needed for the evaluation (See the example provided; Information Sheet 6.2 and Exercise Sheet 6.2) Example Project/Programme title: Nurse Staffing Levels Purpose of the monitoring and evaluation: To ensure that the project runs to plan and achieves the intended outcomes Project Manager: Tacon Moore Aspects to Data Source Method of data Responsible Resources Frequency/ monitor and collection person Timeframe evaluate The project The resource Feedback at JC nil Every 2 weeks was sufficiently list which was team meetings from resourced developed commencement to completion of the project The implemen- The implemen- Feedback at TM nil As above tation process tation plan which team meetings went to plan was developed The process The objectives Feedback BC On completion was effective which were set session with of project all relevant stakeholders The outcomes The outcomes Survey or TM Cost of As above were achieved which were Questionnaire* Questionnaire agreed to all development stakeholders Exercise Using the Monitoring and Evaluation Plan Tool (Exercise Sheet 6.2), complete your monitoring and evaluation plan. 8 MODULE 6: Monitoring and evaluating the project You now have all the systems and processes in place to advocate for your cause. If you don’t have all the necessary skills, you have ensured that there are people around you who have them. You have an understanding of the stakeholder interests and the political environment in which you have influence. You are ready to go. References • Inter American Development Bank (IADB), A Management Tool for Improving Project Performance (www.iadb.org/cont/evo/EngBook/engbook.htm). • Monitoring and Evaluation News (www.mande.co.uk/news.htm). • Research Methods Knowledge Base (www.trochim.human.cornell.edu/kb/index.htm). • The Gateway to Development Information (eldis), Methods, Tools and Manuals (www.nt1.ids.ac.uk/eldis/hot/pm3.htm). • The World Bank, Monitoring and Evaluation: Some Tools, Methods and Approaches, 2002 (www.worldbank.org/html/oed). • UNDP, Managing for Results: Monitoring and Evaluation in UNDP: A Results – Oriented Framework, 2001 (www.undp.org/undpweb/eo/evalnet/docstore3/ yellowbook/documents/). • UNDP, OESP, Who Are the Question-makers? A Participatory Evaluation Handbook, 1997 (www.intra.undp.org/eo/methodology/methodology.html). • United Nations Children’s Fund (UNICEF), A Guide for Monitoring and Evaluation (www.unicef.org/reseval/mande4r.htm). • United States Agency for International Development (USAID), Center for Development Information and Evaluation (CDIE) Performance Monitoring and Evaluation Tips. (www.dec.org/usaid_eval/004). • USAID, Automated Directives System (ADS), Chapter 200 - Introduction: Managing for Results, Functional series 200 - Programming Policy (www.usaid.gov/pubs/ads). • USAID, Center for Development Information and Evaluation (www.dec.org/usaid_eval). • World Bank Institute. Training Evaluation Toolkit (Version 1.3) ( www.worldbank.org/ wbi/). • World Bank, Impact Evaluation, 2001(www.worldbank.org/poverty/impact/index.htm ). All the very best and thank you on behalf of other nurses and the community in which you work for taking an interest and being motivated to take on the role of advocate. 9 MODULE 6: Monitoring and evaluating the project INFORMATION SHEET 6.1 MONITORING Monitoring can focus on: • Projects normally consist of a set of activities undertaken to achieve specific objectives within a given budget and time period. • Programmes are organized sets of projects or services concerned with a particular sector or geographic region or a particular donor. • Services are based on a permanent structure, and, have the goal of becoming, national in coverage, e.g. health services, whereas programmes are usually limited in time or area. • Processes are organizational operations of a continuous and supporting nature (e.g. personnel procedures, administrative support for projects, distribution systems, information systems, management operations). • Conditions are particular characteristics or states of being of persons or things (e.g. disease, nutritional status, literacy, income level). In addition, monitoring may focus on different aspects of a service, programme or project: • Inputs are resources provided for an activity, and include cash, supplies, personnel, equipment and training. • Processes transform inputs into outputs. • Outputs are the specific products, goods or services, that an activity is expected to deliver as a result of receiving the inputs. • A service is effective if it “works”, i.e. it delivers outputs in accordance with its objectives. • A service is efficient or cost-effective if effectiveness is achieved at the lowest practical cost. 1 0 MODULE 6: Monitoring and evaluating the project • Outcomes generally refer to peoples’ responses to a programme and how they are doing things differently as a result of it. They are short-term effects related to objectives. • Impacts are the effects of the project/programme on the people and their surroundings. These may be economic, social, organizational, health, environmental, technical or other intended or unintended results of the project or programme. Impacts are long-term effects. 1 1 MODULE 6: Monitoring and evaluating the project INFORMATION SHEET 6.2 FORMAL SURVEYS/ QUESTIONNAIRES What are they? Formal surveys can be used to collect standardized information from a carefully selected sample of people. Surveys often collect comparable information for a relatively large number of people in particular target groups. What can we use them for? • Providing baseline data against which the performance of the strategy, programme, or project can be compared. • Comparing different groups at a given point in time. • Comparing changes over time in the same group. • Comparing actual conditions with the targets established in a programme or project design. • Describing conditions in a particular community or group. • Providing a key input to a formal evaluation of the impact of a programme or project. • Assessing levels of poverty as basis for preparation of poverty reduction strategies. Advantages • Findings from the sample of people interviewed can be applied to the wider target group or the population as a whole. • Quantitative estimates can be made for the size and distribution of impacts. 1 2 MODULE 6: Monitoring and evaluating the project Disadvantages • Results are often not available for a long period of time. • The processing and analysis of data can be a major bottleneck for the larger surveys even where computers are available. • Household surveys can be expensive and time- consuming. • Many kinds of information are difficult to obtain through formal interviews. Cost Can range from low to high, depending on the size and distribution of the sample. Skills required Sound technical and analytical skills for sample and questionnaire design, data analysis, and processing. Time required Depends on sample size. 1 3 MODULE 6: Monitoring and evaluating the project FACILITATOR’S GUIDE – MONITORING AND EVALUATION Facilitator’s preparation time: 60 minutes Group exercise time: 90 minutes Resources: Exercise Sheets 6.1 - 6.2 Information Sheets 6.1 - 6.2 Butcher paper, white board or black board Pens/pencils/paper Instructions: • The exercise is best done with no more than 20 people. • Read Module 6, Session 9 and go through each of the exercises. • Familiarize yourself with the Exercise Sheets, Information Sheets, and Skill Sheets. • Make sure you have enough copies of the Exercise Sheets for each participant in your group. • Make sure that you have the resources you need, e.g. pre prepared butcher paper. • Introduce the topic and explain the objectives of the exercise. • Make certain that everyone in the group has a full understanding of the problem being considered. • Begin with Exercise Sheet 6.1. This will assist the group to isolate the aspects of the project which require monitoring and the data sources the group should use. • Now go to Exercise Sheet 6.2. This exercise will assist the group to monitor progress towards the achievement of their desired outcomes and measure the actual achievement of the outcomes. This completes Module 6, Session 9 1 4 MODULE 6: Monitoring and evaluating the project EXERCISE SHEET 6.1 MONITORING PLAN ASSESSMENT TOOL What is it? The Monitoring Plan Assessment Tool assists you in isolating the aspects of the project which require monitoring and the data sources you should use. Why use it? To inform the development of a Monitoring Plan. When to use it? When you are ready to commence your project and need to put a monitoring mechanism in place. How to use it • Complete the exercise with a small group of colleagues. • Explain what you want to achieve by doing the exercise. • Determine which aspects of the project you wish to monitor. • Asses the availability of the data and determine what tools to use to collect data not available. Data Data not Monitor Do not Comments available available monitor Inputs Processes Outputs Efficiency Effectiveness Outcomes Impact 1 5 MODULE 6: Monitoring and evaluating the project Example: Data Data not Monitor Do not Comments available available monitor Inputs The resources required to advocate have been listed and can be monitored. Processes An implementation plan was developed therefore the process can be monitored. Outputs There is no specific product, therefore need to focus on outcomes rather than outputs. Efficiency Monitoring the contribution but difficult of the human resources to monitor employed could monitor efficiency of effort. But this may not be worth the effort required. Effectiveness The objectives have been set but the outcomes will need to be monitored. Reporting mechanisms will need to be put in place. Outcomes The objectives have been set but monitoring of progress will need reporting mechanisms put in place. Having completed this assessment develop your monitoring plan which will include the: • aspects of the project to be monitored; • data sources available and to be developed; • the timeframes; and • the resources required. Inputs are resources provided for an activity, and include cash, supplies, personnel, equipment and training. Processes transform inputs into outputs. Outputs are the specific products, goods or services, that an activity is expected to deliver as a result of receiving the inputs. A service is effective if it “works”, i.e. it delivers outputs in accordance with its objectives. A service is efficient or cost-effective if effectiveness is achieved at the lowest practical cost. Outcomes generally refer to peoples’ responses to a programme and how they are doing things differently as a result of it. They are short-term effects related to objectives. Impacts are the effects of the project/programme on the people and their surroundings. These may be economic, social, organizational, health, environmental, technical or other intended or unintended results of the project or programme. 33 3 3 3 3 3 3 3 3 3 1 6 MODULE 6: Monitoring and evaluating the project EXERCISE SHEET 6.2 MONITORING AND EVALUATION PLAN What is it? The Monitoring and Evaluation Plan helps you monitor progress towards the achievement of your desired outcomes and measure the actual achievement of outcomes. Why use it? To ensure that you progress effectively and efficiently toward the achievement of your desired outcomes. When to use it? The plan should be developed as early in the project as possible, that is when you are clear as to the outcomes you wish to achieve. How to use it • Complete the exercise with a small group of colleagues. • Explain what you want to achieve by doing the exercise. • Determine which aspects of the project you wish to monitor. • Asses the availability of the data and determine what tools to use to collect data not available. 1 7 MODULE 6: Monitoring and evaluating the project Project/programme title: ________________________________________________________ Purpose of the monitoring and evaluation: _________________________________________ Project manager: _______________________________________________________________ Aspect to be Data Method of Respon- Resources Frequency/ monitored source data sible Timeframe and evaluated collection person Date developed: ________________________________________________________________ Date last revised: ________________________________________________________________ Example Project/programme title: Nurse Staffing Levels Purpose of the monitoring and evaluation: To ensure that the project runs to plan and achieves the intended outcomes. Project Manager: Tacon Moore Aspect to be Data Method of Responsible Resources Frequency/ monitored source data person Timeframe and evaluated collection The project was The resource Feedback at JC nil Every two 2 sufficiently list which was team meetings weeks from resourced. developed commence- ment to completion of the project The implemen- The implemen- Feedback at TM nil As above tation process tation plan which team meetings went to plan. was developed The process The objectives Feedback session BC On was effective. which were set with all relevant completion stakeholders of project The outcomes The outcomes Survey or TM Cost of As above were achieved. which were questionnaire* questionnaire agreed to all stakeholders development 1 8 MODULE 6: Monitoring and evaluating the project 1 9 MODULE 6: Monitoring and evaluating the project 2 0 MODULE 6: Monitoring and evaluating the project
i MODULE 5: Managing communication and the change process i i MODULE 5: Managing communication and the change process i i i MODULE 5: Managing communication and the change process CONTENTS MODULE 5: MANAGING THE ADVOCACY CHANGE PROCESS Objectives 1 Session 8 2 Introduction to this module 2 The change process 2 Desired outcomes and key performance indicators 3 Project planning 5 Phases of change management experience 6 The change agent 7 Change management 7 Change management team 8 Building commitment 10 Acknowledge and manage resistance 11 References 13 Information sheet 5.1 - The change process 14 Information sheet 5.2 - COmmunication 16 Information sheet 5.3 - Resistance to change 18 Information sheet 5.4 - Performance indicators 20 Skill sheet 5.1 - Effective change agents 22 Skill sheet 5.2 - Effective listening 25 Skill sheet 5.3 - Answering and asking question 27 Skill sheet 5.4 - Delegation skills 30 Skill sheet 5.5 - Group facilitation 31 Skill sheet 5.6 - Feedback skills 33 Skill sheet 5.7 - Conducting meetings 35 i v MODULE 5: Managing communication and the change process Skill sheet 5.8 - Writing and corresponding 38 Skill sheet 5.9 - Public speaking and presentations 40 Skill sheet 5.10 - Assertiveness skills and 43 conflict resolution Facilitator’s guide - Change management 47 Exercise sheet 5.1 - Outcome statements and key 49 performance indicators Exercise sheet 5.2 - Project planning 51 Exercise sheet 5.3 - Change agent self 53 assessment tool Exercise sheet 5.4 - Team formation tool 55 Exercise sheet 5.5 - Communication plan 56 1 MODULE 5: Managing communication and the change process MODULE 5 MANAGING COMMUNICATION AND THE CHANGE PROCESS Objectives Upon completing this session, the reader should be able to: Explain what the change process means and the factors that facilitate change Develop key performance indicators Develop a project plan Describe the attributes of a change agent Develop a change management team Develop a communication plan Use techniques for reducing resistance to change 5 5 5 5 5 5 5 MODULE 2 Identifying and Analysing the Stakeholders and Networks MODULE 5 Managing Communication and the Change Process MODULE 3 Understanding the Contextual Environment MODULE 1 Identifying the Problem and the Desired Outcome MODULE 6 Monitoring and Evaluating the Project MODULE 4 Understanding the Policy, Political and Decision- Making Processes T T T T T T 2 MODULE 5: Managing communication and the change process Session 8 Introduction to this module You are ready to go. You have a clearly defined issue you are advocating for; you have the evidence to support your case; you have identified your stakeholders and completed a risk analysis. You have also developed the necessary networks and have a thorough understanding of the environmental context in which you will be operating as well as the systems, and policy and legal frameworks. You have analysed the decision-making process and know how to access it and at which point. Finally you need an understanding of the management of change. An advocate is intimately involved in change. Their whole reason for being is to bring about change which will bring benefits to the community. This session will introduce you to the management of change and the skills and strategies required to be a change agent and lead a team to advocate for the change. The change process How often have you read a job description that makes some reference to ‘change management’? Although the term is not quite so commonplace today as it was a decade ago, change management skills and experience remain ‘must have’ qualities for many jobs. Like it or not, human interaction and organization take place in an environment which changes. It is these environmental changes which are often the motor for organizational change. In the health industry, change tends to take one of two basic forms. The first kind of change happens when an organization consciously decides to remake itself. This could be part of a merger or major restructure. This kind of change should be an orderly process – at least that is the theory. Such change begins with a master plan and then alterations are made in a systematic fashion. Any reconfiguration lies mainly within the bounds of the organization and can be controlled by that organization. The other type of change happens when organizations are driven to reconfigure because of external pressures. These can be as simple as a new piece of legislation or government regulation. An example might be the changes required within accounting businesses when governments introduce a new tax system. Government led change may be negotiable and often comes CHANGE MANAGEMENT is a structured methodology that incorporates the elements of communication, critical thinking, process analysis, training and process redesign to facilitate future growth. 3 MODULE 5: Managing communication and the change process with plenty of warning. There are many other external forces driving change that are less predictable. For example: social upheaval, radical technological advances, economic upsets, competitor action, accidents, war, etc. Although there are exceptions, few organizations can expect to have much influence over these external forces and even where there is an opportunity to influence external change, things might not happen the way one might expect. However you want to advocate for change and not necessarily drive the actual change process itself. To do this, you need an understanding of the change process. For further information on change see Information Sheet 5.1. For additional information on skills for managing change see Skill Sheet 5.1. Exercise Think about your own attitudes towards change. How do you respond when something in your environment changes in such a way that it could affect you or your immediate setting? Reflect on any current or past changes in your life. Desired outcomes and key performance indicators Before you proceed to develop your change management plan, you should be clear about the outcomes you want to achieve and the indicators (see Information Sheet 6.1) you can use to measure progress towards the achievement of the desired outcomes. The test of the clarity of the outcomes is to ask the question “If these outcomes are achieved, will the project be considered to be completely successful by customers and all major stakeholders?” (See Exercise Sheet 5.1) Example Using the Health Centre Case Study “Insufficient nursing staff to meet client needs”, the following outcome statements were derived: Outcome statements Internal Staffing levels are sufficient to meet service demands at a cost which is not greater that of an equivalent size health centre while improving staff satisfaction and morale. External Clients are able to get appointments according to their need and complaints have reduced. 4 MODULE 5: Managing communication and the change process Exercise Using the Outcome Statement Tool (Exercise Sheet 5.1), develop outcome statements for the problem you have been working on in the previous exercises. Given that “what you measure is what you get” it is important that the key performance indicators (KPIs) selected support the outcomes you want to achieve. It is quite possible that if you get this wrong, everything that follows will be out of alignment. The indicators need to be: • measurable • simple • realistic • manageable Two rules in developing KPIs are: • measure the “big” elements of each goal, not all elements (keeping KPIs to a reasonable number); and • modify KPIs to suit the existing management information system, and decide where this system needs to be improved to generate better KPIs in the future. (See Exercise Sheet 5.1) Example Outcome statements Key performance indicators Measures Achieving staffing levels to meet Increased staffing levels Workforce monitoring service demand Maintain operating costs at the Operating costs benchmarked Operating costs of equivalent level of equivalent size health against equivalent size health size health centres centres centres Operating costs of the Health Centre Improving staff satisfaction Improved staff satisfaction Staff satisfaction survey and morale Monitor sick leave Monitor staff turnover Improving service levels to users Reduction in user complaints Record of complaints Increase in user compliments Record of compliments Improved client outcomes User satisfaction survey Exercise Using the Key Performance Indicator Tool (Exercise Sheet 5.1) develop KPIs and measures for each of the outcome statements you have developed. 5 MODULE 5: Managing communication and the change process The final step is to check whether the data is currently being collected. If not, assess the feasibility and cost effectiveness of collecting it. You may have to adjust the indicators if the effort to measure the indicator is going to be greater than the result from collecting it. Project planning You should now be ready to develop your plan of action. You have defined and analysed the problem, established priorities, documented your outcomes and defined your KPIs. The Project Planning Template directs you to establish the strategies, assign the responsibilities and set the timeframes. The strategies can be developed from a brainstorming exercise and need to identify the person who will be responsible for undertaking each task and the timeframe within which the task will be completed. Things to remember when assigning responsibility are: • delegate wherever possible, ensuring that the person has the skills to complete the work assigned; • work with another as back up and for skill development of that person; • ensure timelines are realistic; and • each responsible person must develop an action plan for the strategy they are to pursue. (See Exercise Sheet 5.2) Example Problem statement: “Insufficient nursing staff to meet client needs” Strategies By whom By when Analyse the stakeholders Staff member 2nd week January Develop appropriate networks Self 2nd week February Document the contextual issues Staff member with input from professional 2nd week February association Document the systems and Self with input from professional association 4th week February policy context Analyse the decision-making Self with another member of staff 2nd week in March process Implement the change process Self with staff and professional 2nd week April association Exercise Using Project Planning Tool (Exercise Sheet 5.2), complete a Project Plan for the project you are working on. 6 MODULE 5: Managing communication and the change process You are now ready to proceed to implementing the first strategy which is understanding the environment in which you will be advocating. Lets now move to the change process and the development of the team support that will be required. Phases of change management experience There are six phases people go through whenever they are experiencing any type of change, be it personal or professional. These phases are: • Anticipation. People in Phase 1 are in the waiting stage. They do not know what to expect so they wait, anticipating what the future holds. • Confrontation. At some point, people reach Phase 2 and begin to confront reality. At this stage, they are beginning to realize that the change is really going to happen or is happening. • Realization. Once the change has happened, people will usually reach Phase 3 - the stage in which they realize that nothing is ever going to be as it once was. Often times, this realization will plunge them into Phase 4. • Depression. Phase 4 is a necessary step in the change process. This is the stage where a person mourns the past. Not only have they realized the change intellectually, but also they are beginning to comprehend it emotionally. • Acceptance. Phase 5 marks the point where the person begins to accept the change emotionally. Although they may still have reservations, they are not fighting the change at this stage. Usually, they are beginning to see some of the benefits even if they are not completely convinced. • Enlightenment. In Phase 6, people completely accept the new change. In fact, many wonder how they ever managed the “old” way. Overall, they feel good about the change and accept it as the status quo from here forward. An understanding of these phases is necessary for the advocate. This knowledge assists the advocate to understand why people are responding in the way they are to the proposed change. Exercise Consider a change that you have been involved in and map the phases that you experienced during that change process. 7 MODULE 5: Managing communication and the change process The change agent Change is a common occurrence in the health industry today. Because of this, it is important that you possess strong change management skills if you want to succeed as an advocate. To be an effective change agent, it helps if you: • Set an example. Others will look to you for direction, not only in terms of project needs, but also related to behaviour, ethics, and standards. If you want others to change, you must set an example for them to follow. • Walk around and talk to people. The old school of business management promoted the idea that the top person was off limits, enclosed in his or her own glass tower. Leaders of today interact more with their employees. They manage by walking around and getting to know their employees and learning about the problems they are facing on a day-to-day basis. • Be genuine. As a leader of change, it is important to be as real and honest as possible in your interactions with others. Let others get to know you. Being a leader does not mean hiding your emotions. By interacting with employees on a one-to-one basis, you will build rapport and trust. • Have passion. To be a strong leader, you must have passion about your vision. Without it, you may soon be exhausted. Leadership is tiring and saps energy at a very high rate so make sure you are passionate about what you do. Exercise Using the Change Agent Self Assessment Tool (Exercise Sheet 5.3) determine the extent to which you have the characteristics of a change agent and whether you need to develop any additional skills. For assistance with the type of skills you may require see Skill Sheet 5.1. Change management There are five major activities of change management that should occur continuously throughout the project: • Identify key change management roles. Key roles are identified such as the Change Sponsor, Change Agents and the management and staff who must change their work practices. 8 MODULE 5: Managing communication and the change process • Build and maintain effective project sponsorship. Sponsorship is built and maintained through activities such as educating project and change sponsors on their role, ensuring they understand the benefits that the change will provide and optimising the use of their time on the project. • Build commitment through effective communication. A communication plan is developed and maintained to ensure that expectations of the project remain in line with reality. • Acknowledge and manage resistance. Any resistance to the technology and new or changed business processes associated with the project is recognised and managed. • Build synergy through teamwork. Synergy is developed to create an atmosphere that allows individuals from different backgrounds and with diverse skills, experience, needs and aspirations to work together. Change management team The roles and responsibilities of each participant and stakeholder in the team you put together must be clearly defined from the start of the project. The four key roles are: • Project Leader who must demonstrate commitment to the change and ensure that the Change Sponsor accepts ultimate responsibility for its successful implementation. The Project Leader should also be a vocal and active champion of any major change projects that are undertaken by the agency. • Change Sponsor, who could be the Project Sponsor and who has the authority and organizational power to initiate the change and sustain it through to its implementation. The Change Sponsor must have the seniority to ensure that the necessary resources are available throughout the change process. • Change Agents who are responsible for making the change a reality through activities such as design of the elements of the change and development of plans for its implementation. Individuals with this role include the Project Manager, project team members and key influencers within the agency. • The individuals or groups who must actually change. Typically these are the staff that will use the new system or technology and includes all who are a source or recipient of information from the system. 9 MODULE 5: Managing communication and the change process The team formed to advocate for the change must have a good knowledge of current practices and the confidence of those who must change. If the change management team does not have experience in implementing changes of comparable scope and complexity, it should obtain specialist advice and assistance. The stakeholder analysis should aid you in defining the right mix of people to assist you. During the extended implementation of a large change it is likely that one or more of the key stakeholders or participants in the change process will need to be replaced. It is essential that a formal process be identified at the start of the project to manage these situations and to ensure that there is adequate hand-over of responsibilities, and that sufficient time is allowed for orienting new Sponsors and Change Agents. Forming the team to support you is a vital step on the pathway to success. It is essential that the people you have supporting you have complimentary skills and knowledge, and of course commitment to the cause. (See Exercise Sheet 5.4) Example Using the Health Centre Case Study, the following team membership would be required Skills and knowledge Self Stakeholders Networks Others Knowledge of the health system Advocacy skills Chief Nurse Representative of Local general professional association practitioner (GP) Networks Local GP Chief Nurse Search skills Colleague Speaking skills Chief Nurse Writing skills Representative of profes- Colleague sional association Data analysis Colleague It would be useful in this situation to try and get the Chief Nurse, a local GP, a representative from the professional association and two or three colleagues to form part of the support team. Remembering that it is quality not quantity that is important. Exercise Using the Team Formation Tool (Exercise Sheet 5.4), develop a team to support you in your advocacy for change. 1 0 MODULE 5: Managing communication and the change process Building commitment A key element in building commitment to the advocacy for change is effective communication between the team and the stakeholders and participants in the potential change. See Information Sheet 5.2 for further information on communication. A formal communication plan which identifies the rationale for change and key activities and also defines responsibilities is an essential element of effective communication. The plan must focus on marketing the change by building and maintaining understanding of, and commitment to, the change. While the communication plan should focus on building commitment to the desired change, it should also ensure that their expectations remain realistic. It is equally important to manage positive perceptions about a change as much as the negative perceptions. If people expect too much of an improvement or benefit from the change, then their acceptance of what is actually delivered may be at risk. The information provided to those affected by the change needs to be consistent. It is essential that the communication approaches that are adopted for a change are dynamic. A “set and forget” approach will not work and the effectiveness of the communication must be surveyed and adjusted as necessary. Both formal and informal feedback to assess the effectiveness of the communication should be built into the communication plan. These mechanisms should measure the success of the marketing of the change. Skills required for effective team building include group facilitation and feedback skills. For information see Skill Sheets 5.5 and 5.6. Methods which can be used for communicating and marketing the change include: • involvement in the decision-making process; • project newsletters; • agency magazines or intranet; • briefings and workshops; • interactive presentations; • educating and training management and staff on how to use the new systems and technology; and • support for people affected by the change. 1 1 MODULE 5: Managing communication and the change process At this point you need to develop a communication plan. For further information on conducting meetings, writing and corresponding and public speaking see Skill Sheets 5.7, 5.8 and 5.9. Example Again using the Health Centre Case Study, the following Communication Plan might be developed: Objective Strategy By whom By when All stakeholders will be Use meetings and letters Team with For the duration of informed of the intent and to brief staff, clients and assistance from the advocacy. progress the nursing profession. the professional association. The case will be put to the Produce a position paper Team relevant parties with supporting evidence. Relevant media and Draft ‘Letters to the Editor’ Team with politicians will be kept briefed Hold a press conference assistance from if appropriate. the professional association. Exercise Using the Communication Plan template (Exercise Sheet 5.5), develop a Communication Plan. Acknowledge and manage resistance Resistance to change is a natural human reaction and to manage change successfully a clear understanding must be developed of the specific reasons for the resistance. The resistance to the change must be anticipated and the potential resistance factors need to be identified as early in the project as possible. Resistance can range from valid questioning and challenging of the basis of the change to unfounded rejection of the change. Staff associations and unions can have a significant impact on the level of resistance that develops in response to a proposed change. If these key influencers are kept well informed and involved from the inception of the change process, they have the ability to significantly reduce the level of resistance to the change. For further information regarding assertiveness skills and conflict management see Skills Sheet 5.10. 1 2 MODULE 5: Managing communication and the change process Approaches that are effective in the management of resistance include: • providing mechanisms for individuals to discuss their concerns openly, such as facilitated workshops, rather than suppressing the concerns and raising their level of resistance even higher; • clearly communicating to management and staff aspects of the change such as the benefits that individuals will obtain from the change and why the agency needs to be restructured to obtain those benefits; • managing the number of minor and uncontrolled changes which people must cope with such as changes to screen field names; • providing adequate information; • providing adequate support for staff before, during and immediately after implementation; and • involving people who resist in the project as much as possible to provide assurance that their concerns are understood and addressed. For further information on resistance, see Information Sheet 5.3. Exercise We can further analyse responses to change in terms of their meaning: • Change means an end to certainty, a leap into the unknown. Example: a new job may entail uncertainties about your new role and capabilities, unknown changes in social contacts, the need to move house, etc. These may be seen as exciting challenges or threatening instabilities. Think of an example from your own experience. • Change may threaten a system of meaning, organizational system or cultural establishment. Example: a move from clinical to managerial control of health services substitutes one set of values with another. Those adhering to the old system will find the changes threatening to their assumptions about what is to be valued, and may question their own worth. Think of an example from your own experience. • Change may bring loss. Example: a move to a better job entailing emigration means loss of many familiar aspects of life in one’s home country. These losses may outweigh the possibilities of the new position, or may enhance the feeling of a new start. Think of an example from your own experience. • Change may threaten existing power or other interests. Example: a new system of ‘quality circles’ within a primary care group which cuts across traditional hierarchies may be threatening to GPs who had previously been seen as the ‘leaders’ within their practices on issues of service delivery. Think of an example from your own experience. 1 3 MODULE 5: Managing communication and the change process References • Bennis, W.G., and E.H. Schein. “Principles and Strategies in the Use of Laboratory Training for Improving Social Systems.” In W.G. Bennis, K.D. Benne, and R. Chin (Eds.), The Planning of Change. (2nd ed.) New York: Holt, Rinehart, and Winston, 1969. • BPR Online Learning Center Change Management Tool Kit (www.prosci.com/t4.htm). • BPR Online Learning Center Project Planning Tool Kit (www.prosci.com/t1-toc.htm). • Change Management Resource Library (www.change-management.org). • Kanter, Rosabeth Moss. The Change Masters. New York: Simon and Schuster, Inc. 1983. • McKeon T, Benchmarks and performance indicators: two tools for evaluating organisational results and continuous quality improvement efforts. Nursing Care Quality, 1996 April, 10:3, pages 12–17. • Nickols F Change Management 101 A Primer (www.nickols/change.htm). • Performance indicators. All quiet on the front line. Health Service Journal 1998 May 14, 108:5604, pages 24–26. • McCartney Sean. Brown, Reva Berman.(1998) Managing by numbers: using outcome measures in the NHS. International Journal of Health Care Quality Assurance 12:1(1997) pages 6–12. • Mindtools (www.mindtools.com). • This Management Essentials Presents: Developing Key Performance Indicators (www.mgt-online.com/essentials/iedex/22set04.php3). 1 4 MODULE 5: Managing communication and the change process INFORMATION SHEET 5.1 THE CHANGE PROCESS The change problem At the heart of change management lies the change problem, that is, some future state to be realized, some current state to be left behind, and some structured, organized process for getting from the one to the other. The change problem might be large or small in scope and scale, and it might focus on individuals or groups, on one or more divisions or departments or the entire organization. Change as a “how” problem The change problem is often expressed, at least initially, in the form of a “how” question. How do we get people to be more open, to assume more responsibility, to be more creative? How do we get this organization to be more innovative, competitive, or productive? How do we reduce client complaints? How do we improve the quality of our service? In short, the initial formulation of a change problem is means-centred, with the goal state more or less implied. Change as a “what” problem To frame the change effort in the form of “how” questions is to focus the effort on means. Diagnosis is assumed or not performed at all. Consequently, the ends sought are not discussed. This might or might not be problematic. To focus on ends requires the posing of “what” questions. What are we trying to accomplish? What changes are necessary? What indicators will signal success? What standards apply? What measures of performance are we trying to affect? 1 5 MODULE 5: Managing communication and the change process Change as a “why” problem “Why” questions prove extremely useful in identifying the need for change. Consider the following hypothetical dialogue with yourself: • Why do people need to be more creative? Because we have to change the way we do things. • Why do we have to change the way we do things? Because they cost too much the way we are doing them now. • Why do they cost too much? Because we pay higher wages than we used to. • Why do we pay higher wages? Because we are not using staff effectively and efficiently. • Why are we not using staff effectively and efficiently? Because of professional demarcation lines. To ask “why” questions is to get at the ultimate purposes of functions and to open the door to finding new and better ways of performing them. Why do we do what we do? Why do we do it the way we do it? 1 6 MODULE 5: Managing communication and the change process INFORMATION SHEET 5.2 COMMUNICATION Oral communication: People communicate with each other most often by talking or oral communication. Popular forms of oral communication include speeches, formal one-on-one and group discussions, and informal discussions. The advantages of oral communications are quick transmission and quick feedback. A verbal message can be conveyed and a response received in a minimum amount of time. If the receiver is unsure of the message, rapid feedback allows the sender to detect the uncertainty and to correct it. The major disadvantage of oral communication surfaces whenever a message has to be passed through a number of people. The more people who are involved, the greater the potential for distortion. Each person interprets the message in his or her own way. The message’s content, when it reaches its destination, is often very different from the original. Written communication: Written communications include memos, letters, bulletin boards and any other device that transmit written words or symbols. Written communications are permanent, tangible and verifiable. Typically, both sender and receiver have a record of the communication. The message can be stored for an indefinite period of time. If there are questions about the content of the message, it is physically available for later reference. A final benefit of written communication comes from the process itself. More care is taken with the written word than with the oral word. Having to put something in writing forces the writer to think more carefully about what s/he wants to convey. Nonverbal communication: Some of the most meaningful communications are neither spoken nor written. These are nonverbal communications. A loud siren or a red light at an intersection tells you something without words. However, the best known areas of nonverbal communication are body language and verbal intonation. Body language: refers to gestures, facial configurations and other movements of the body. A snarling face, for example, says something different from a smile. Hand movements, facial expressions and other gestures can communicate such emotions or temperaments as aggression, fear, shyness, arrogance, joy and anger. 1 7 MODULE 5: Managing communication and the change process Verbal intonation: refers to the emphasis someone gives to words or phrases. A soft, smooth tone creates a different meaning from one that is abrasive. Most of us would view the first intonation as coming from someone who sincerely sought clarification whereas the second suggests that the person is aggressive or defensive. Electronic media: Today we rely on a number of sophisticated electronic media to carry our communications. In addition to the more common media there is the telephone and public address system; we have closed-circuit television, voice-activated computers, xerographic reproduction, fax machines and a host of other electronic devices that we can use in conjunction with speech or paper to create more effective electronic mail communication. The fastest growing medium is electronic mail. Electronic mail allows the instantaneous transmission of written messages on computers that are linked by the appropriate software. Messages sit at the receiver’s terminal to be read at the receiver’s convenience. Electronic mail is fast and cheap and can be used to send the same message to dozens of people at the same time. Potential barriers to effective communication Filtering is the deliberate manipulation of information to make it appear more favourable to the receiver. For example, when you tell a person what they want to hear, you are filtering information. Selective perception occurs when in the communication process a person sees and hears communications selectively, depending on their needs, motivations, experience, background and other personal characteristics. How the receiver feels when a message is received influences how it is interpreted. A message can often be interpreted differently, depending on whether you are happy or distressed. Extreme emotions such as jubilation or depression are most likely to hinder effective communication. Language is a collection of words, and words can mean different things to different people. Age, education and cultural background are three of the more obvious variables that influence the language a person uses and the definitions given to words. The language of some people working in the public bureaucracy is clearly different from that of the typical high school-educated factory worker. Nonverbal communication is an important way in which people convey messages to others. But nonverbal communication is almost always accompanied by oral communication. As long as the two are in agreement, they tend to reinforce each other. When nonverbal cues are inconsistent with the oral message, the receiver becomes confused, and the clarity of the message suffers. 1 8 MODULE 5: Managing communication and the change process INFORMATION SHEET 5.3 RESISTANCE TO CHANGE Resistance is not the enemy. It is much more complex than it may first appear. Change fails for a variety of reasons - as with many concepts there is not one best way to address difficulties brought about by change. Resistance can occur where an individual’s own rational assessment of change outcomes differ with those of management. Individual reaction to change is also a function of predispositions and preferences not necessarily based on a rational assessment of change. Resistance is also influenced by political factors such as favouritism or “point scoring” against those initiating the change. Poor management styles also contribute to resistance. What are the benefits of supporting change? The benefits of supporting change are: • Enhanced respect and reputation. • Improved personal and professional growth opportunities (especially for active supporters of the change). • Increased job satisfaction. • Knowing you have ‘made a difference’. Additional frequently asked questions are: • What is the risk of not changing? • If I wait long enough, will the change just go away? • What are my choices during the change process? • What are the potential consequences to me of not changing? • What are the benefits of supporting the change? • What if I think they are fixing the wrong problem? • What if they have tried before but failed? Resistance as an ally. That resistance can play a useful role in organizational change certainly stands juxtaposed to a traditional mindset that would view it as nothing more than an obstacle. However a variety of authors subscribe to this view and believe that resistance can assist the change effort. RESISTANCE is an expression of reservation which normally arises as a response or reaction to change. This is often interpreted as any actions perceived as attempting to stop or alter change. 1 9 MODULE 5: Managing communication and the change process It is a fallacy to consider change itself to be inherently good. Change can only be evaluated through its consequences and these cannot be known until sufficient time has elapsed. People resist the uncertainties that change can cause and for this reason resistance plays a crucial role in drawing attention to the potential pitfalls of a change initiative. After all, because management has proposed a change does this automatically mean it is the correct way to proceed? Perhaps not, as many management decisions are non-rational and fail to generate enough alternative solutions without the input of others. Resistance adds a charge of energy to the change process. There is a real danger of apathy when there is a need for growth and development. Where resistance occurs, it is possible to examine more closely the problems that exist. Resistance encourages a search for alternative, perhaps superior methods and outcomes in order to synthesize the conflicting opinions being observed. Thus resistance becomes a useful source of innovation. Without resistance there is the danger of proposals being accepted simply because they are favoured by management. This can be detrimental as an organization’s change will be limited to the prescriptive capabilities of those proposing the change. 2 0 MODULE 5: Managing communication and the change process INFORMATION SHEET 5.4 PERFORMANCE INDICATORS What are they? Performance indicators are measures of inputs, processes, outputs, outcomes, and impacts for development projects, programmes, or strategies. When supported with sound data collection, perhaps involving formal surveys analysis and reporting, indicators enable managers to track progress, demonstrate results, and take corrective action to improve service delivery. Participation of key stakeholders in defining indicators is important because they are then more likely to understand and use indicators for management decision- making. What can we use them for? • Setting performance targets and assessing progress toward achieving them. • Identifying problems via an early warning system to allow corrective action to be taken. • Indicating whether an in depth evaluation or review is needed. Advantages • Effective means to measure progress toward objectives. • Facilitates benchmarking comparisons between different organizational units, districts, and over time. Disadvantages • Poorly defined indicators are not good measures of success. • There is a tendency to define too many indicators, or those without accessible data sources, making system costly, impractical, and likely to be under utilized. 2 1 MODULE 5: Managing communication and the change process • There is often a trade-off between picking the optimal or desired indicators and having to accept the indicators which can be measured using existing data. Cost Can range from low to high, depending on number of indicators collected, the frequency and quality of information sought, and the comprehensiveness of the system. Skills required Several days of training are recommended to develop skills for defining practical indicators. Data collection, analysis and reporting skills, and management information system (MIS) skills are required to implement performance monitoring systems. Time required Several days to several months, depending on extent of participatory process used to define indicators and program complexity. Implementing performance monitoring systems may take 6 to 12 months. World Bank, Key Performance Indicator Handbook, Washington, D.C., 2000. Hatry, H., Performance Measurement: Getting Results, The Urban Institute, Washington, D.C., 1999. 2 2 MODULE 5: Managing communication and the change process SKILL SHEET 5.1 EFFECTIVE CHANGE AGENTS The most effective change agents share seven common characteristics: Commitment to a better way. They share a seemingly inexhaustible and visible commitment to a better way, and believe deeply that the company’s future is dependent upon the change - particularly their part of it - being successfully executed. They see the change target as exciting, worthwhile and essential to the future success of the institution, as well as to their own personal satisfaction. Courage to challenge existing power bases and norms. They develop the personal courage needed to sustain their commitment in the face of opposition, failure, uncertainty, and personal risk. While they do not welcome failure, they do not fear it. Above all, they demonstrate the ability to rise again, and thereby build courage in those around them. Personal initiative to go beyond defined boundaries. They consistently take the initiative to work with others to solve unexpected problems, break bottlenecks, challenge the status quo, and think outside the box. Setbacks do not discourage them from trying again - and again. Certainly they are responsive to top leadership’s inspiration, but they do not wait around for it to move them to action. Motivation of themselves and others. Not only are they highly motivated themselves, but they have the power to motivate, if not inspire, others around them. They create excitement and momentum in others and provide opportunities for people around them to follow their example and take personal responsibility for changing. Caring about how people are treated and enabled to perform. They really care about other people, but not to the extent of blind self-sacrifice. They are also intent upon enabling the performance of others as well as their own. They do not knowingly manipulate or take advantage of others. Staying undercover. They attribute part of their effectiveness to keeping a low profile; grandstanding, strident crusading, and self promotion are viewed as sure ways to undermine their credibility and acceptance as change leaders. 2 3 MODULE 5: Managing communication and the change process A sense of humour about themselves and their situations. Not a trivial trait. A sense of humour is often what gets them through when those around them are losing their spirit. Managing the kinds of changes encountered requires an unusually broad and finely honed set of skills, chief among which are the following: Political skills. Change agents dare not join political game playing but they do understand it. This is one area where you must make your own judgments and keep your own counsel; no one can do it for you. Analytical skills. A lucid, rational, well-argued analysis can be ignored and even suppressed, but not successfully contested and, in most cases, will support change. If not, then the political issues may not have been adequately addressed. People skills. People come characterized by all manner of sizes, shapes, colours, intelligence and ability levels, gender, sexual preferences, national origins, first and second languages, religious beliefs, attitudes toward life and work, personalities, and priorities - and these are just a few of the dimensions along which people vary. System skills. The system skills required is the set associated with a body of knowledge generally referred to as General Systems Theory (See Module 6). This set deals with people, organizations, industries, economies, and even nations as socio-technical systems - as “open,” purposive systems, carrying out transactions with other systems and which demonstrate a commitment to survival, continuance, prosperity, dominance, plus a host of other goals and objectives. Business skills. This entails an understanding of money – where it comes from, where it goes, how to get it, and how to keep it. It also involves knowledge of markets and marketing, products and product development, customers, sales, selling, buying, hiring, firing, and a number of other variables. How to manage change The honest answer is that you manage change much the same way you would manage anything else of a turbulent, messy, chaotic nature, that is, you do not really manage it, you grapple with it. It is more a matter of leadership ability than management skill. • The first thing to do is jump in. You cannot do anything about it from the outside. 2 4 MODULE 5: Managing communication and the change process • A clear sense of mission or purpose is essential. • Build a team. • Maintain a flat organizational team structure and rely on minimal and informal reporting requirements. • Pick people with relevant skills and high energy levels. • Shift to an action-feedback model. Plan and act in short intervals. • Set flexible priorities. You must have the ability to drop what you are doing and tend to something more important. • Treat everything as a temporary measure. Do not “lock in” until the last minute, and then insist on the right to change your mind. • Ask for volunteers. You will be surprised at who shows up and you will be pleasantly surprised by what they can do. • Give the team members whatever they ask for - except authority. They will generally ask only for what they really need in the way of resources. • Concentrate dispersed knowledge. Keep the communications barriers low, widely spaced, and easily hurdled. Initially, if things look chaotic, relax - they are. Remember, the task of change management is to bring order to a messy situation, not pretend that it is already well organized and disciplined. 2 5 MODULE 5: Managing communication and the change process SKILL SHEET 5.2 EFFECTIVE LISTENING Eight specific behaviours that effective listeners demonstrate As you review these behaviours, ask yourself how accurately they describe your listening practices. If you are not currently using these techniques, there is no better time than today to begin developing them. Make eye contact. How do you feel when the person you are speaking to does not look at you? If you are like most people, you probably interpret this as aloofness or lack of interest. It is ironic that while you listen with your ears, people judge whether you are listening by looking at your eyes. Attention reduces the likelihood that you will become distracted and encourages the speaker. Exhibit affirmative nods and appropriate facial expressions. The effective listener shows interest in what is being said through nonverbal signals. Affirmative nods and appropriate facial expressions, when added to good eye contact, convey to the speaker that you are listening. Ask questions. Critical listeners analyse what they hear and ask questions. This behaviour provides clarification, ensures understanding and assures the speaker that you are listening. Paraphrase. Paraphrasing means restating in your own words what the speaker has said. Effective listeners use such phrases as: ‘What I hear you saying is …’ or ‘Do you mean ... ?’ There are two reasons for rephrasing what has been said: (1) it is an excellent control device to make sure you are listening carefully; and (2) it identifies the essence of the speaker’s message. Avoid interrupting the speaker. Let the speaker complete his or her thought before you try to respond. Do not try to second-guess where the speaker’s thoughts are going. When the speaker is finished, you will know it. 2 6 MODULE 5: Managing communication and the change process Do not talk when someone else is speaking. Most of us would rather express our own ideas than listen to what someone else says. While talking might be more fun and silence might be uncomfortable, you cannot talk and listen at the same time. The good listener recognizes this fact and does not talk when someone else is speaking. Make smooth transitions between the roles of speaker and listener. In most situations you are continually shifting back and forth between the roles of speaker and listener. The effective listener makes transitions smoothly from speaker to listener and back to speaker. From a listening perspective, this means concentrating on what a speaker has to say rather than thinking about what you are going to say in response. Listening skills The ability to be an effective listener is often taken for granted. We confuse hearing with listening. Hearing is merely picking up sound vibrations. Listening is making sense of what we hear. Listening requires paying attention, interpreting and remembering sound stimuli. Effective listening is an active rather than passive process. You absorb the information given. If the speaker provides you with a clear message and makes the delivery interesting enough to keep your attention, you will likely understand and internalize what the speaker is trying to communicate. The challenge for the active listener is to absorb what is being said and to withhold judgment on content until the speaker is finished. A widely used active listening technique is asking questions to ensure understanding. There are four essential requirements for active listening. You need to listen with: • intensity • empathy • acceptance • a willingness to take responsibility for completeness. 2 7 MODULE 5: Managing communication and the change process SKILL SHEET 5.3 ANSWERING AND ASKING QUESTIONS As an advocate, you may find yourself in situations where you will be questioned and will be required to question. Many may think that this is a simple thing. After all we are asking and answering questions every day. But when we place ourselves in situations where there are policy or political implications to what we may say, there is a need to be very aware of how we respond and how we question. Possible ways of answering questions include: • Directly answering the question. One obvious option when asked a question is to answer it. In general, it is not recommend answering a question directly if you wish to foster thinking or problem-solving skills on the issue. However, when the questions ask for information that the questioner is not likely to have (or questions asking for an opinion), directly answering the question is appropriate. If you choose to answer directly, make your answer brief and to the point. • Repeating the question, paraphrasing it. This serves two purposes. It insures that everyone hears the question and more importantly, it lets the questioner check your understanding of the question. When you have not completely understood, often the person posing the question will rephrase or elaborate upon what was asked. • Asking probing questions. You might respond to a question by directing attention to a particular aspect of the issue raised, or drawing attention to some previous situation or similar issue that is relevant to answering the question, or by going beyond what the person’s has said in some way. • Promoting a discussion. The previous suggestions usually involve communication between two people, typically the questioner and the answerer, with other participants simply listening. It may be that you will want 2 8 MODULE 5: Managing communication and the change process to involve all participants in trying to answer some questions, for example, where there is considerable difference of opinion about the answer. • Postponing answering the question. On certain occasions you may decide to postpone answering a question, for instance: when you are very short of time, especially if the answer is complex. It is wise to ensure that you have all the facts and enough time to answer a question satisfactorily. • Admitting when you do not know an answer. If you do not know the answer to a question, you say so. Although one of your roles is to be seen as expert on the issue you are advocating, admitting that you do not know the answer to a question will probably not damage the questioner’s confidence in you. If you try to fake a reply, there is a chance that your credibility could be damaged. Possible ways of asking questions include using: • Open-ended, not just close-ended questions. A close- ended question structures the response and can be answered by one word, often “yes” or “no”, or by a very brief phrase. An open-ended question leaves the form of the answer up to the person answering and so elicits more thinking or information. • Convergent as well as divergent questions. The distinction between convergent and divergent questions is whether there is a single or accepted “correct” answer (to a convergent question) or are there a number of possible answers, many of which may be acceptable (to divergent questions). Convergent questions may expect the respondent to repeat some conventional wisdom. Divergent questions often require new, creative insights. Examples of powerful questions to ask How important is this? Where do you feel stuck? What is the intent of what you’re saying? What can we do for you? What do you think the problem is? What is your role in this issue? What have you tried so far? What worked? What did not? 2 9 MODULE 5: Managing communication and the change process Have you experienced anything like this before? (If so, what did you do?) What can you do for yourself? What do you hope for? What is preventing you from ...? What would you be willing to give up for that? If you could change one thing, what would it be? Imagine a point in the future where your issue is resolved. How did you get there? What would you like us to ask? What have you learned? 3 0 MODULE 5: Managing communication and the change process SKILL SHEET 5.4 DELEGATION SKILLS Advocates get things done through other people. This description recognizes that there are limits to any advocate’s time and knowledge. Effective advocates, therefore, need to understand the value of delegating and know how to do it. Advocates usually take on the their advocacy role in additional to their normal professional and personal responsibilities. It is essential therefore that the advocate has people around them they can trust and to whom they can delegate responsibilities. It might well be true that you are capable of doing the tasks better, faster or with fewer mistakes. The catch is that your time and energy are scarce resources. It is not possible for you to do everything yourself. You need to learn to delegate if you are going to be an effective advocate. This fact suggests two important points. First, you should expect and accept some mistakes by those to whom you have delegated. Mistakes are part of delegation. They are often good learning experiences as long as their costs are not excessive. Second, to ensure that the costs of mistakes do not exceed the value of the learning, you need to put adequate controls in place. Feedback controls are critical for successful delegation. Contingency factors should be considered in determining the degree to which tasks are delegated. The following contingency factors provide some guidance: Importance of the duty or decision. The more important a duty or decision is (as expressed in terms of cost and impact), the less likely it is to be delegated. Size of the task/project. The larger the task, the greater the number of decisions that have to be made and the more likely you are to need to delegate. Task complexity. The more complex the task, the more difficult it is for an advocate to possess current and sufficient technical information to make effective decisions. Complex tasks require greater expertise, and decisions about them should be delegated to the individuals who possess the necessary technical knowledge. Organizational culture. If the advocate has confidence and trust in others, the culture will support a greater degree of delegation. 3 1 MODULE 5: Managing communication and the change process SKILL SHEET 5.5 GROUP FACILITATION Group facilitation is a process in which a trained facilitator helps a group work together more effectively in achieving its objectives. These might include solving problems, identifying opportunities, making good decisions and reaching consensus, developing and implementing plans, or improving the group’s ongoing performance. The facilitator basically serves as an impartial third party, who by helping the group improve its processes, can also help it to accomplish its tasks. Facilitation increases productivity by increasing group motivation, confidence and commitment. It provides a better climate for radical change and optimises group dynamics. When is group facilitation needed? A group often can benefit by having a facilitator help with its meetings. Here are some situations when using a facilitator can be useful: • When the group is having difficulty working together or making good decisions. • When the group needs help setting goals, achieving its objectives, or staying on schedule. • When the group needs assistance in sorting through complex issues and reaching consensus. • When it would be hard for a member of the group itself to participate and manage the group’s process at the same time. Role of the facilitator The facilitator must be neutral to the discussion, taking a pragmatic view of all points raised. This allows the facilitator to concentrate on the group rather than on the content of the discussion and hence they can ask pertinent and stimulating questions. 3 2 MODULE 5: Managing communication and the change process Personal skills and qualities of a facilitator include: Flexibility. The ability to fulfil different group roles; leader, supporter, inquisitor etc. in order to keep the group process fluid and maximize its potential. Confidence. To instil confidence in the group by appearing purposeful and in control, therefore subduing group insecurities. Authenticity. To be consistent in approach to the task, ensuring that the discussion focuses on the tasks and goals, and becoming trustworthy to the group. Patience/perseverance. To appreciate the difficulties of group dynamics and have the determination to see a task finished. Integrity. To be an example to the group of how to conduct oneself at work. Initiative. To be able to start the group working on the task or when a problem is discovered/developed to find an alternative way around it to maintain the group’s focus. Perceptiveness. To have the capability to recognize undertones in the group; using the positive ones to the group’s advantage and countering the negative ones to diminish them. 3 3 MODULE 5: Managing communication and the change process SKILL SHEET 5.6 FEEDBACK SKILLS Ask anyone about feedback and you are likely to get a qualified answer. If the feedback is positive, it is likely to be given and received promptly and enthusiastically. Negative feedback is often treated very differently. People fear offending or having to deal with the recipient’s defensiveness. The result is that negative feedback is often avoided, delayed or substantially distorted. This section demonstrates the importance of providing both positive and negative feedback and identifies specific techniques to make feedback more effective Positive versus negative feedback Positive feedback is more readily and accurately perceived than negative feedback. Positive feedback is almost always accepted, while negative feedback often meets resistance. People want to hear good news and block out the bad. You need to be aware of potential resistance and learn to use negative feedback in situations where it is most likely to be accepted. Negative feedback is most likely to be accepted when it comes from a credible source or if it is objective in form. Subjective impressions have importance only when they come from a person with high status and credibility. Focus on specific behaviours. Feedback should be specific rather than general. Avoid such statements as ‘You have a bad attitude’ or ‘I’m really impressed with the good job you did’. Such comments are vague and, while they provide information, they do not tell the recipient enough to correct the ‘bad attitude’ or on what basis you concluded that a ‘good job’ had been done. Keep feedback impersonal. Feedback, particularly negative feedback, should be descriptive rather than judgmental or evaluative. No matter how upset you are, keep the feedback relevant and never criticise someone personally because of an inappropriate action. 3 4 MODULE 5: Managing communication and the change process Keep feedback goal-oriented. Feedback should not be used to unload your frustrations on another person. If you have to say something negative, make sure it is directed towards the recipient’s goals. Ask yourself whom the feedback is supposed to help. Make feedback timely. Feedback is most meaningful to a recipient when there is only a short interval between the behaviour and the receipt of feedback about that behaviour. Ensure understanding. Is your feedback concise and complete so that the recipient clearly and fully understands your communication? Remember that every successful communication requires both transference and understanding of meaning. If feedback is to be effective, you must ensure the recipient understands it. 3 5 MODULE 5: Managing communication and the change process SKILL SHEET 5.7 CONDUCTING MEETINGS We meet to make decisions, solve problems, develop budgets, plan projects, create policies, hire and fire staff, coordinate activities, and more. The amount of time spent in meetings is so substantial that skills in managing them are vital to productivity. Most people concede that meetings are important — for communication, team participation, shared decision-making, etc. Most organizations cannot function without them. But the general consensus is: “If we must have meetings, do they have to waste so much time?” The answer is: “No, they do not.” It is useful to have some knowledge of Parliamentary Procedure. Parliamentary procedure is simply a system of rules to insure that formal meetings run efficiently. Behind the rules are five basic principles: • One question or proposal at a time. • The right of every member to free and full debate. • The democratic principle that the will of the majority shall prevail. • The principle of equality. • Courtesy. The key to holding good meetings is for the convener to spend more time preparing for the meeting and wasting less of everyone’s time participating in it. To have pleasant, productive meetings, you will need to understand what goes into planning and conducting such meetings. You will need to plan an agenda that is well-organized, logical, deals with the important issues in a timely manner, but does not get sidetracked. You will need a team that can work together to conduct the meeting. You will need a basic understanding of parliamentary procedure. 3 6 MODULE 5: Managing communication and the change process Meeting tips and tricks Welcome participants as they enter the room. Making the meeting’s participants feel comfortable will go a long way toward ensuring their involvement in the meeting. Start on time. Participants have other things they could be doing. Show them you value their time by starting when you say you will. If you need to delay the start, let attendees know when you will start so they can make phone calls or tend to other business. Distribute extra copies of handouts, the agenda, or other meeting materials. You sent the agenda to invitees prior to the meeting but someone is sure to forget it. Be prepared with extra copies. Introduce the meeting leader and the participants. Even if you think all participants know each other, it’s a good idea to do introductions. This reminds people and keeps them from being put on the spot. Icebreakers are very important to starting your meeting out on the right note. Using an appropriate icebreaker will: • Allow attendees to warm up to each other and get focused on the meeting • Help attendees get to know each other • Encourage participation • Start the meeting off on a positive note • Include all participants Clarify roles (e.g., meeting leader, timekeeper, recorder, etc.) This lets participants know who will do what task and that important tasks will be addressed. Review the meeting agenda and clarify ground rules and the meeting framework. Reviewing this information will answer many questions participants have and will help make them feel comfortable. If appropriate, ask participants for any suggestions, additions, or changes to either the agenda or format. Break every 50 minutes to one hour. Adults need a break every hour. Keeping participants refreshed will help keep them focused. Hourly breaks for long meetings or events will minimize disruptions. Review the meeting before adjournment (e.g., What was accomplished? What are the tasks to be done? Who will do what? What are the deadlines for the tasks? When will the next meeting be?). Reviewing the major points from the meeting will help ensure that all participants know what is expected of them. 3 7 MODULE 5: Managing communication and the change process End on time. Again, be respectful of participants’ time. If you must go beyond the announced end time, ask participants if they mind extending the meeting time. If they are unable to stay, add any unfinished business to your next meeting’s agenda. Roles in a meeting might include: • Facilitator. Keeps the discussion moving in the proper direction, introduces agenda items and facilitates discussion, remains neutral. • Time-keeper. Sets time limits for agenda items. • Recorder: Records the group’s ideas on newsprint, remains neutral. • Gate-keeper. Ensures that everyone in the meeting has a chance to speak. This can be a sub-role of the facilitator. • Devil’s advocate. Brings up alternative points of view so that the group does not fall into a “group-think” mentality and come to consensus too soon. • Mediator. Diplomatically mediates conflicts and differences of opinion. Minutes of meetings Although it is natural to think only in terms of the “here and now”, the decisions you make today may have significant impact on the organization in future years. Therefore, it is important that a thorough and accurate record of all organization meetings be maintained. The minutes should normally contain the following information: • The name of the organization • The nature of the meeting (regular or special) • The date and place of the meeting • The presiding officer and secretary • The approval of minutes of the previous meeting • All reports and action taken • All key motions carried or lost with the vote count where needed • All other motions carried which contain information necessary to subsequent meetings • Adjournment 3 8 MODULE 5: Managing communication and the change process SKILL SHEET 5.8 WRITING AND CORRESPONDING Advocates are often called upon to prepare various forms of correspondence, including: • Letters to editors of newspapers • Letters to ministers and/or their staff • Heads of government departments • Press releases There are some useful hints which will assist you in this task, and they include: Targeting your writing. It is essential to have a clear idea of who your reader is. You should know why they are going to be reading your piece, where and when they will be reading it, and what they will want to get out of it. Knowing this, and knowing what information you want to convey allows you to decide on an aim for the written material. You should focus all decisions on content, structure, style and presentation on meeting this aim. Preparing an outline. Once you have decided the aim of the writing, you are ready to prepare an outline. This allows you to start to organize the information into a coherent structure. Once you have selected information and organized a structure, prepare an outline of the introduction and summary. The shape of these should be obvious from the structure you have given your information. The introduction should help the reader to prepare an overall structure into which the information in the article can be fitted. The summary should organize the facts in the middle of the article into a coherent whole. Writing your piece. When you have prepared your outline, it is time to start writing. The easiest way of doing this is just to let the words and ideas flow. Move quickly through the piece without editing or reviewing it. Only when you have finished a section should you review it. At this stage, you may decide to reorganize it, edit it, change it around, and add or delete information. As you review it, you should check that what you have written meets the aim you set and gives the reader the information they want. 3 9 MODULE 5: Managing communication and the change process Style. The style of the article should be completely focused on the reader’s needs. Language used should be pitched at the appropriate level for the reader. People generally prefer information presented in short sentences with little or no jargon. You may be tempted to write in a way that you think will impress your readers, using long words and complex sentences. All this shows is that you are not able to communicate ideas clearly and simply. It is likely that material written like this will not be read at all. If you need to use technical language that may not be understood, include a glossary. Remember that you have responsibility for the clarity, effectiveness and focus of your communication. Beyond this, style will emerge on its own without you needing to worry about it. Things to remember: • It is essential to know who you are writing for, and what they will want from your writing. Once you know this you should know precisely the level you are writing at and what information to include. • Preparation of an outline helps you to give structure to your piece. An effective way of doing this is to transfer notes onto a computer, and then cut and paste words and sections into a coherent form. • Including an introduction and summary helps readers to structure information in their minds. • When you write, try to let words and ideas flow. Only edit and review a section once you have completed its first draft. As you review it, ensure that the material meets the aim you set for the piece. • The style of the piece should be focused on the readers needs. Avoid trying to impress people with your knowledge. • Remember that the responsibility for effective communication lies with you! 4 0 MODULE 5: Managing communication and the change process SKILL SHEET 5.9 PUBLIC SPEAKING AND PRESENTATIONS Presentations are a way of communicating ideas and information to a group. A good presentation has: • Content - It contains information that people need. Unlike reports, it must account for how much information the audience can absorb in one sitting. • Structure - It has a logical beginning, middle, and end. It must be sequenced and paced so that the audience can understand it. While reports may have appendices and footnotes, the presenter must be careful not to lose the audience when wandering from the main point of the presentation. • Packaging - It must be well prepared. A report can be reread and portions skipped over, but the audience is at the mercy of a presenter. • Human element - A good presentation will be remembered much more than a good report because it has a person attached to it. Throughout your presentation, display: • Eye contact. This helps to regulate the flow of communication. It signals interest in others and enhances the speaker’s credibility. Speakers who make eye contact open the flow of communication and convey interest, concern, warmth, and credibility. • Facial expressions. Smiling is a powerful cue that transmits happiness, friendliness, warmth, and liking. So, if you smile frequently you will be perceived as more likable, friendly, warm, and approachable. Smiling is often contagious and others will react favourably. • Gestures. If you fail to gesture while speaking, you may be perceived as boring and stiff. A lively speaking style captures attention, makes the material more interesting, and facilitates understanding. 4 1 MODULE 5: Managing communication and the change process • Posture and body orientation. You communicate numerous messages by the way you talk and move. Standing erect and leaning forward communicates that you are approachable, receptive, and friendly. Speaking with your back turned or looking at the floor or ceiling should be avoided as it communicates disinterest. • Proximity. Cultural norms dictate a comfortable distance for interaction with others. You should look for signals of discomfort caused by invading other’s space. Some of these are rocking, leg swinging, tapping, and gaze aversion. To counteract this, move around the room to increase interaction with your audience. • Vary your voice. One of the major criticisms of speakers is that they speak in a monotone voice. Listeners perceive this type of speaker as boring and dull. People report that they learn less and lose interest more quickly when listening to those who have not learned to modulate their voices. Preparing the presentation • A good presentation starts out with introductions and an icebreaker such as a story, interesting statement or fact, joke, quotation, or an activity to get the group warmed up. The introduction also needs an objective, that is, the purpose or goal of the presentation. This not only tells you what you will talk about, but it also informs the audience of the purpose of the presentation. • Next, comes the body of the presentation. Do NOT write it out word for word. All you want is an outline. By jotting down the main points on a set of index cards, you not only have your outline, but also a memory jogger for the actual presentation. To prepare the presentation, ask yourself the following: o What is the purpose of the presentation? o Who will be attending? o What does the audience already know about the subject? o What is the audience’s attitude towards me (e.g. hostile, friendly)? A 45-minute talk should have no more than about seven main points. This may not seem like very many, but if you are to leave the audience with a clear picture of what you have said, you cannot expect them to remember much more than that. 4 2 MODULE 5: Managing communication and the change process Things to remember • If you have handouts, do not read straight from them. The audience does not know if they should read along with you or listen to you read. • Speak to the audience...NOT to the visual aids, such as flip charts or overheads. Also, do not stand between the visual aid and the audience. • Speak clearly and loudly enough for all to hear. Do not speak in a monotone voice. Use inflection to emphasize your main points. • Use coloured backgrounds on overhead transparencies and slides (such as yellow) as the bright white light can be harsh on the eyes. This will quickly cause your audience to tire. If all of your transparencies or slides have clear backgrounds, then tape one blank yellow one on the overhead face. For slides, use a rubber band to hold a piece of coloured cellophane over the projector lens. • Learn the name of each participant as quickly as possible. Based upon the atmosphere you want to create, call them by their first names or by using Mr., Mrs., Miss, Ms. • Tell them what name and title you prefer to be called. • Listen intently to comments and opinions. By using a lateral thinking technique (adding to ideas rather than dismissing them), the audience will feel that their ideas, comments, and opinions are worthwhile. • Circulate around the room as you speak. This movement creates a physical closeness to the audience. • List and discuss your objectives at the beginning of the presentation. Let the audience know how your presentation fits in with their goals. • Vary your techniques (lecture, discussion, debate, films, slides, reading, etc.) • Get to the presentation venue before your audience arrives and be the last one to leave. • Be prepared to use an alternate approach if the one you have chosen seems to lose the audience’s interest. Use your background, experience, and knowledge to interrelate your subject matter. • Consider the time of day and how long you have got for your talk. Time of day can affect the audience. After lunch is known as the “graveyard” section in training circles as audiences will feel more like napping than listening to a talk. 4 3 MODULE 5: Managing communication and the change process SKILL SHEET 5.10 ASSERTIVENESS SKILLS AND CONFLICT RESOLUTION Are you comfortable stating your opinion, even if the rest of your team and the so called “opposition’ disagrees? When you leave a meeting, do you regret that you did not share more of your ideas? Asserting yourself is not easy. One reason is that some people see assertiveness as a negative behaviour. Perhaps they confuse assertiveness with aggressiveness. Assertiveness is especially difficult for women. Many of us are taught to be agreeable, be polite, and make those around us at ease. Putting those thoughts together you can see why assertive behaviour is difficult for many women. Assertiveness is the ability to express yourself and your rights without violating the rights of others. It is appropriately direct, open, and honest communication, which is self-enhancing and expressive. Acting assertively will allow you to feel self- confident and will generally gain you the respect of your peers and friends. It can increase your chances for honest relationships, and help you to feel better about yourself and your self-control in everyday situations. This, in turn, will improve your decision-making ability and possibly your chances of getting what you really want from life. Things to remember • Think win-win. What is best for you and the team? • When speaking, include statements that illustrate the benefits to the team. • Respect your team members. • Share your knowledge and ideas with the team. • Point out potential problems in a constructive way. • Enable processes that move the team toward its goals. 4 4 MODULE 5: Managing communication and the change process Specific Techniques for Assertiveness Be as specific and clear as possible about what you want, think, and feel. It can be helpful to explain exactly what you mean and exactly what you do not mean, such as “I do not want to break up over this, but I would like to talk it through and see if we can prevent it from happening again.” Be direct. Deliver your message to the person for whom it is intended. If you want to tell Jane something, tell Jane; do not tell everyone except Jane; do not tell a group, of which Jane happens to be a member. Own your message. Acknowledge that your message comes from your frame of reference, your conception of good vs. bad or right vs. wrong, and your perceptions. You can acknowledge ownership with personalized (“I”) statements such as “I don’t agree with you” (as compared to “You’re wrong”). Ask for feedback. “Am I being clear? How do you see this situation? What do you want to do?” Asking for feedback can encourage others to correct any misperceptions you may have as well as help others realize that you are expressing an opinion, feeling, or desire rather than a demand. Specific techniques for conflict resolution Basic principles • Be hard on the problem and soft on the person • Focus on needs, not positions • Emphasize common ground • Be inventive about options • Make clear agreements • Respond not react • Manage your emotions • Let some accusations, attacks, threats or ultimatums pass • Make it possible for the other party to back down without feeling humiliated. 4 5 MODULE 5: Managing communication and the change process Walk a problem through these questions Win/Win • What is my real need here? • What is theirs? • Do I want it to work for both of us? Creative responses • What opportunities can this situation bring? • Rather than “how it is supposed to be”, can I see possibilities in “what is”? Empathy • What would it be like to be in their shoes? • What are they trying to say? • Have I really heard them? • Do they know I am listening? Appropriate assertiveness • What do I want to change? • How will I tell them this without blaming or attacking? Managing emotions • What am I feeling? • Am I blaming them for my feelings? • Will telling them how I feel help the situation? • What do I want to change? • Have I removed the desire to punish from my response? • What can I do to handle my feelings? Willingness to resolve • Do I really want to resolve the conflict? • Is resentment caused by: o something in my past that still hurts? o something I have not admitted to needing? o something I dislike in them, because I will not accept it in myself? 4 6 MODULE 5: Managing communication and the change process Designing options • What are the possibilities? • What options give us both more of what we want? Negotiating skills • What do I wish to achieve? • How can we make this a fair deal - with both people winning? • What can they give me? • What can I give them? • Am I ignoring objections? Can I include them? • What points would I want covered in an agreement? • Is there something that could be included to help them save face? • Is saving face important to me? Do I particularly need anything? Mediation • Can we resolve this ourselves or do we need help from a neutral third person? • Who could take on this role for us? • Is mediation the most appropriate role for me in this? If so: o How would I set up and explain my role to both parties? o Can I create the right environment for people to open up, understand each other and develop their own solutions? What might help? 4 7 MODULE 5: Managing communication and the change process FACILITATOR’S GUIDE – CHANGE MANAGEMENT Facilitator’s preparation time: 45 minutes Group exercise time: 90 minutes Resources: Exercise Sheets 5.1 - 5.5 Information Sheets 5.1 - 5.4 Skill Sheets 5.1 - 5.10 Butcher paper, white board or black board Pens/pencils/paper Instructions: • The exercise is best done with no more than 20 people. • Read Module 5, Session 8 and go through each of the exercises. • Familiarize yourself with the Exercise Sheets, Information Sheets, and Skill Sheets. • Make sure you have enough copies of the Exercise Sheets for each participant in your group. • Make sure that you have the resources you need, e.g. pre-prepared butcher paper. • Introduce the topic and explain the objectives of the exercise. • Make certain that everyone in the group has a full understanding of the problem being considered. • Begin with Exercise Sheet 5.1. This exercise will assist the group to develop the key performance indicators to monitor progress towards the achievement of their desired outcomes. • Go to Exercise Sheet 5.2 and use it to help the group establish the strategies, assign the responsibilities and set the timeframes for a project. • Go to Exercise Sheet 5.3 and use it to assist the group to determine their strengths and weaknesses as change agents. 4 8 MODULE 5: Managing communication and the change process • Now use Exercise Sheet 5.4 to identify the key support people required to provide appropriate support. • Finally, go to Exercise 5.5 and, using the results of Exercise 38, assist the group to establish a plan for communicating the intent and progress of the project to all stakeholders. This completes Module 5, Session 8 4 9 MODULE 5: Managing communication and the change process EXERCISE SHEET 5.1 OUTCOME STATEMENTS AND KEY PERFORMANCE INDICATORS What is it? Key performance indicators (KPIs) are what you measure to monitor progress towards the achievement of your desired outcomes. Who uses it? Any person or group who are wanting to monitor progress towards the achievement of desired outcomes. Why use it? To monitor your success in solving the particular problem you set out to solve. How to use it • Explain the objectives and the process of this session. • As an individual or group, consider the information you have collected from the previous exercises and document the outcomes you want to achieve for the organization (internal) and for stakeholders (external). • The next step is to test the outcomes you have documented by answering the question “If these outcomes are achieved will we be seen as completely successful by all our major stakeholders?” Outcome statements Internal External • Once you have agreed on the outcomes to be achieved, document the indicators of achievement and the means of measuring these indicators. Remember, “what you measure is what you get”. 5 0 MODULE 5: Managing communication and the change process Outcome statements Key performance indicators Measures Example Outcome statements Key performance indicators Measures Achieving staffing levels to Increased staffing levels Workforce monitoring meet service demand Maintain operating costs at Operating costs benchmarked Operating costs of equivalent the level of equivalent size against equivalent size health size health centres health centres centres Operating costs of the health centre Improving staff satisfaction Improved staff satisfaction Staff satisfaction survey and morale Monitor sick leave Monitor staff turnover The final step is to check whether the data is currently being collected. If not assess the feasibility and cost effectiveness of collecting it. You may have to adjust the indicators if the effort to measure the indicator is going to be greater than the result from collecting it. 5 1 MODULE 5: Managing communication and the change process EXERCISE SHEET 5.2 PROJECT PLANNING What is it? Project Planning assists you to establish strategies, assign responsibilities and set the timeframes for a project. Who uses it? Any person or group wanting to develop a clear and rational way forward with solving a problem. Why use it? To identify the strategies the responsibilities and the timeframes for solving a problem. How to use it Explain the objective of the session and give the participants all the information you gathered in the SWOT Analysis, the Force Field Analysis and the desired outcomes that have been documented. The strategies are developed from a brainstorming exercise (Exercise Sheet 1.2). In the first column write the strategies from the brainstorming exercise then clarify them with the group checking on: • Meaning • Feasibility • Sequencing In the second column write in the name of the person who will be responsible for implementing the strategies. The person may delegate to others but they will be responsible for getting the work done and on time. Finally in the third column write in the completion date for implementing the strategy. Clarify them with the group checking on: • Sequencing • Achievability • Available time and resources 5 2 MODULE 5: Managing communication and the change process Problem: ______________________________________________________________ _________________________________________________________________________ ________________________________________________________________________ Strategies By whom By when 5 3 MODULE 5: Managing communication and the change process EXERCISE SHEET 5.3 CHANGE AGENT SELF ASSESSMENT TOOL What is it? The Change Agent Self Assessment Tool assists you to determine your strengths and weaknesses as a change agent. Why use it? To ensure that you have the characteristics of a change agent. When to use it? When you are ready to advocate for change you need to be sure that you have the characteristics of a change agent. How to use it • Assess your change agent characteristics by answering YES or NO to the statements below. • From the results list your strengths and weakness. • Take your weaknesses and design a development plan for yourself. Characteristics of a Change Agent Yes No Plans ahead Is persistent and doesn’t give up Is sensitive to the needs of the others involved Identifies opinion leaders within the group and outside the group Asks for feedback from those against the change Keeps participants informed Views the change process from the perspectives of both participants Identifies root causes of problems Continually collects and analyses data about the change as it occurs Shares the success with everyone involved 5 4 MODULE 5: Managing communication and the change process Strengths Weaknesses 1. 1. 2. 2. 3. 3. Self development plan: _________________________________________________ _________________________________________________ _________________________________________________ ________________________________________________ 5 5 MODULE 5: Managing communication and the change process EXERCISE SHEET 5.4 TEAM FORMATION TOOL What is it? The process establishing the team you want to support you in advocating for change. Who uses it? Any person wanting support when advocating for change. Why use it? To identify the key support people required to provide appropriate support. How to use it • First list the knowledge and skills you require in your team to support you. • Return to the results of your Self Leadership in Session 4 Exercise 2.7 and note the skills you assessed you had relevant to the project and complete column 2. • Then look at the Stakeholder Analysis you did in Exercises 2.2 - 2.6 and fill in column 3. • Now go to Exercise Sheet 2.9 for the information you need for column 4. • Complete the exercise by filling in column 5 as if there are still some knowledge and skills you require in the team. Skills and Self Stakeholders Networks Others knowledge 5 6 MODULE 5: Managing communication and the change process EXERCISE SHEET 5.5 COMMUNICATION PLAN What is it? The process for establishing a plan for communicating the intent and progress of the project to all stakeholders. Who uses it? Any person/team embarking on an advocacy path for change who needs to commit to the activity. Why use it? To ensure that all stakeholders are kept informed of the intent and progress of the advocacy change process. How to use it • First decide what you want to achieve and state in outcome terms in the ‘Objective’ column. • List the strategies for each of the objectives. • Complete the exercise by putting in the people who will be responsible for carrying out the strategy and the timelines for completing the strategy. Objective Strategy By whom By when 5 7 MODULE 5: Managing communication and the change process 5 8 MODULE 5: Managing communication and the change process
i MODULE 4: Understanding the policy, political and decision-making processes i i MODULE 4: Understanding the policy, political and decision-making processes i i i MODULE 4: Understanding the policy, political and decision-making processes CONTENTS MODULE 4: UNDERSTANDING THE POLICY, POLITICAL AND DECISION- MAKING PROCESS Objectives 1 Session 6 2 Introduction to the policy development processes 2 Systems thinking and impact 2 Policy categorization 2 The policy-making process 3 Policy analysis 5 Policy intervention 5 Politics, laws and budgets 6 Political processes 8 The political arena 9 Rulemakers and timeframes 9 Session 7 10 Introduction to the decision-making process 10 The decision-making process 11 Decision-making models 11 Types of decisions 12 Resources 13 Entering the decision-making process 14 References 15 Information sheet 4.1 - Policy, public policy and 17 health policy Information sheet 4.2 - How laws are made in a 19 Westminster System i v MODULE 4: Understanding the policy, political and decision-making processes Information sheet 4.3 - Decision making models 20 Facilitator’s guide - Understanding policy 22 development processes Exercise sheet 4.1 - Policy categorization tool 24 Exercise sheet 4.2 - Policy process assessment check list 26 Exercise sheet 4.3 - Policy analysis check-list 28 Exercise sheet 4.4 - Policy interventions planning 30 framework Exercise sheet 4.5 - Political system type 32 assessment tool Exercise sheet 4.6 - Political arena assessment tool 34 Facilitator’s guide - Understanding decision-making 36 processes Exercise sheet 4.7 - Type of decision-making 37 assessment tool Exercise sheet 4.8 - Resource assessment tool 39 Exercise sheet 4.9 - Entering the decision-making 40 process tool 1 MODULE 4: Understanding the policy, political and decision-making processes MODULE 4 UNDERSTANDING THE POLICY, POLITICAL AND DECISION- MAKING PROCESSES Objectives Upon completing this session, the reader should be able to: Understand and apply systems theory Understand the policy development process, complete a policy analysis and develop a policy intervention plan Analyse political and legislative processes Know how decisions are made Understand the social and political dimensions of decision- making Know when and how to enter the decision-making process 5 5 5 5 5 5 MODULE 2 Identifying and Analysing the Stakeholders and Networks MODULE 5 Managing Communication and the Change Process MODULE 3 Understanding the Contextual Environment MODULE 1 Identifying the Problem and the Desired Outcome MODULE 6 Monitoring and Evaluating the Project MODULE 4 Understanding the Policy, Political and Decision- Making Processes T T T T T T 2 MODULE 4: Understanding the policy, political and decision-making processes Session 6 Introduction to the policy development processes When advocating, nurses and midwives must understand that there will be competing priorities, existing policies and legislation that will act as barriers, competition for scarce resources, conflicting positions on the subject, and power vested in others who will need to be influenced. This session will assist you to understand these forces, use them to your advantage, and thereby advocate successfully. The session will introduce you to “systems thinking” in relation to policy development and analysis processes, as well as political and legislative processes. Systems thinking and impact The two basic types of system are closed and open. Closed systems are not influenced by their environment and do not interact with it. By contrast, an open system recognizes the dynamic interaction of the system with its environment. Today, when we call organizations ‘systems’, we mean open systems; that is, we accept that an organization continually interacts with its environment. The health system is very much an ‘open system’. This is important to understand this as an advocate. When wanting to influence decision-makers, you need to understand that they operate within an ‘open system’ and they are influenced by many factors and players. Your case is not the only case. You should be aware of the competing influences on the decision-makers you are wanting to influence. The job of the advocate is to ensure that everything influencing the decision-makers is understood and considered when developing a plan of action to influence them in the making of policy. Policy categorization There are important overlaps between social policy, economic policy and health policy. Social policy is concerned largely with the maintenance and distribution of income, and the provision of welfare services such as housing and transport to specific target groups such as the poor. While, in principle, health policy has a narrower focus, for example in meeting the health needs of a specified population, health insurance policies may be designed to cater to the same target groups SYSTEM A system is a set of interrelated and interdependent parts arranged in a manner that produces a unified whole. POLICY is seen as ‘the continuing work done by groups of policy actors who use available public institutions to articulate and express the things they value.’ (M. Considine 1994) 3 MODULE 4: Understanding the policy, political and decision-making processes as those catered to by the social welfare sector. Similarly, health policies may have very significant budgetary implications for governments. For further information see Information Sheet 4.1 and Exercise Sheet 4.1) Example The elements of a policy include: • the area affected, public hospitals, community health, public health; • the objective or desired outcome, such as a reduction in hospital waiting lists, reduction in incidence of scabies; and • the actions that have been, or are to be, taken, including the legislative, financial and administrative mechanisms involved in the process of implementation. Exercise Using the Policy Categorization Tool (Exercise Sheet 4.1), categorize the following policy examples: • Primary health care policy • Food safety regulations • Mandatory reporting of child abuse • Drug use regulations • Clinical privileging • Professional regulations • Course accreditation • Programme evaluation The policy-making process It is important to understand the policy development process so that as an advocate you can plan the type of input you need in order to have an impact on the final policy. Perhaps you have identified a need for a policy and want to advocate for it to be put on the agenda. Your approach will be different to that needed if you want to be involved in the formulation, adoption, implementation or evaluation phases of the process. So what are the phases of the policy development process? The five key stages in the health policy-making process are: • Problem identification and agenda setting, in which policy problems are defined and the policy agenda set. Here it is acknowledged that public problems will only reach the political agenda if they are converted into political ‘issues’. This usually occurs when an interest group demands government action on a problem, or when there is public disagreement over ways in which a problem should be addressed. 4 MODULE 4: Understanding the policy, political and decision-making processes • Policy formation is the stage in which policies are created or changed. Policies are products of the political context within which they are developed. It is useful to understand policy formation as a social and political process in order to conceptualize how policies are formulated. • Adoption is the stage when the policy is enacted, or brought into force, for example, by state or federal legislation. New or changed public policies are often adopted by means of a decision of the cabinet, or indeed of an individual minister, without any legislative change. • Policy implementation includes the actions and mechanisms whereby policies are brought into practice, that is, where what is written in the legislation or policy document is turned into a reality. In this stage the content of the policy, and its impact on those affected, may be modified substantially, or even negated. In analysing this stage in the policy-making process, one needs to examine how, when and where particular policies have been implemented. • Policy evaluation, the final stage in the policy-making process, includes monitoring, analysis, criticism and assessment of existing or proposed policies. This covers the appraisal of their content, their implementation and their effects. Moreover, evaluation is designed to help governments to implement policies in an effective and efficient manner. (See Exercise Sheet 4.2) Example Problem Policy Adoption Policy Policy Identification Formation ImplementationEvaluation Question raised in Parliament X Discussion paper X Service review X Strategic planning process X X Parliamentary inquiry X X Call for submissions Parliamentary bill X Legislation X X Implementation guidelines X You will note that some of the above examples could fall into more than one category so further investigation would be needed to clarify which category is the most appropriate. Exercise Using the Policy Process Assessment Tool (Exercise Sheet 4.2), determine where your issue would fit along the policy development spectrum. 5 MODULE 4: Understanding the policy, political and decision-making processes Policy analysis In health policy analysis it is useful to acknowledge that there are three broad levels of analysis, or emphasis, within which studies can be carried out (Ham and Hill, 1984): • micro-level analysis which is concerned chiefly with identifying who makes decisions and how choices are made within organizations; • mid-level analysis which focuses on the health ‘policy making process’ and the actions and mechanisms whereby the agenda is defined and policies brought into practice; and • macro-level analysis where analysis, criticism and evaluation of the existing health care system within its economic, political and cultural context, is the principal objective. While it is useful to acknowledge that there are three broad levels of analysis, you can carry out an analysis by applying a broad spectrum of questions to the policy under question. Exercise Using the Policy Analysis Check List (Exercise Sheet 4.3), complete a policy analysis on a policy of your choice. Policy intervention It is now appropriate to look at how to plan policy interventions. When planning policy interventions the following framework of approach is suggested. (See Exercise Sheet 4.4) 6 MODULE 4: Understanding the policy, political and decision-making processes Exercise Using the Policy Interventions Planning Framework (Exercise Sheet 4.4), complete a plan to develop solutions for a policy issue you are experiencing, Politics, laws and budgets If policies are the outcomes of choices that entities make to achieve their goals, then politics is the means to those ends. The product of the two (policy and politics) is usually legislation and the budgetary process that is required to support implementation. “POLITICS means striving to share power or striving to influence the distribution of power, either among states or among groups within states.” -- Max Weber Example Policy interventions to reduce rates of teenage pregnancies on the Island of Pohnpei Is it feasible?(Implementation) Is it plausible?(Design) Resources Activities Strategy Objectives ———>Things needed———> —>To do —> —>If —> —>Then 2) Community clinic-based educational programme: a. Curriculum development and procure- ment of teaching supplies and equipment. b.Legislative statute allocating necessary monies; c. Centre and outreach worker training; d.Memorandum of understand- ing with site locations (e.g., existing community groups: churches, sports, councils, clinics, women’s clubs). 1) Media public awareness campaign: a. Market survey of media sources preferred by teenagers. b. Developed media announce- ments. c. Legislative statute allocating necessary monies. d. Memoran- dum of agreement with the media (e.g., radio station). e. Evaluation using pre/ post - KAP surveys of the representative high school population. 3) School-based educational programme: a. Curriculum development and procurement of teaching supplies. b. An inter-agency memorandum of under-standing. c. Legislative statute allocating necessary monies. d. Teacher/ school nurse aide training. e. Pilot study site to evaluate programme, e.g., pre/post-KAP test. f. School principal’s endorsement and parental release agreeing to student’s participation. 1) Increased preconceptual education programme: a. School- based educational programme. b. Community clinic-based educational programme. c. Media public awareness campaign. 1) Increased preconceptual educational programme 2) Increased rates of prenatal care 3) Increased rates of well- baby care Example Objective: To reduce the number of infant deaths born to Pohnpeian teenagers to 15/1000 by 1998 and 10/ 1000 by 2003. 7 MODULE 4: Understanding the policy, political and decision-making processes Politics is an activity whereby people achieve what they want by exerting power and influence. It involves conflict over the distribution of scarce resources. Schattschneider (1960) states that “every conflict consists of two parts: the individuals engaged and the audience attracted to the conflict”. Example Nurses in a community wish to mandate the vaccination of infants against polio. The individuals engaged are the nurses and midwives. The audience in this case consists of two groups: government policy- makers and the community (with parents who may or may not want vaccinations mandated). As can be seen in this example, once the audience becomes involved it is never neutral; people take sides and influence the outcome thereby expanding the scope of the conflict. It is important to remember that as long as the conflict remains with the individual and does not engage an audience, the political process is limited, if initiated at all. Therefore nurses and midwives who set out to advocate for a particular position need to understand the political processes and the power bases that might exist within the environment they will be operating. They need to recognize that conflict is an essential ingredient to success and that success is dependent on how that conflict is managed. Although policy and politics are usually associated with government, there are four spheres in which nurses may be required to advocate and therefore be involved in political action (Leavitt and Mason 1998): • Workplace: influencing workplace policy, procedures, funding allocation decisions, and practice models. • Government: influencing local, state and national policy and legislation. • Professional: organizations: influencing the setting of standards, licensure, and credentialing. • Community: influencing through engagement in community activities such as environmental groups, child care groups, etc. Effective government relations requires an understanding of how government works and what drives government decision-making. The Western Pacific Region is diverse and contains different forms of government, with different legislative processes and structures. As mentioned above, effective advocates will research the system in their country and be aware of how the processes work and where the points and people of influence are. 8 MODULE 4: Understanding the policy, political and decision-making processes The law making and budgetary processes are two key political activities for advocates to be involved in. The mechanics of each process may vary depending on the government structures of a country. It is important to investigate how the system operates, at various levels, wherever and whenever the advocacy effort is being undertaken. Not all policy comes into effect through the law-making process, but it is the ultimate expression of a government’s intent. Political processes Any analysis of political processes should identify realities and institutional relationships that are reflected in daily events. They need to be identified to assist in understanding where, who and how to lobby to achieve your objectives in policy development or reform. When looking at the kind of political system that characterizes the country, five elements (which are not fully distinct or mutually exclusive) are taken into consideration: • Consensus: Is there basic agreement on the most fundamental rules of political life? Is the political contest played by those rules? Is there agreement on who is a citizen, and what the rules for achieving power are? • Rule of law: Are there basic legal structures for public and private activities and interactions? Are basic human rights observed? Is the rule of law applied equitably? Is personal security guaranteed by the state? Does the judiciary have integrity and is it independent? Do similar cases have similar outcomes? • Competition: Is there competition in the system? Is there competition through elections, in the media, and in the marketplace of ideas? Can people legally organize to pursue their interests and ideas? Is there competition within government, including checks and balances between branches of government? • Inclusion: Are there problems of inclusion and exclusion? Are any elements of the population excluded (formally or informally) from meaningful political, social, or economic participation because of religion, ethnicity, gender, geography, or income status? • Good governance: Is there adequate governance by the state and by public and private sector institutions? Are these institutions accountable, transparent, and efficient? Do political institutions work well? Do they deliver what they promise? 9 MODULE 4: Understanding the policy, political and decision-making processes Exercise Use the Tool to Assess Type of Political System (Exercise Sheet 4.5) to assess the political system you live and work in and summarize your conclusion regarding the type of political system you have. The political arena Once you have assessed the type of political system you are dealing with, whether it be in the workplace, government, professional association or the community, the particular entities that are responsible for the problem and proposed solutions need to be identified. A common mistake made by advocates is to start the process by targeting the wrong people or person. If you want to change worker safety standards you need to target not only your employer but also those who set the standards which may be government. If you want to influence the allocation of resources to a new community development programme you need to determine where the resource allocation decisions are made. Once you have identified the appropriate political arena, the formal and informal functioning of the arena should be analysed. Questions to be answered in an analysis of the political arena include: • What is the entity’s structure? • What are the stated mission and goals? • What subgroups or committees have responsibility for the issue? • What are the formal and informal methods of communication by the entity? • What is the budget process? How might an individual influence it? Exercise Using the Political Arena Analysis Tool (Exercise Sheet 4.6), apply it to a particular issue you might want to pursue. Rulemakers and timeframes The next stage involves identifying key players in the political process, including the proponents and opponents of the policy development or change you want to achieve. The goal is to identify who will support the reform, and which political, economic, and social interests oppose the policy direction. You will have completed this list when you do the stakeholder analysis in Module 2. For further information on the legislative process see Information Sheet 4.2. 1 0 MODULE 4: Understanding the policy, political and decision-making processes It is useful to find out the timetable of the events which influence policy development. For example: • Typically, proposals are developed six to nine months before the budget. Advocacy in this early period should target ministers and departmental officials. • Three to six months before the budget, the proposals are with senior members of government (Cabinet or a Cabinet sub-committee). They will be considering the possible trade-offs between different sectors and within sectors. This is an important consideration in the health sector where funds may be withdrawn from one area to support another. • Advocacy during this budget period should target Finance and Treasury as well as key members of Cabinet or the Cabinet sub-committee. • Policy ideas that are not expensive (or that generate revenue) are popular. • For costly policies and programmes, potential budget savings will have to be determined. • In budget submissions it is important to have a convincingly costed proposal. Congratulations you have now completed the overview of the contextual environment including values, traditions, ethics, gender and risk. You have an understanding of systems theory and have a policy intervention plan. You have also investigated the political and legislative process relevant to the issue you have selected. Session 7 Introduction to the decision-making process You now have some understanding of the policy, political and legal processes in your region. However knowing the processes and accessing them to influence decision-making are very different activities. In the previous session you developed a policy intervention plan, now you will be given an understanding of the decision-making processes themselves. This session will introduce you to the decision-making processes so as to assist you to access them in an effective and efficient way. 1 1 MODULE 4: Understanding the policy, political and decision-making processes The decision-making process Individuals at all levels of an organization make decisions. That is they make choices from two or more alternatives. Although decision-making is typically described as ‘choosing between alternatives’ that view is overly simplistic. If we go back to the previous session we are reminded that we operate within a system and that the system is “a set of interrelated and interdependent parts arranged in a manner that produces a unified whole.” If we apply this thinking to decision-making we understand that there will be many economic, political, social and environmental factors both formal and informal which can have an impact on any decision-making process. In Module 3 reference was made to the issue of gender and the involvement of nurses and midwives in policy development and decision-making. Women are under- represented in decision-making bodies in the political arena, as well as in the private sector, in public services, trade unions and non-government organizations. This means that women’s views as well as women’s special concerns are not fully taken into account. The empowerment and autonomy of women and the improvement of women’s social, economic and political status is essential for the achievement of both good governance and sustainable development in all areas of life. The traditional working patterns of many political parties and government structures continue to be barriers to women’s participation in public life. Women have demonstrated considerable leadership in community and informal organizations, as well as in public office. However, socialization and negative stereotyping of women reinforces the tendency for political decision-making to remain the domain of men. Similarly, the under-representation of women in decision-making positions in the areas of art, culture, sports, the media, education, religion and law have prevented women from having a significant impact on many key institutions including those in health. Decision-making models It is useful to have some understanding of the various models of decision-making. This will assist you when determining how you should engage the relevant decision-making process to achieve your intentions. These intentions may be to advocate for change as an external change agent or by establishing yourself in a decision-making position. For information on decision-making models with an example and exercise see Information Sheet 4.3. DECISION: a choice made from two or more alternatives. DECISION-MAKING PROCESS: A set of steps that include identifying the problem, selecting an alternative and evaluating the decision’s effectiveness. 1 2 MODULE 4: Understanding the policy, political and decision-making processes Types of decisions Decisions can be located at points along a continuum from structured to unstructured. Unstructured decisions require managerial judgement and consideration of unquantifiable factors. They may also require consideration of qualitative factors, ethical judgements or simply personal taste; and may even be the result of a decision-maker’s inability to fully comprehend a structure in a complex situation. An unstructured decision may either be incapable of being structured or may not yet have been examined in depth, so may appear to the organization as unstructured. Unstructured decisions can be characterized as: involving trial and error approaches, intuition and common sense; tending to be ad hoc; and are usually made at the middle and top levels of management. It is also appropriate to mention the widespread existence of non-rational decision- making, often involving hidden agendas and objectives. Structured decisions are often those which can be automated, and where often a single ‘best’ solution can be identified. Many problems are difficult to structure without ignoring important qualitative features. Decision levels can also be seen as existing on a spectrum from strategic to operational. Strategic decisions can be defined as those concerned with deciding the objectives of an organization, the resources used to attain the objectives and policies governing acquisition, use and disposition of those resources. Operational decisions, on the other hand, are concerned with ensuring that resources are used efficiently in the accomplishment of the organizational objective. For example, in health services, strategic decisions may include: allocating funds among programme areas, assessing programme performance with respect to strategic objectives (evaluation), and setting standards for operations. Operational control decisions ensure that specific tasks are performed in an effective and efficient manner: monitoring daily operations and activities with respect to standards, corrective actions, and scheduling. It is useful to determine what type of decision-making process you are entering. Your response to the decision-making process may depend on the type you are confronted with. (See Exercise Sheet 4.7) 1 3 MODULE 4: Understanding the policy, political and decision-making processes Example A decision was made during the departmental budget setting process to reduce the budget of the health centre and reduce the nurse staff levels. This means that the decision was made at a strategic level and through the structured budget process. Structured X Operational Strategic Unstructured The decision was both structured and strategic and therefore needs both a structured and strategic response. This example indicates that there would be no point approaching the problem at an organizational level, but there is a structure that you would have to understand and work with. Exercise Using the Type of Decision-Making Tool (Exercise Sheet 4.7), determine the decision-making type with which you may have to influence. Having determined the model of decision-making, the types of decisions and the decision-making stages, you should be in a position to decide how and where you need to have some influence. This will very much depend on the nature of the influence or intervention you wish to make. For example, if you want to influence policy it will be the policy making process; if you what to influence decisions regarding resource allocation it may be the policy making and/or budget process. If you want to bring about lasting and mandated change then it may be the legislative process. You need to maximize your effort and resources (because they are likely to be limited) so assess carefully what resources you do have and when best to enter the relevant process. Timing is important. Resources You have completed a stakeholder analysis, you have assessed the networks you need, and you may have established or accessed a relevant support group. So, who can do what? (See Exercise Sheet 4.8) 1 4 MODULE 4: Understanding the policy, political and decision-making processes Example Using the example of the health centre, certain people and groups have been engaged in the exercise. Lets look at what they can offer and when. Person/Group Skills/Interests Comments Nursing staff Passion, knowledge of consequences Preferably get them to work through the of current situation but do not have the professional association. political skills and ‘know how’. Local general Have an interest but no time and have Provide them with a letter to sign to the practitioners other priorities. Minister and the Department Head listing the medium to long-term financial consequences. Professional Have an interest and have indicated Develop plan of action with the association they want to use this situation as a professional association and a benchmark case, therefore they are timetable. Will be available when the prepared to put resources into it. time is right. Staff of similar Have an interest, can provide additional Need to work together on the issue. health centres supporting information; are prepared to speak out through the media; and to put a case to their local politician, the Minister and Department Head. Local member Has taken an interest; has other Need to provide her with relevant of Parliament priorities but if given the right information evidence based consequences of can be a political ‘in house’ supporter. current action and way forward. Local media Have indicated they will publish an article Provide material for article at if given the details. appropriate time. Exercise Using the Resource Assessment Tool (Exercise Sheet 4.8), complete an assessment of the resources available to you and the action which you need to take. Entering the decision- making process As indicated before, the timing for entering the decision- making process depends on the resources available. If you are doing it alone or with just a couple of colleagues you may need a long term plan with entry at the beginning of the process so as to build up credibility and ability to influence. If you have an organization’s support, you may enter at any stage in the process, but often the ‘big bang’ approach can be successful. What is meant here is that all resources are put into impacting on a particular stage in the decision-making process. (See Exercise Sheet 4.8) 1 5 MODULE 4: Understanding the policy, political and decision-making processes Example The health centre, which has had its budget cut and staffing levels reduced, has the support of the staff nurses, staff of other similar health centres and the professional association. The media and the general practitioners in the area can provide support at the right time and the local member of Parliament is prepared to provide support by influencing the Minister. So when is the best time to move on the issue? Stage Entry point Comments Agenda setting Second step would then to be to Resetting the agenda requires reset the agenda. constant vigilance and can be quite time resource intensive. Formation Adoption Implementation Evaluation Enter at this stage. The decision to alter the budget and staffing levels has been made so an evaluation of the outcomes of the decision needs to be made. The issue, in this case, is to change the decision made regarding the allocation of resources and staffing levels. The decision has been made. Therefore the need is to advocate for an evaluation of the outcomes of the decision. Exercise Using the Entering the Decision-Making Process Tool (Exercise Tool 4.9), assess first what process you need to access and then at what point in the decision-making process you need to enter. You are now well on the way. You are armed with a clearly defined issue; you have the evidence to support your case; you have some understanding of the policy, political and legal processes in your region; you have an understanding of the context in which decisions are made and you know how and when to access the appropriate step in the process of decision-making. References • Anderson J.E., Public Policy-Making (3rd Edition), Holt Rinehart and Winston, New York, USA, 1984. • Brown V., Health Care Policies, Health Policies, or Policies for Health? In Gardner, H. (Ed), Health Policy: Development, Implementation, and Evaluation in Australia, Churchill Livingstone, Melbourne, Australia, 1992. • Colebatch H., Policy, Open University Press, Buckingham, 1998. • Considine M., Public Policy: A Critical Approach, Macmillan Education, Australia, 1994. • Evers A., Farrant W. and Trojan A. (Eds.), Healthy Public Policy at the Local Level, Campus Verlag, Frankfurt am Main, Germany, 1990. • Ham C. and Hill M., The Policy Process in the Modern Capitalist State, Harvester Wheatsheaf, London, 1984. • Kalisch P.J. and Kalisch P.A., Politics of Nursing, JB Lippincott, Toronto, Canada, 1982. • Lowi T., American Business, Public Policy, Case-Studies and Political Theory, World Politics, Meyer, USA, 1964. 1 6 MODULE 4: Understanding the policy, political and decision-making processes • Mason D.J. and Leavitt J.K., Policy and Politics in Nursing and Health Care 3rd Edition, WB Saunders, Philadelphia, USA, 1998. • Milio N., Promoting Health Through Public Policy, Canadian Public Health Association Ottowa, Canada, 1988. • Palmer G. and Short S., Health Care and Public Policy, Macmillan, Melbourne, Australia 1994. • Salisbury R. and Heinz J., A Theory of Policy Analysis and Some Preliminary Applications in I Sharkansky (Ed) Policy Analysis in Political Science, Markham, Chicago, Illinois, USA, 1970. • Schattschneider, E., The Semisoverign People: A Realist’s View of Democracy in America, Holt, Rinehart and Winston, New York, 1960. • Senge P.M. The Fifth Discipline, Random House Australia,1992. • Senge P.M., Kleiner A et al, The Fifth Discipline Field Book, Doubleday New York, USA, 1994. • World Health Organization, The World Health Report 1998: Life in the 21st Century. A Vision for All, WHO Geneva, 1998. 1 7 MODULE 4: Understanding the policy, political and decision-making processes INFORMATION SHEET 4.1 POLICY, PUBLIC POLICY AND HEALTH POLICY Policy is a deceptively simple term that conceals some very complex activities. Policy evolves. As new issues arise, e.g. AIDS, new fields of public policy emerge and develop through stages. Policy both evolves over time and goes through iterations of stages as changes occur in the context of the policy issue. Policy is a purposeful planned attempt to establish principles and programmes designed to address perceived problems. What is public policy? Public policies are carried out in the name of the people as a whole, and they affect the public interest. The term ‘public’ implies that a distinction can be made between these activities and those of private individuals and groups (Forward, 1974). In the health field we are concerned primarily with government policy-making, although private policies of organizations such as the medical association, impinge heavily on the overall policy-making process. What is health policy? Health policy includes actions or intended actions by public, private and voluntary organizations that have an impact on health. The term also includes political parties’ policies that may be translated into government action at a later stage. Thus, policy may refer either to a set of actions and decisions, or to statements of intent. Policy-making is a competitive process, with the competing interests of different groups involved in shaping the direction that policy takes. Policy results from ‘a synthesis of power relationships, demographic trends, institutional agendas, community ideologies (and) economic resources’ (Brown 1992). PUBLIC POLICIES are normally used when we are dealing with those policies for which governments are primarily responsible. HEALTH POLICY generally embraces courses of action that affect that set of institutions, organiza- tions, services and funding arrangements that we have called the health care system. 1 8 MODULE 4: Understanding the policy, political and decision-making processes Some interest groups involving themselves in the policy- making process have a great deal more power than others because of their political position and their ability to influence the views represented in the mass media. For example, mainstream medical interest groups are usually listened to by members of parliament and shape the public agenda more strongly than other groups, and their opinions are reported more often by the mass media. It is the politicians, bureaucrats and powerful interest groups who set the agenda and decide the framework and philosophy of a policy. Members of the public commenting on a document are often in the position of trying to change the policy after the framework has been set. According to Lowi’s (1964) very useful typology, as adapted by Salisbury and Heinz (1970), there are four distinct ways in which public policies are perceived to affect individuals and organizations: Distributive: The provision of services or benefits to particular segments of the population. Distributive policies are characterized by the relative ease with which they can be adopted and implemented, since each policy can be implemented more or less in isolation from other policies. Regulatory: The imposition of limitations or restrictions on the behaviour of individuals or groups. An example in the health field is legislation regulating the behaviour of registered health professionals, such as medical practitioners and nurses. Regulatory policies are reasonably specific and narrow in their impact. They determine who is restricted and who is given greater freedom. Self-regulatory: Sought by an organization as a means of promoting its own interests. Self-regulation may benefit an organization directly or indirectly since being seen to be self- regulatory may enhance the official credibility of the organization. This self-regulatory principle can apply to peer review policies as developed by a number of health professions. Redistributive: Deliberate efforts by governments to change the distribution of income, wealth, property, or rights between groups in the population. In general, redistributive policies tend to provoke strong disagreement between sections of the population. Redistributive policies are relatively difficult to implement, and even more difficult to maintain, because there are always parties who gain and parties who lose when money and power are reallocated between groups. 1 9 MODULE 4: Understanding the policy, political and decision-making processes INFORMATION SHEET 4.2 HOW LAWS ARE MADE IN A WESTMINSTER SYSTEM Legislation is Legislation may come from different sources including proposed ministers, their staff, from recommendations of commissions, and from parliamentary committees. The proposal is Government agencies and ministers will be involved. refined Public input may be sought through the release of Discussion Papers. It goes to Cabinet Usually Cabinet approval is needed for the proposal to proceed. Party approval is This is a good point of influence for advocates who sought support your issue can request changes to the proposal. The bill The bill is read a first, second and third time. introduced During the second reading, the bill may be debated in detail and amendments are presented and voted on. Royal approval The Governor General (on the Queens behalf) gives royal approval to the bill – it is now an Act of Parliament. Many of the countries in the Western Pacific Region will have a different system of law making. However, this model indicates the different stages in the process. In each country these different stages need to be identified so that the advocacy effort can be effectively targeted. Being involved in the budgetary process is a key activity for advocates seeking policy and programme solutions to their issues. While the process may vary from country to country there are two areas to investigate: • What is the timing of the process (that is, when is the most effective time to feed ideas into the process)? • What are the costs and pay-offs for your proposed solution (that is, in what economic terms can your solution be sold)? 2 0 MODULE 4: Understanding the policy, political and decision-making processes INFORMATION SHEET 4.3 DECISION MAKING MODELS Rational model: This is the classical, scientific approach to decision-making which views the process as essentially orderly and rational. A problem is defined and isolated, information is gathered, alternatives identified, and an end is established. Garbage can model: This describes decision-making processes in organizations which are characterized by ambiguity, where objectives are ill-defined or inconsistent for individual decision-makers. The model applies when resource constraints are high and it encapsulates the complex environment which surrounds organizational decision-making. This is often found in the public health system and is very hard to affect. Contingency model: The contingency approach considers organizational goals and structures as dependent (contingent) upon technological and environmental forces rather than as properties to be manipulated at will by management. This is often used as an excuse for not proceeding with change. Organizational process model: This model recognizes a real difference between an individual decision-maker and an organization, emphasizing the centrality of routines and procedures in reducing the effects of uncertainty. It is important to understand the difference between individual and organizational decision-making. Incremental model: This approach suggests that there are interrelated decision-making processes which may be depicted as a sequence of steps, or series, comprising: 1. an identification phase; 2. an alternatives development phase, and 3. a selection phase. This model is often used when introducing a new specifically funded programme, technology or capital works. Political bargaining model: Underlying this model is the view that individuals, groups and organizations have self- defined interests to protect. When faced with a decision, participants in the process focus on those aspects which they perceive as affecting their own interests and, 2 1 MODULE 4: Understanding the policy, political and decision-making processes consequently, a range of linked issues compete for attention, rather than a single strategic problem requiring a solution. Again this model is often seen in the health system. As previously stated, understanding the model of decision- making you are involved with will assist you to determine how you should engage the decision-making process to achieve your intentions. Example Take a few traditional decision-making activities to which you can apply the test, and ascertain what type of model you are dealing with. Legislative Budget Computer Changing change process hardware work Purchase practice Rational Garbage can Contingency Organizational Incremental Political The interesting thing in this exercise is that some of the decision-making is unambiguous and easily understood (e.g. legislative change and equipment purchase). Whereas others are ambiguous and complicated and therefore not very transparent (e.g. budget process and changing work practices). 2 2 MODULE 4: Understanding the policy, political and decision-making processes FACILITATOR’S GUIDE – UNDERSTANDING POLICY DEVELOPMENT PROCESSES Facilitator’s preparation time: 60 minutes Group exercise time: 90 minutes Resources: Exercise Sheets 4.1 - 4.6 Information Sheets 4.1 - 4.2 Butcher paper, white board or black board Pens/pencils/paper Instructions: • The exercise is best done with no more than 20 people. • Read Module 4, Session 6 and go through each of the exercises. • Familiarize yourself with the Exercise Sheets and Information Sheets. • Make sure you have enough copies of the Exercise Sheets for each participant in your group and that you have the resources you need, e.g. pre-prepared butcher paper. • Introduce the topic and explain the objectives of the exercise. • Make certain that everyone in the group has a full understanding of the problem being considered. • Using the Policy Categorization Tool (Exercise Sheet 4.1), categorize the policy examples provided. Primary health care policy Food safety regulations Drug use regulations Professional regulations Course accreditation Programme evaluation 2 3 MODULE 4: Understanding the policy, political and decision-making processes • Then ask the group to decide what policy it will be working with and what category it falls into. • Use Exercise Sheet 4.2 to determine where the policy is in the policy development process. • Use Exercise Sheet 4.3 to help the group understand the nature, intent and impact of the policy with which it is dealing. • Now go to Exercise Sheet 4.4. This tool will assist the group to develop the interventions necessary to have an impact on the policy. • Use Exercise Sheet 4.5 to assist the group to understand the type of political system they have in their country. • If the group represents an organization, then use Exercise Sheet 4.6 to understand the nature of their organization. This is not necessary if it is an informal group addressing the problem. This completes Module 4, Session 6 2 4 MODULE 4: Understanding the policy, political and decision-making processes EXERCISE SHEET 4.1 POLICY CATEGORIZATION TOOL What is it? Policy Categorization is a technique for determining the type of policy one is working with and how that policy might affect organizations and population groups. Who uses it? An individual or group. Why use it To understand the type of policy you are working with and the group/ s it might impact on. How to use it: • If working with a group, explain to them the objective of the exercise. • Describe the policy in one sentence and write it down. Policy description: _________________________________ _________________________________________________ • Agree on which description bests fits the policy you are working with. • Then agree on whether the policy applies to an individual, organization or a population group by placing a • in the appropriate box. Policy description Individual Organization Population Distributive The provision of services or benefits to particular segments of the population. Distributive policies are characterizsed by the relative ease with which they can be adopted and implemented, since each policy can be implemented more or less in isolation from other policies. 2 5 MODULE 4: Understanding the policy, political and decision-making processes Policy description Individual Organization Population Regulatory The imposition of limitations or restrictions on the behaviour of individuals or groups. Regulatory policies are reasonably specific and narrow in their impact. They determine who is restricted and who is given greater freedom. Self-Regulatory Sought by an organiszation as a means of promoting its own interests. Self-regulation may benefit an organiszation directly or indirectly since being seen to be self-regulatory may enhance the official credibility of the organiszation. Redistributive Deliberate efforts by governments to change the distribution of income, wealth, property, or rights between groups in the population. Finally summarize the policy description and what person, organization, or group will be impacted ________________ __________________________________________________ __________________________________________________ _________________________________________________ 2 6 MODULE 4: Understanding the policy, political and decision-making processes EXERCISE SHEET 4.2 POLICY PROCESS ASSESSMENT CHECK LIST What is it? Policy Process Assessment is a technique for determining where a policy is in the policy development process. Who uses it? An individual or group. Why use it? To plan your course of action for advocating change based on where the policy is in the development process. How to use it • If working with a group, explain to them the objective of the exercise. • Describe in one sentence the policy you will be assessing. Policy description: _________________________________ _________________________________________________ • Then agree on where in the process of policy development the policy is by placing a •in the appropriate box. Stage of development Problem identification and agenda setting: In which policy problems are defined and the policy agenda set. Policy formation: Is the stage in which policies are created or changed. Adoption Is the stage when the policy is enacted, or brought into force. Policy implementation: Includes the actions and mechanisms whereby policies are brought into practice. Policy evaluation: The final stage in the health-policy-making process, includes monitoring, analysis, criticism and assessment of existing or proposed policies. 2 7 MODULE 4: Understanding the policy, political and decision-making processes Examples Problem Policy Adoption Policy Policy identification formation implementation evaluation Discussion Ppaper X Service Rreview X Strategic planning process X X Parliamentary inquiry X X Parliamentary Bill X Legislation X X Implementation guidelines X The result of this exercise will assist you to determine at what point in the development of a policy you need to influence the decision-making. This exercise will ensure that you are focused and minimize the effort you need to make. 2 8 MODULE 4: Understanding the policy, political and decision-making processes EXERCISE SHEET 4.3 POLICY ANALYSIS CHECK-LIST What is it? Policy analysis is a technique for understanding the nature, intent and impact of a policy. Who uses it? An individual or group. Why use it? To assess the strengths and weaknesses of a policy. How to use it • If working with a group, explain to them the objective of the exercise. • Define in one sentence the policy you will be analysing. Policy description: _________________________________ __________________________________________________ • Apply each question to the policy and provide a response. Questions Response What is the present policy? How, when, and why did the policy come into being? What influenced policy -makers to adopt a particular course of action, what were the objectives of the policy? Who are the policy-makers? Which, if any, interest groups do they represent? What have been the stages and methods, including organizational arrangements and structures, used in the policy-making process? What interested groups, if any, have been consulted and what sources and kinds of advice have been obtained? Is the process of policy -making that has been adopted the best we can hope for? How might it be improved? 2 9 MODULE 4: Understanding the policy, political and decision-making processes Questions Response Is it good policy? What has it achieved? Would a different policy be likely to yield better results? For whom? Does the present policy need changing? Is it feasible to change it and in what ways? • Summarize your analysis Strengths _________________________________________________ _________________________________________________ _________________________________________________ Weaknesses _________________________________________________ _________________________________________________ _________________________________________________ The results of this exercise will assist you to understand the strengths and weaknesses of the policy and guide you in developing appropriate strategies for minimizing the weaknesses and building on the strengths. 3 0 MODULE 4: Understanding the policy, political and decision-making processes EXERCISE SHEET 4.4 POLICY INTERVENTIONS PLANNING FRAMEWORK What is it? The Policy Interventions Planning Framework is a tool for developing the interventions necessary to impact on the policy. Who uses it? An individual or group. Why use it? To determine the best course of action to take. How to use it • If working with a group, explain to them the objective of the exercise. • Describe the policy in one sentence and write it down. Policy description:_________________________________ ________________________________________________ • Take each column separately and brainstorm (Exercise Sheet 2) the answers to the questions • go left to right when carrying out planned solutions. • go right to left when planning solutions. 3 1 MODULE 4: Understanding the policy, political and decision-making processes Is the policy feasible Is the policy plausible (Can it be implemented?) (Can it be designed to make sense?) Are the needed Are there appropriate Are there good Are there defined resources available? programmes and strategies? policy goals and activities objectives? Identify Describe Define Identify • List describe and • Existing services that • Alternative means for • Measurable aims, quantify essential could contribute to achieving objectives; based upon: resources: strategy; • detailed problem • personnel • Reasons for believing analysis; • funds • Needed services that strategy is plausible • explicit priorities; • data are conceivable to based upon: value conflicts and • technology help implement the • research and constraints. • plant and equipment strategy; evaluation; • management/other • expert stakeholder Problems are negative systems • Evidence about opinion; statements. • leadership applicability of possible • logic and brainstorm- • enabling legislation, services drawn from: ing;key assumptions Goals are positive regulations, insu- • known research and about external factors statements. rance, memoranda evaluation studies; (current, future) that of agreement • experts/stakeholder could effect strategy Objectives are measu- opinion; rable steps towards • personal observation achievement of goals and experience. and resolution of problems. • Check the results with the group for accuracy and then document a summary of your findings: ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Is the policy feasible Is the policy plausible (Can it be implemented?) (Can it be designed to make sense?) Are the needed Are there appropriate Are there good Are there defined resources available? programmes and strategies? policy goals and activities? objectives? 3 2 MODULE 4: Understanding the policy, political and decision-making processes EXERCISE SHEET 4.5 POLITICAL SYSTEM TYPE ASSESSMENT TOOL What is it? Political System Type Assessment is a means for determining the type of political system you have in your country. Who uses it? An individual who wants to influence or understand the political system in which they live. Why use it? To clarify the nature of the political system which you want to influence. How to use it • Answer the questions listed below You will need to find the answers to the questions through your own research by contacting any one or more of the following: • Library • Internet • Parliamentary official • Local Member of Parliament Question Response Consensus Is there basic agreement on the most fundamental rules of political life? Is the political contest played by those rules? Is there agreement on who is a citizen, and what the rules for achieving power are? 3 3 MODULE 4: Understanding the policy, political and decision-making processes Question Response Rule of law Are there basic legal structures for public and private activities and interactions? Are basic human rights observed? Is the rule of law applied equitably? Is personal security guaranteed by the state? Does the judiciary have integrity and is it independent? Do similar like cases have similar outcomes? Competition Is there competition in the system? Is there competition through elections, and in the media? Can people legally organize to pursue their interests and ideas? Is there competition within government? Inclusion Are there problems of inclusion and exclusion? Are any elements of the population excluded (formally or informally) from meaningful political, social, or economic participation because of religion, ethnicity, gender, geography, or income status? Good governance Is there adequate governance by the state and by public and private sector institutions? Are these institutions accountable, transparent, and efficient? Do political institutions work well? Do they deliver what they promise? Summarize the results of your assessment Strengths _______________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Weaknesses ____________________________________ _________________________________________________ _________________________________________________ __________________________________________________ You will use this information when developing your change management plan. 3 4 MODULE 4: Understanding the policy, political and decision-making processes EXERCISE SHEET 4.6 POLITICAL ARENA ASSESSMENT TOOL What is it? Political Arena Assessment is a technique for analysing the political nature of an organization. Who uses it? An individual or group. Why use it? To understand the nature of an organization that has the issue or problem. How to use it • If working with a group, explain to them the objective of the exercise. • Describe the issue/problem in one sentence and write it down. Issue/Problem ___________________________________ _________________________________________________ Name of organization ______________________________ _________________________________________________ Questions Comments What is the entity’s structure? E.g. Public/private For profit/Not for profit Religious/Non sectarian Local, State or National Government What are the stated mission and goals? E.g. Values clarification (see Exercise Sheet 21) 3 5 MODULE 4: Understanding the policy, political and decision-making processes Questions Comments What subgroups or committees have responsibility for the issue? E.g. Where are they located? When do they meet? What are their terms of reference? Who is the contact point? What are the formal and informal methods of communication of the entity? E.g. What is the chain of command Are there public reports available? Is there an informal network and way of operating? What is the budget process? How might an individual influence it? E.g. How much money is available? Who makes the decisions? When are they made? • Check the results with the group for accuracy and then document a summary of your findings: _________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ You will use this information when developing your change management plan. 3 6 MODULE 4: Understanding the policy, political and decision-making processes FACILITATOR’S GUIDE – UNDERSTANDING DECISION- MAKING PROCESSES Facilitator’s preparation time: 60 minutes Group exercise time: 90 minutes Resources: Exercise Sheets 4.7 - 4.9 Information Sheet 4.3 Butcher paper, white board or black board Pens/pencils/paper Instructions: • The exercise is best done with no more than 20 people. • Read Module 4, Session 7 and go through each of the exercises. • Familiarize yourself with the Exercise Sheets, Information Sheets, and Skill Sheets. • Make sure you have enough copies of the Exercise Sheets for each participant in your group. • Make sure that you have the resources you need, e.g. pre-prepared butcher paper. • Introduce the topic and explain the objectives of the exercise. • Make certain that everyone in the group has a full understanding of the case study being considered for stakeholder analysis. • Begin with Exercise Sheet 4.7, which will assists the group to determine what type of decision-making process it will be entering. • Then use Exercise Sheet 4.8 to assist the group to determine the level of resources available to assist when accessing the decision-making process. • Now go to Exercise Sheet 4.9, which will help the group assess when in the decision making-process they should enter to advocate for change. This completes Module 4, Session 7 3 7 MODULE 4: Understanding the policy, political and decision-making processes EXERCISE SHEET 4.7 TYPE OF DECISION-MAKING ASSESSMENT TOOL What is it? The Type of Decision-Making Assessment Tool assists you to determine what type of decision-making process you are entering. Why use it? To determine what type of response you need to plan when entering the decision-making process. When to use it? When you need to know be clear about how to enter the decision- making process. How to use it • Write down the details of who made the decision and what process was used to make the decision. • Determine as to whether the decision was structured or unstructured. • Determine whether the decision was operational or strategic. • Place a mark in the quadrant that best describes the decision. Statement ______________________________________ _________________________________________________ Structured Operational Strategic Unstructured 3 8 MODULE 4: Understanding the policy, political and decision-making processes Unstructured decisions require managerial judgement and consideration of unsupported evidence. They may also require consideration of qualitative factors, ethical judgements or simply personal taste; they may also be the result of a decision-maker’s inability to fully comprehend a structure in a complex situation. Structured decisions are often those which can be automated and where often a single ‘best’ solution can be identified. Many problems are difficult to structure without ignoring important qualitative features. Strategic planning decisions can be defined as those concerned with deciding the objectives of an organization, the resources used to attain the objectives and policies governing acquisition, use and disposition of those resources. Operational control decisions can be seen as the process for ensuring that resources are used efficiently in the accomplishment of the organizational objective. 3 9 MODULE 4: Understanding the policy, political and decision-making processes EXERCISE SHEET 4.8 RESOURCE ASSESSMENT TOOL What is it? The Resource Assessment Tool assists you in determining the level of resources you have available to assist you when accessing the decision-making process. Why use it? To determine who is available to assist with the task of infiltrating and influencing the decision-making process. When to use it? When there is a need to assess the level and type of resources you have available to you before infiltrating the relevant decision-making process. How to use it • Complete the exercise with a small group of interested colleagues. • Explain what you want to achieve by doing the exercise. • Refer to the results of your stakeholder analysis and relationship building. • List the people/organizations from these exercises who can assist you access the decision and influence the decision-making process. • List the skills each have and their level of interest in assisting you. • Make comments on what you may need to do to assist them to support you. Person/Group Skills/Interests Comments 4 0 MODULE 4: Understanding the policy, political and decision-making processes EXERCISE SHEET 4.9 ENTERING THE DECISION- MAKING PROCESS TOOL What is it? The Entering the Decision-Making Process Tool assists you to assess when in the decision-making process you should enter to advocate for change. Why use it? To determine when your advocating will be most effective. When to use it? When you are ready to advocate for change and need to determine when it is the right time to take action. How to use it • Complete the exercise with a small group of interested colleagues. • Explain what you want to achieve by doing the exercise. • Using the results of the Resource Assessment exercise you know what resources you have available to you and take this into account when determining the appropriate entry point. Stage Entry point Comments Agenda Setting Formation Adoption Implementation Evaluation 4 1 MODULE 4: Understanding the policy, political and decision-making processes Example Stage Entry point Comments Agenda setting Second step would then Resetting the agenda requires constant be to reset the agenda. vigilance and can be quite time resource intensive Formation Adoption Implementation Evaluation Enter at this stage. The decision to alter the budget and staffing levels has been made so an evaluation of the outcomes of the decision needs to be made. 4 2 MODULE 4: Understanding the policy, political and decision-making processes 4 3 MODULE 4: Understanding the policy, political and decision-making processes 4 4 MODULE 4: Understanding the policy, political and decision-making processes
i MODULE 3: Understanding the contextual environment i i MODULE 3: Understanding the contextual environment i i i MODULE 3: Understanding the contextual environment CONTENTS MODULE 3: UNDERSTANDING THE CONTEXTUAL ENVIRONMENT Objectives 1 Session 5 2 Introduction to assessing the contextual issues 2 Values 2 Ethics 4 Traditions 5 Gender 7 Risk 9 References 11 Information sheet 3.1 - International Council of 12 Nurses Code of Ethics for Nurses Facilitator’s guide - Assessing contextual issues: 14 Values, ethics, traditions, and risks Exercise sheet 3.1 - Values clarification check list 16 Exercise sheet 3.2 - Ethics intensity assessment tool 18 Exercise sheet 3.3 - Harmful traditions assessment 20 tool Exercise sheet 3.4 - Gender analysis tool 22 Exercise sheet 3.5 - Risk prioritization tool 24 i v MODULE 3: Understanding the contextual environment 1 MODULE 3: Understanding the contextual environment MODULE 3 UNDERSTANDING THE CONTEXTUAL ENVIRONMENT Objectives Upon completing this session, the reader should be able to: Apply a values clarification tool to describe own and others’ ascribed values Analyse the strength of intensity of ethical issues you may be confronted with Assess harmful traditions which work against the interests of individuals, families and communities 5 5 5 MODULE 2 Identifying and Analysing the Stakeholders and Networks MODULE 5 Managing Communication and the Change Process MODULE 3 Understanding the Contextual Environment MODULE 1 Identifying the Problem and the Desired Outcome MODULE 6 Monitoring and Evaluating the Project MODULE 4 Understanding the Policy, Political and Decision- Making Processes T T T T T T 2 MODULE 3: Understanding the contextual environment Session 5 Introduction to assessing the contextual issues Policy, planning and decision-making are each influenced by the environmental context within which they operate. An understanding of the major influences and how to consider their impact will contribute to more positive outcomes. When planning your approach to advocating, it is wise to consider all possible contingencies, risks, behaviours and arguments which may be put before you. The influences covered in this session are not all of those that may arise, but certainly include the main ones and the ones likely to have the most impact on your progress. The probability of an influence occurring and the strength of its impact will also be discussed. You may not be required to use all the tools in a given situation but over the course of your advocacy on behalf of nurses and midwives you will draw on most of them. This session will consider: • Values • Ethics • Traditions • Gender • Risk (people, environment, finance, reputation) Values Values are one of the most important aspects of our character. • Our personal values underlay every aspect of our life. • Values give meaning and purpose to what we do. • We value what we care about. • Sometimes we find ourselves in conflict with a work or life situation because it clashes with our values. Policy development, planning and decision-making are to a large extent about values, that is they are value laden processes. As influential agents, those responsible for policy development, planning and decision-making need some sense of what they bring to their work. Their own values, shaped by their background - their ways of working, knowledge base, information sources, contacts, culture and life experiences - influence the way they perceive a policy VALUES are one’s judgment of what is valuable or important in life. 3 MODULE 3: Understanding the contextual environment issue and the approach they take. So too do the values of the system in which they work. Values change over time in response to changing life experiences. Recognizing these changes and understanding how they affect one’s actions and behaviours is the goal of the values clarification process. Values clarification will not tell you what your values should be; it simply provides the means to discover your own values and the values of others. Individuals who choose to influence policy development, planning or decision-making must: • be aware of their own values and those of the environment in which they operate; and • understand how these influence their decision-making and the decision-making of others. (See Exercise Sheet 3.1) Example Preference for sons In many societies, preference for sons is a powerful tradition. This preference manifests itself in neglect, deprivation, and discriminatory treatment of daughters to the detriment of their physical and mental health. Male preference begins early in life. In regions where this practice is firmly entrenched, high rates of poverty and infant mortality frequently occur. Parents with scarce economic resources may feel that it is more important for male children to survive. Dowries, to be paid when daughters marry, may be a further incentive for son preference. As a result, female children and infants are often fed after males and receive food of lower nutritional value. In rural Bangladesh, malnutrition is nearly three times as common among girls as among boys. Further, boys are more than twice as likely as girls to receive medical care for diarrhoea. In India, every sixth infant death is specifically due to practices arising from son preferences. The values displayed here include: • Economic security • Power Therefore, to change this situation, one would have to ensure that economic security is provided in another way (e.g. social security programmes, family planning) and that the family structure is not threatened. 4 MODULE 3: Understanding the contextual environment Exercise Using the Values Clarification Tool (Exercise Sheet 3.1), complete the following exercise. 1. Select the 10 statements which you relate to more than other statements and then select your top 5 values. 2. Consider a person in a decision-making position whom you have had a disagreement with on a work issue and select what you think their values were that led them to their particular position on the issue. 3. Compare your values with those of the other person and note any differences. 4. Write down what you might have done differently if you had been aware of any difference in values. Ethics Fulfilling the role of community advocate dictates that nurses and midwives support actions that are in the best interest of public health and defend the rights of patients. The rights of patients include accessibility, accountability, quality, effectiveness, efficiency, safety, responsiveness, continuity and competence. A Code of Ethics provides nurses with direction for ethical decision-making and practice in everyday situations as they are influenced by current trends and conditions. A code applies to all nurses whether they are engaged in clinical practice or delegating care to providers at other levels of care. This code also plays a role in other areas, for example, the role and impact of ethics has to be taken into consideration when developing teaching materials for nurses in training. Ethics will also play a role in administration in terms of influencing resource allocation decisions. With respect to research, ethics will also influence the development of programmes to evaluate the cost- and quality-effectiveness of different care models. There are a number of codes produced by various nursing organizations. It is suggested that you obtain a copy of the Code of Ethics produced by the nursing organization in your country. Should one not be available, you could use the one provided by the International Council of Nursing (ICN). (See Information Sheet 3.1) When advocating on behalf of nursing and midwifery on a particular issue you may analyse ethical issues to: • support your argument for change on the grounds that the current policy is unethical; or • ensure that the approach you are advocating is ethical. ETHICS The term ethics commonly refers to the rules and principles that define right and wrong conduct. 5 MODULE 3: Understanding the contextual environment The ethics of policy development and decision-making can be influenced by values and tradition but values and traditions which are different from one’s own do not necessarily result in unethical decision-making. However, ethical standards are not universal. So it is better to consider the intensity of the impact of the decision rather than the decision itself. (See Exercise Sheet 3.2) Example Using the ‘Preference for sons’ case study: Low Medium High How great a harm (or good) is done to X the recipients of the act in question? How much consensus is there that the act X is harmful (or good)? What is the probability that the act will X actually take place and will cause the harm (or benefit) predicted? What is the length of time between the act X in question and its expected consequences? How close do you feel (socially, psycholo- X gically or physically) to the recipients of the harmful (beneficial) act in question? A large number of people are harmed; there is not general consensus that the act is harmful; there is a high probability that the act will take place and actually cause harm; there is a short time for the consequences of the act to surface; and observers feel close to the recipients of the act. The sum of these characteristics indicates that this is an important ethical issue. Exercise Using the Ethics Intensity Assessment Tool (Exercise Sheet 3.2), complete an assessment on an issue that you consider might be unethical. Traditions Traditions constitute learned habits which are passed on from generation to generation and which form part of the identity of a particular community. People adhere to these patterns of behaviour, believing that they are the right things to do. Traditions are often guarded by taboos and are not easy to change. Some traditions are harmful and can either influence policy or in some cases policy can reinforce the harmful tradition. TRADITIONS are the customs, beliefs and values of a community which govern and influence members’ behaviour. 6 MODULE 3: Understanding the contextual environment A harmful tradition can be as simple as a nursing procedure which exists through ‘custom and practice’ rather than through evidence to support its effectiveness, or as extreme as genital mutilation sanctioned by governments. When advocating on behalf of nursing and midwifery on a particular issue you may need to support your argument for change on the grounds that current policy is a harmful tradition. Harmful traditions exist in many different forms, but they usually share origins in the historically unequal social and economic relationships between men and women. Efforts to alter or eradicate harmful traditional practices are often met with suspicion or hostility from those communities practicing them, particularly when efforts originate from outside the community. For many members of these societies, ending their traditions is unimaginable, as such practices constitute an integral part of their socio-cultural fabric. Cultural traditions are powerful, and only careful and sustained efforts will alter or eliminate harmful ones. Efforts to change harmful traditions are most effective when they originate within the culture that practices them. (See Exercise Sheet 3.3) Example Using the ‘Preference for sons’ case study: Low Medium High How great a harm is done to the individual X or group by the continuance of the traditional practice? What is the level of agreement that the X practice is harmful? To what extent does the traditional practice X disempower the individual or group? To what extent does the practice reduce the X individual or groups choices? A large number of people are harmed; there is not a general consensus that the tradition is harmful; women are greatly disempowered by the tradition; and it reduces women’s choices. Therefore there is great harm generated by the tradition. Exercise Using the Harmful Traditions Assessment Tool (Exercise Sheet 3.3), complete an assessment on a tradition you think may be harmful. 7 MODULE 3: Understanding the contextual environment Gender First and foremost it must be recognized that the involvement of nurses and midwives in policy development and decision- making is a gender based issue. Gender is significant for two reasons. First, women are disproportionately represented among the most vulnerable population groups. Second, women are the major providers of health care but have the least influence over health policy, planning and decision-making. Nurse and midwives, working in feminised or female dominated professions, also experience disempowerment and subordination with less influence in decision-making, contributing to a reduction in occupational prestige. The feminization of these professions has contributed to a lack of recognition of the intellectual rigor, the clinical judgment and the sound professional knowledge base embodied in these professions. Nurses and midwives have been disadvantaged in the health system but they are slowly claiming and sharing more power and influence. Continued efforts must be directed toward the achievement of gender equity in the health workforce. Women’s access to political and economic power is not commensurate with their numbers, their needs or their contributions as citizens. Some do exercise considerable influence within their own families and communities but many do not have formal power in the arenas where important decisions are made. Globally, gender disparities in economic and political life, calculated by indices such as gender empowerment measures (GEM),1 reflect the inequality in political and economic opportunities for women. The closer a country’s GEM value is to 1, the more empowered women in that country are relative to men. Notably, only nine out of seventy-eight countries ranked have GEM values higher than 0.8, indicating that much progress remains to be made toward achieving full empowerment of women. In some countries, these gender inequalities in power continue to be reflected in the discriminatory nature of the law. Many women, for example, are denied the right to manage their own property, to travel abroad, or to control their own fertility. Gender is the culturally specific set of characteristics that identifies the social behaviour of women and men and the relationship between them. 1GEM is a composite measure of parliamentary and legislative shares of seats held by women, female and professional techni- cal workers and gender disparity in earned income. 8 MODULE 3: Understanding the contextual environment Example The executive management team of a health department is considering a draft policy on the transmission of health information. The draft document assumes that all health information will be available on the Internet and provides no alternative. A gender analysis which applied a set of easy questions would show the following: Question What it does What it should do Who is the target of the proposed policy? People who want health information who have access to the Internet It should be the community at large, and in particular those who do not have easy access to current information [e.g. rural and remote communities, people with vulnerable health status (usually the poor and the elderly), and culturally and linguistically diverse people]. Who will benefit? People with computer access All those people in the community who have a need for health information Who will lose? People without computer access (who will likely be those who are in most need of the health information) Have women been consulted on the proposed solution? Likely they have not been consulted. As the primary care givers, they would likely have recommended that a range of communication options should be provided. This gender analysis process does not discriminate against men. It discriminates in favour of those in need. It not only shows the deficiencies in the policy, but also provides a way forward for overcoming the deficiencies. Gender analysis can help ensure provision of services that both men and women want and that are appropriate to their circumstances. Gender analysis leads to informed policy-making and good governance. Exercise Apply the Gender Analysis Tool (Exercise Sheet 3.4) to the issue you have selected. 9 MODULE 3: Understanding the contextual environment Risk Risk assessment is a discipline for dealing with the possibility that some future event will cause harm. It provides strategies, techniques, and an approach to recognizing and confronting any threat faced by an organization in fulfilling its mission. A risk is any uncertainty about a future event that threatens your organization’s ability to accomplish its mission. The greater the level of uncertainty in the health industry environment, the greater the need for risk management. Generally risks fall into the following categories: • People • Environment and property • Finance • Reputation There are many benefits to implementing risk management procedures. Some of these include • More effective strategic planning • Better cost control • A systematic, well-informed and thorough method of decision-making • Minimized disruptions • Better utilization of resources Risk assessment may be as uncomplicated as asking and answering three basic questions: • What can go wrong? • What will we do (both to prevent the harm from occurring and in the aftermath of an “incident”)? • If something happens, how will we pay for it? These priorities are now categorized according to the response required: Accept; Avoid; Control; Transfer There are a number of options available when determining a response to any risk that has been diagnosed. They include: • Avoidance: Use an alternate approach that does not have the risk. This mode is not always an option. There are programmes that deliberately involve high risks in the expectation of high gains. However, this is the most effective risk management technique if it can be applied. RISK is defined as the possibility of loss, injury, disadvantage or destruction. It is the likelihood that an event or action may have a negative impact upon organizational and/or operational goals and objectives. 1 0 MODULE 3: Understanding the contextual environment T T Example Ask the question ‘what can go wrong in this situation which might have an impact on people, the environment, the infrastructure, or our reputation?’ After making a list of what can go wrong, the risks are prioritized by placing the risk on the Risk Prioritization Matrix Tool (Exercise Sheet 1.3) according to the degree of probability of it occurring and the degree of impact that it would have. 10 High impact x x x x 0 x x 10 Low x High probability x 0 Low The risks you must attend to fall into the High impact/High probability quadrant. • Control: involves the development of a risk reduction plan and then following the plan. The key for successful risk control is the involvement of experienced persons in the risk reduction planning process. • Acceptance: Simply accept the risk and proceed. A risk may be accepted in order to realize an opportunity. Acceptance is not the same as “do-nothing” strategy: a rationale for why the risk has been accepted is required. Ongoing monitoring of accepted risks permits preventive or risk reduction measures to be implemented if necessary2. • Risk transfer: Sometimes it is possible to transfer the risk to a programme unit or organization outside the project best placed to manage it. For example, a risk may be transferred through the use of external consultants with greater technical expertise or the outsourcing of a service. 2Microsoft Solutions Framework, White Paper. MSF Risk Manage- ment Discipline vol 1.1, June,2002, http://www.microsoft.com/msf. 1 1 MODULE 3: Understanding the contextual environment Exercise Apply the Risk Prioritization Tool (Exercise Sheet 3.5) to the issue you are working with. You now have an understanding of the environment in which you will be advocating. You have assessed your values and those of other key stakeholders. You have also assessed the ethics, traditions and gender issues associated with your problem. References • Brown B., Model for Ethical Analysis of a Case Study, 1996 ( www.chass.utoronto.ca/ philosophy/phlwrite.brown2.html). • Center for Development and Population Activities, Gender Equity Concepts and Tools, 1996. • Discovering and Uncovering Values: Pathways of values clarification (www.help- yourself.com/values/intro_values.htm). • Gender and Development Research Centre ( www.gdrc.org/gender/framework/ framework.html). • Johns Hopkins Bloomers School of Public Health Center for Communication Programmes, Questionnaire for values clarification, 2002 (www.jhuccp.org/research/ down;oad/Valuesinstrument.pdf). • Josephson Institute of Ethics, The seven-step path to better decisions, 2002 (www.josephsoninstitute.org/MED/MED_4sevensteppath.htm ). • Markula Center for Applied Ethics, A framework for ethical decision-making, 2004 (www.scu.edu/ethics/practicing/decision/framework.html ). • Resource Centre for Adolescent Pregnancy Prevention (www.etr.org/recapp/theories/ mip/index5.htm) • United Nations Development Programme. Human Development Report 2004: Cultural Liberty in Today’s Diverse World. New York: United Nations Development Programme, 2004. 1 2 MODULE 3: Understanding the contextual environment INFORMATION SHEET 3.1 INTERNATIONAL COUNCIL OF NURSES CODE OF ETHICS FOR NURSES Preamble Nurses have four fundamental responsibilities: to promote health, prevent illness, restore health and alleviate suffering. The need for nursing is universal. Inherent in nursing is respect for human rights, including the right to life, to dignity and to be treated with respect. Nursing care is unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, nationality, politics, race or social status. Nurses render health services to the individual, the family and the community and coordinate their services with those of related groups. Elements of the Code Nurses and people The nurse’s primary professional responsibility is to people requiring nursing care. In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected. The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment. The nurse holds in confidence personal information and uses judgement in sharing this information. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse also shares responsibility to sustain and protect the natural environment from depletion, pollution, degradation and destruction. 1 3 MODULE 3: Understanding the contextual environment Nurses and practice The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning. The nurse maintains a standard of personal health such that the ability to provide care is not compromised. The nurse uses judgement regarding individual competence when accepting and delegating responsibility. The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence. The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people. Nurses and the profession The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. The nurse is active in developing a core of research-based professional knowledge. The nurse, acting through the professional organization, participates in creating and maintaining equitable social and economic working conditions in nursing. Nurses and co-workers The nurse sustains a cooperative relationship with co-workers in nursing and other fields. The nurse takes appropriate action to safeguard individuals when their care is endangered by a co-worker or any other person. 1 4 MODULE 3: Understanding the contextual environment FACILITATOR’S GUIDE – ASSESSING CONTEXTUAL ISSUES: VALUES, ETHICS, TRADITIONS, GENDER, AND RISKS Facilitator’s preparation time: 60 minutes Group exercise time: 90 minutes Resources: Exercise Sheets 3.1 - 3.5 Information Sheet 3.1 Butcher paper, white board or black board Pens/pencils/paper Instructions: • The exercise is best done with no more than 20 people. • Read Module 3, Session 5 and go through each of the exercises. • Familiarize yourself with the Exercise Sheets and Information Sheets. • Make sure you have enough copies of the Exercise Sheets for each participant. • Make sure that you have the resources you need, e.g. pre-prepared butcher paper. • Introduce the topic and explain the objectives of the exercise. • Make certain that everyone in the group has a full understanding of the problem being considered. • Begin with Exercise Sheet 3.1. This exercise will assist the group to clarify the values held by the group and the stakeholders in order to plan a course of action which takes into account the values of those involved. 1 5 MODULE 3: Understanding the contextual environment • Then use Exercise Sheet 3.2, which will guide the group in determining how important an ethical issue is and gives some indication as to whether it has the potential to be an unethical act or decision. This may not be relevant to the group’s problem. • Then use Exercise Sheet 3.3 to guide the group in determining how harmful a tradition is and gives some indication as to whether existing formal or informal policy supports a harmful tradition. Again, this may not be relevant to the problem being addressed, • Now go to Exercise Sheet 3.4 to determine the gender based issues that might have an impact on policy and need to be taken into account when advocating for the change the group wants. This exercise will always need to be done. • Finally, use Exercise Sheet 3.5 to guide the documentation of all the risks associated with the problem and assists in determining the degree of probability of a risk occurring and the extent of the impact. This completes Module 3, Session 5 1 6 MODULE 3: Understanding the contextual environment EXERCISE SHEET 3.1 VALUES CLARIFICATION CHECK LIST What is it? The Values Clarification Check List is a tool which assists with the clarification and documentation of ascribed values. Who uses it? An individual or small group. Why use it? To clarify the values held so as to plan a course of action which takes into account the values of the individual, group, community or organization. How to use it: 1. Select the 10 statements, which you relate to more than any other statements and then select your top 5 values . 2. Select what you think might be the values of the individual, group, community, organization you may have to work with. ACHIEVEMENT (sense of accomplishment) ADVANCEMENT (moving forward in your career through promotions) ADVENTURE (work which frequently involves risk taking) AESTHETICS (involved in studying or appreciating the beauty of ideas, things, etc.) AUTONOMY (determine the nature of your life/work without significant direction from others) CARING (love, affection) CHALLENGE (stimulates full use of your potential) CHANGE & VARIETY (varied, frequently changing responsibilities and/or settings) COMPETITION (pit your abilities against others with clear win/lose outcomes) COOPERATION (opportunity to work as a team toward common goals) CREATIVITY (being imaginative, innovative) ECONOMIC SECURITY (having enough money) 1 7 MODULE 3: Understanding the contextual environment EXCITEMENT (experience a high degree of excitement in life) FAMILY (being able to spend quality time with immediate and extended family) FRIENDSHIP (develop close personal relationships) HEALTH (physical and psychological wellbeing) HELP OTHERS (a direct way, individually or in a group.) HELP SOCIETY (do something to contribute to the betterment of the world) INNER HARMONY (being at peace with oneself) INTEGRITY (sincerity and honesty) INTELLECTUAL STATUS (be regarded as an expert in your field) KNOWLEDGE (understanding gained through study and experience) LEADERSHIP (influence over others) LEISURE (have time for hobbies, sports, activities and interests) LOYALTY (steadfastness and allegiance) PLEASURE (enjoyment) POWER (authority) PRECISION (work in situations where there is little tolerance for error) RESPONSIBILITY (being accountable for results) RECOGNITION (getting acknowledged for your contribution) STABILITY (lifestyle and work largely predictable with little change SPIRITUALITY WEALTH (profit, gain, making a lot of money) WISDOM (understanding based on accumulation of knowledge) (You may wish to add values that are not listed here. This list is not exhaustive.) 3. Compare your values with those of the other and note any differences. Own values Values of other/s Summary of differences ___________________________ _________________________________________________ _________________________________________________ Develop strategies for minimizing the differences _________ _________________________________________________ _________________________________________________ 1 8 MODULE 3: Understanding the contextual environment EXERCISE SHEET 3.2 ETHICS INTENSITY ASSESSMENT TOOL What is it? The Ethics Intensity Assessment Tool is a technique to determine how important an ethical issue is and gives some indication as to whether it has the potential to be an unethical act or decision. Who uses it? An individual or group. Why use it? To assess the intensity of an ethical issue. When to use it? To test the ethical status of an issue or a response to an issue. How to use it: 1. If this exercise is being done with a group, explain the objective to the group. 2. Define the problem or issue you will be discussing and apply the questions below to the problem/issue. Low Medium High How great a harm (or good) is done to the recipients of the act in question? How much consensus is there that the act is harmful (or good)? What is the probability that the act will actually take place and will cause the harm (or benefit) predicted? What is the length of time between the act in question and its expected consequences? How close to you feel (socially, psychologically or physically) to the recipients of the harmful (beneficial) act in question? 1 9 MODULE 3: Understanding the contextual environment 3. Clarify the responses and summarize them. Summary of response: __________________________________ ________________________________________________ __________________________________________________ _________________________________________________ If necessary develop action plan for overcoming any ethical issues highlighted by this assessment exercise. Issue Action The larger the number of people harmed; the greater the consensus that the act is evil; the higher the probability that an act will take place and actually cause harm; the shorter the time until the consequences of the act surface: and the closer the observer feels to the recipients of the act, the greater the issue intensity. The sum of these characteristics determine how important an ethical issue is and gives some indication as to whether it has the potential to be an unethical act or decision. 2 0 MODULE 3: Understanding the contextual environment EXERCISE SHEET 3.3 HARMFUL TRADITIONS ASSESSMENT TOOL What is it? The Harmful Traditions Assessment Tool is a technique to determine how harmful a tradition is and gives some indication as to whether existing formal or informal policy supports a harmful tradition. Who uses it? An individual or group. Why use it? To assess the level of harm of a tradition. How to use it: 1. If this exercise is being done with a group, explain the objective to the group. 2. Define the problem or issue you will be discussing and apply the questions to the issue. 3. Clarify the responses and summarize them. Low Medium High How great a harm is done to the individual or group by the continuance of the traditional practice? What is the level of agreement that the practice is harmful? To what extent does the traditional practice disempower the individual or group? To what extent does the practice reduce the individual or groups choices? Summary of response _____________________________ _________________________________________________ _________________________________________________ 2 1 MODULE 3: Understanding the contextual environment If necessary, develop action plan for overcoming any issues highlighted by this assessment exercise. Issue Action The larger the number of people harmed; the greater the consensus that the tradition is harmful; the greater the extent of disempowerment of a group by the tradition; and the higher the likelihood that the tradition reduces an individual or group’s choice the greater the harm generated by the tradition. 2 2 MODULE 3: Understanding the contextual environment EXERCISE SHEET 3.4 GENDER ANALYSIS TOOL What is it? Gender Analysis is a tool to assist in systematically integrating gender considerations into the policy, planning and decision-making processes. Who uses it? An individual or small group. Why use it? To determine the gender based issues that impact on policy and need to be taken into account when developing policy. When to use it? During a strategic analysis process. How to use it • If this exercise is being done with a group, explain the objective to the group. • Define the problem/issue/policy you will be discussing and apply the questions to it. • Clarify the responses and summarise them. Who is the target of the proposed policy, programme or project? Who will benefit? Who will lose? Have women been consulted on the ‘problem’ the intervention is to solve? How have they been involved in the development of the ‘solution’? Does the intervention challenge the existing gender division of labour, tasks, responsibilities and opportunities? What is the best way to build (and strengthen) the government’s commitment to the advancement of women? What is the relationship between the intervention and other actions and organizations – national, regional or international? Where do opportunities for change or entry points exist? And how can they be best used? 2 3 MODULE 3: Understanding the contextual environment What specific ways can be proposed for encouraging and enabling women to participate in the policy/programme/ project, despite their traditionally more domestic location and subordinate position? What is the long-term impact in regard to women’s increased ability to take charge of their lives, and to take collective action to solve problems? Summary of results ________________________________ _________________________________________________ __________________________________________________ If necessary develop an action plan for overcoming any issues highlighted by this assessment exercise. Issue Action 2 4 MODULE 3: Understanding the contextual environment EXERCISE SHEET 3.5 RISK PRIORITIZATION TOOL What is it? The Risk Prioritization Tool guides the documentation of all the risks associated with a problem/issue/policy/plan/project and assists in determining the degree of probability of a risk occurring and the extent of the impact. Who uses it? An individual or group. Why use it? To determine the best course of action to take given the priorities diagnosed. When to use it? During a strategic analysis process. How to use it • If this exercise is being done with a group, explain the objective to the group. • Define the problem/issue you will be discussing. Problem definition _________________________________ __________________________________________________ • Brainstorm (See Exercise Sheet 1.2) the risks which you think relate to the problem/issue/policy. Risks Degree of probability Degree of impact 1-5 1-5 1 2 3 4 2 5 MODULE 3: Understanding the contextual environment • Assess the degree of impact and the probability of the risk occurring for each of the risks that have been listed on a scale of 1-5 with 1 being the least and 5 being the most. • Now mark them on the chart. For example, if risk number 1 has a probability of occurring of 4 and an impact level of 4 then it will be placed as set out below. • Clarify the responses and summarize them. • List the risks according to the quadrant they fell into. The risks which you should attend to fall into the High impact/ High probability quadrant and may also fall into the Low impact/High probability quadrant. High impact/ Low impact/ High impact/ Low impact/ High probability High probability Low probability Low probability The priorities in the first two columns are now to be categorized according to the response required: Accept; Avoid; Control; or Transfer by placing a in the appropriate response column. Priority Accept Avoid Control Transfer A risk management plan can now be developed. 5 Impact 5 Probability 4 4 321 1 3 2 6 MODULE 3: Understanding the contextual environment 2 7 MODULE 3: Understanding the contextual environment 2 8 MODULE 3: Understanding the contextual environment
i MODULE 2: Identifying and analysing the stakeholders and establishing networks i i MODULE 2: Identifying and analysing the stakeholders and establishing networks i i i MODULE 2: Identifying and analysing the stakeholders and establishing networks CONTENTS MODULE 2: IDENTIFYING AND ANALYSING THE STAKEHOLDERS AND ESTABLISHING NETWORKS Objectives 1 Session 3 2 Introduction to stakeholder analysis 2 The stakeholders 2 Identifying the stakeholders and creating a list 3 Drawing out stakeholders’ interests in relation 3 to the project Assessing the influence and importance of 5 stakeholders Combining influence and importance in a matrix 6 diagram Identifying assumption and risks about stakeholders 7 Identifying appropriate stakeholder participation 8 Session 4 9 Introduction to networking 9 The networks 9 Self-leadership 10 Effective relationships: the relationships audit 10 Networking: the networks audit 11 References 13 Skill sheet 2.1 - Self-leadership 14 Skill sheet 2.2 - Developing and maintaining 16 relationships Skill sheet 2.3 - Networks and networking 18 Facilitator’s guide - Stakeholder analysis 21 i v MODULE 2: Identifying and analysing the stakeholders and establishing networks Exercise sheet 2.1 - Stakeholder listing tool 23 Exercise sheet 2.2 - Stakeholder interest tool 25 Exercise sheet 2.3 - Stakeholder influence and 26 importance tool Exercise sheet 2.4 - Stakeholder clarification tool 27 Exercise sheet 2.5 - Stakeholder risk assessment 29 tool Exercise sheet 2.6 - Summary stakeholder participation matrix tool 31 Facilitator’s guide - Networking 33 Exercise sheet 2.7 - Self-leadership skills audit tool 34 Exercise sheet 2.8 - Relationship audit and 36 planning tool Exercise sheet 2.9 - Network audit tool 37 1 MODULE 2: Identifying and analysing the stakeholders and establishing networks MODULE 2 IDENTIFYING AND ANALYSING THE STAKEHOLDERS AND ESTABLISHING NETWORKS Objectives Upon completing this session, the reader should be able to: Identify key stakeholders and assess their interests and influence Develop a stakeholder participation strategy Understand the elements of self-leadership Understand the skills required for developing effective relationships Identify existing networks Establish appropriate networks 5 5 5 5 5 5 MODULE 2 Identifying and Analysing the Stakeholders and Networks MODULE 5 Managing Communication and the Change Process MODULE 3 Understanding the Contextual Environment MODULE 1 Identifying the Problem and the Desired Outcome MODULE 6 Monitoring and Evaluating the Project MODULE 4 Understanding the Policy, Political and Decision- Making Processes T T T T T T 2 MODULE 2: Identifying and analysing the stakeholders and establishing networks Session 3 Introduction to stakeholder analysis Stakeholder analysis is a technique you can use to identify and assess the importance of key people, groups of people, and institutions that may influence the success of your activity or project. Stakeholder analysis should always be done at the beginning of a project, even if it involves simply making a quick list of stakeholders and their interests. You can use this technique alone or with your team members. However, a team approach is likely to be more effective than an individual doing the analysis alone. The type and scale of the project, and the complexity of the issues, will determine how much time you should devote to this task. The stakeholders Findings can provide early and essential information about: • Who will be affected • Who could influence the process or outcomes • Which individuals, groups or organisations need to be involved; and • Whose capacity needs to be enhanced to enable them to participate. Stakeholder analysis helps assess a project environment, and to determine how best to negotiate during discussions about the project. More specifically, doing a stakeholder analysis can: • draw out the interests of stakeholders in relation to the problems which the project is seeking to address (at the identification stage) or the purpose of the project (once it has started); • identify conflicts of interest between stakeholders, which will influence the assessment of a project’s riskiness; • help to identify relations between stakeholders which can be built upon, and may enable “coalitions” of project sponsorship, ownership and cooperation; and • help to assess the appropriate type of participation by different stakeholders, at successive stages of the project. STAKEHOLDERS: are persons, groups or institutions with interests in a project or policy or who may be directly or indirectly affected by the process or the outcome. KEY STAKEHOLDERS: are those who can significantly influence, or are important to the success of the project. 3 MODULE 2: Identifying and analysing the stakeholders and establishing networks Identifying the stakeholders and creating a list Stakeholders can be listed and categorized in various ways. However a simple list of those who have an interest in the issue is a good starting point. (See Exercise Sheet 2.1.) Example Using the Health Centre Case Study, a brainstorming session was held with fellow staff members and a representative from the professional association. Based on this discussion, a list of stakeholders was developed. The checklist was used to ensure that the list was comprehensive. The list of stakeholders included the following: Stakeholders: Clients Department Head Clients’ families Union Local community Professional association Staff – Nursing Other local health services Staff - Others Other health services in similar position Management of centre Department Chief Nurse Local politician Minister of Health Local media Local general medical practitioners Exercise Using the Stakeholder List (Exercise Sheet 2.1) record the likely stakeholders in your project. Drawing out stakeholders’ interests in relation to the project The list of stakeholders forms the basis for identifying the interest each stakeholder has in the project, and the project’s likely impact on them. By going through the checklist provided below, the interest each stakeholder has in the project can be identified. The likely or actual impact of the project on these interests should be assessed. (See Exercise Sheet 2.2) 4 MODULE 2: Identifying and analysing the stakeholders and establishing networks Example Stakeholder Interest Clients Have a very strong interest but not a cohesive group. Clients families Have a very strong interest but not a cohesive group. Local community Have a very strong interest but not a cohesive or informed group. Staff – Nursing All the nursing staff are affected but a few of them do not want to get involved. Staff - Others There is some self-interest here. Some of the staff just want the problem to go away and do not want to get involved. Management of centre Want the problem to go away. Not interested in change since the health centre is now operating within its budget. Concerned that change will bring more trouble. Local politician Is indifferent at the moment but an election is coming up. Local media Not much interest at the moment but if given the right information at the right time (election) could be very interested. Department Head Has been told to sort out the budget problem. Has done this so does not want the problem revisited at all. Union Interested but has bigger issues elsewhere at the moment. Professional association Interested but has limited resources. Other local health services Have an interest as clients are starting to move to use their services, and are therefore putting pressure on their resources. Other health services in Have a stake in the project being a similar position success therefore may be interested. Department Chief Nurse Can provide covert support but has a conflict of interest. Minister of Health This project may not be a priority but an election is coming up so may wish to have this issue resolved quickly. Local general medical Have to deal with disgruntled clients practitioners therefore they may provide some support to the project. Exercise Using the Stakeholder Interest Tool (Exercise Sheet 2.2) record the interests of the stakeholders. 5 MODULE 2: Identifying and analysing the stakeholders and establishing networks Assessing the influence and importance of stakeholders Key stakeholders are those who can significantly influence, or are important to the success of, the project. Influence is the power which stakeholders have over a project - to control what decisions are made, facilitate its implementation, or exert influence which affects the project negatively. Influence is perhaps best understood as the extent to which people, groups or organizations (i.e. stakeholders) are able to persuade or coerce others into making decisions and follow certain courses of action. Importance indicates the priority given by you to satisfying stakeholders’ needs and interests through the project. Importance is likely to be most obvious when stakeholder interests in a project converge closely with your objectives. (See Exercise Sheet 2.3) Example A group brainstormed the likely influence and importance of the listed stakeholders in the Health Centre Project Stakeholder Interest Influence Importance As per U=Unknown U=Unknown exercise 3.2 1=Little/no 1=Little/no influence influence 2=Some influence 2=Some influence 3=Moderate 3=Moderate influence influence 4=Significant 4=Significant influence influence 5=Very influential 5=Very influential 1. Clients 2 5 2. Clients families 2 5 3. Local community U 5 4. Staff – Nursing 3 5 5. Staff - Others U 2 6. Management of centre 4 2 7. Local politician 4 2 8. Local media 4 2 9. Department Head 5 1 10. Union 2 3 11. Professional association 3 5 12. Other local health services 3 4 13. Health services in similar position 3 4 14. Department Chief Nurse 2 5 15.Minister of Health 5 2 16.Local general medical practitioners 4 2 6 MODULE 2: Identifying and analysing the stakeholders and establishing networks Exercise Using the Stakeholder Influence and Importance Tool (Exercise Sheet 2.3) record the influence and importance of the stakeholders. Combining influence and importance in a matrix diagram Importance and influence can be combined by using a matrix diagram. This is done by positioning stakeholders in relative terms according to the two broad criteria in a two by two matrix. This exercise in positioning will indicate relative risks posed by specific stakeholders, and the potential grouping of support for the project. (See Exercise Sheet 2.4) Example Taking the information from the Stakeholder Influence and Importance Tool, the group brainstormed the relative position of each of the stakeholders on the project. Importance A 3 1;2;14 5 4;11 B 12;13 10 0 5 Influence Influence 5 16 6;7;8 15 9 D 0 C Importance Exercise Using the Stakeholder Matrix Clarification Tool (Exercise Sheet 2.4), position each of the stakeholders you have listed according to the degree of influence and importance you think they have. 7 MODULE 2: Identifying and analysing the stakeholders and establishing networks The stakeholders which fall into Boxes A, B and C are the key stakeholders of the project - those who can significantly influence the project, or are most important if the objectives are to be met. For the implications of each box see Exercise Sheet 2.4. Identifying assumptions and risks about stakeholders Process projects are often particularly affected by stakeholder interactions and responses to project activities. Advocates must therefore identify (and assess the importance of) the most plausible assumptions about each “key” stakeholder which are necessary if you are to be successful. By assessing the influence and importance of key stakeholders, some risks emerge from the matrix diagram. These key stakeholders may be able to “block” the project, and if this is probable, there is a risk that they could have a negative impact on the project or effectively stop it from being implemented. For the checklist for drawing out assumptions about (and risks deriving from) stakeholders see Exercise Sheet 2.5. Example The group considered the Stakeholder Clarification Tool and assessed the relative risks associated with each of the stakeholders. Stakeholder Degree of Risk - 0 + 1. Clients - 2. Clients families - 3. Local community - 4. Staff – Nursing — 5. Staff - Others 0 6. Management of centre ++ 7. Local politician ++ 8. Local media ++ 9. Department Head ++ 10. Union - 11. Professional association — 12. Other local health services — 13. Other health services in similar position — 14. Department Chief Nurse - 15. Minister of Health ++ 16. Local general medical practitioners ++ Exercise Using the Stakeholder Risk Assessment Tool (Exercise Sheet 2.5) record your assessment of the degree of risk associated with each of the stakeholders. 8 MODULE 2: Identifying and analysing the stakeholders and establishing networks Identifying appropriate stakeholder participation Stakeholder analysis can help determine how the key stakeholders can be included in the project. Note that “key” refers to high importance, high influence, or both. Key stakeholders with high influence and importance to the project’s success could provide the basis of the project’s “coalition of support”, and are potential partners in planning and implementation. Conversely, key stakeholders with high influence, but with low importance to the project’s success may be “managed” by being consulted or informed. (See Exercise Sheet 2.6) Example The group then developed participation plans for each of the key stakeholders. Examples of these plans are: Local politician Inform Consult Partnership Planning “ Implementation “ Monitoring and Evaluation “ Other local health services Inform Consult Partnership Planning “ “ Implementation “ Monitoring and Evaluation “ Exercise Using the Summary Stakeholder Participation Matrix Tool (Exercise Sheet 2.6) record your consideration of how and when the key stakeholders should be involved in the process. Findings from a stakeholder analysis are already recorded in the tables and matrix diagrams, and the risks and assumptions arising from the analysis should be included in the project plan. In addition, the analysis should have contributed to a participation matrix that is used to explain the project’s design. These records of the analysis are the basis for revision as the project’s development progresses. Congratulations - You have now completed your stakeholder analysis! 9 MODULE 2: Identifying and analysing the stakeholders and establishing networks Session 4 Introduction to networking You have defined your problem or issue, you have accessed the evidence you need to support your case, and you have completed an analysis of the stakeholders who can either help or hinder your progress. You are ready to proceed, but you should not proceed alone. To be effective, you should join friends and colleagues, and even opponents, to achieve your objective. This session will address: • Self-leadership attributes • Effective relationships • Networking The networks Networking is a valuable tool for gathering information. Information is helpful for those who want to advance along their career path, as well as for those who wish to remain where they are. Information is useful to learn about changes in the employment setting that will have an impact on a nurse’s practice, job opportunities, upcoming professional events, and more. Obtaining information about professional activities can be of invaluable assistance to you in advocating for change. Your networks partly control and shape your position within your profession, workplace or social setting. You can negotiate your way through any system or structure by having or establishing a variety of acquaintances and relationships on multiple levels. But to establish or be an effective member of a network, you need to understand what is required for developing and maintaining effective relations. If it is your intention to influence a network then you must have some understanding of your personal leadership skills. The “old boys” networks were not established overnight. They were built on schooldays spent together, competition in the sporting arena, common social and business experiences, and of course at all stages, built on mutual experiences and mutual benefit. What can be learned from these phenomena? You do not have a life time to develop effective relationships. You have perhaps weeks or months! NETWORK Independent elements/ contacts linked to achieve a common product or outcome. NETWORKING “…the process of developing and using your contacts for information, advice and moral support….” MS Welch (1980) 1 0 MODULE 2: Identifying and analysing the stakeholders and establishing networks You need to assess your level of self-leadership. Effective self-leadership involves achieving a balance between focusing on your own identity and values and those of the individual or group you are working with or trying to influence. You need to assess and establish the appropriate relationships before you can effectively influence them to meet your objectives. Self-leadership Self-leadership is the first level of leadership and applies to any person, whether or not they hold a management or supervisory position. Self-leadership is the ability of someone to guide themselves to positive places that they have never been before. It enables a person to fulfil their potential while building a strong foundation from which to make daily decisions, both professionally and personally. For further information see Skill Sheet 2.1. Exercise Using the Self-Leadership Skills Audit Tool (Exercise Sheet 2.7), assess your self-leadership skills and develop a plan for nurturing and developing these skills. Effective relationships: the relationships audit What are the skills necessary for developing effective relationships? There are many types of relationships but you are interested in those that will assist you in achieving your desired outcomes. What you need to do is return to the stakeholder analysis which you have completed and use this information to decide what relationships you need to use and those you might have to develop to achieve your purpose. (See Exercise Sheet 2.8.) SELF-LEADERSHIP The process of leading oneself to establish self- direction and self- motivation to perform. 1 1 MODULE 2: Identifying and analysing the stakeholders and establishing networks Example Applying the Health Centre Case Study, the desired outcome is “Sufficient nursing staff to meet client needs”.. The stakeholder analysis has helped to identify those individuals or groups who are of both ‘high influence’ and ‘high importance’: · Nursing staff · Professional association · Other local health services · Health services in a similar position; and The high risk stakeholders: · Management · Local politician · Local media · Departmental Head · Minister of Health · Local general medical practitioners. This analysis gives you a clear picture of the relationships you need to use and develop. Exercise Take the results of your stakeholder analysis and using Exercise Sheet 2.8, assess which stakeholders you have relationships with and those with whom you do not. For those stakeholders with whom you do not have a relationship, develop strategies for fostering these relationships. For further information see Skill Sheet 2.2 The degree of success you will have in establishing and maintaining networks will be directly related to the level of communication skills you have. For information regarding listening and questioning skills see Skills Sheets 5.1 and 6.1. Networking: the networks audit An effective network can: • Open doors to new opportunities inside and outside your work place. • Provide support when dealing with positive and negative changes in your personal and professional life. • Create a resource pool or skill bank that may help you to round out weak areas or to enhance your effectiveness in new skills or work efforts. • Provide referrals for new career opportunities. For further information about networks, see Skill Sheet 2.3 and see Exercise Sheet 2.9 1 2 MODULE 2: Identifying and analysing the stakeholders and establishing networks Example Using the Health Centre Case Study, and the assessment of the relationships which it would be advisable to establish and maintain, an assessment of the networks involved can be undertaken. Networks Involved Action to be taken Nursing staff Workplace Staff Meetings Social gatherings X Attend next function Committee Meetings X Join a relevant committee. Professional association Professional Assoc activities X Participate in relevant meetings/ activities. Offer to speak at next relevant meeting. Write to the association, bringing their attention to the issues. Other local health services Professional associations Health services associations X As above. Check whether. friends/colleagues belong. Offer to speak at a meeting. Health services in similar Professional associations X As above. position Health services associations Management Workplace Be visible but credible in the Staff meetings workplace. Local politician Political party X No direct action. Are any friends/colleagues members? Local media Not known X Do any friends/colleagues have media contacts? Departmental Head Health services associations X These associations are important so seriously consider joining and becoming very active. Minister of Health Political party X No immediate action. Local general medical Medical college X Do any friends/colleagues practitioners have contacts at the medical college? Exercise Using the Network Audit Tool (Exercise Sheet 2.9), complete an audit of relevant networks and develop an action list (as above). You now have a clear understanding of the self-leadership attributes you need to work on, the relationships you need to develop and the networks you need to access and influence. 1 3 MODULE 2: Identifying and analysing the stakeholders and establishing networks References • Action Research Resources, Resource Papers in Action Research, Australia, 2003 (www.scu.edu.au/schools/gcm/ar/arp/stake.ftml). • AusAID, The Logical Framework Approach, Commonwealth Government of Australia, 2000 (www.ausaid.gov.au/ausguide/ausguidelines/1-2-6.cfm). • Best Practices, LLC Patient Advocacy and Professional Organizations: Building Effective Relationships, 2002 (www.benchmarkingreports.com/salesandmarketing/ sm156_patient_advocacy_groups.asp). • CanadaOne Magazine, Ask-an-Expert: Interpersonal Networking Skills, 2000 (www.canadaone.com/ezine/expert/expert39.html). • Jacobs, S., Stakeholder Analysis: methods and concepts, Slide Presentation and Notes for Workshop Series on Participatory Tools. Mimeo, World Bank, Washington, D.C., January 1996. • Manz CC and Neck CP, “Mastering Self-Leadership: Empowering Yourself For Personal Excellence”, (2nd Edition), Prentice-Hall, (ISBN: 0-13-011087-6), Upper Saddle River, New Jersey, 1999. • Manz CC, The Art of Self Leadership, Simon and Schuster, 1983 (ISBN 0130488356). • Mind Tools (www.mindtools.com/pages/article/newPPM_07.htm). • Overseas Development Administration, Guidance Note on How to Do Stakeholder Analysis of Aid Projects and Programmes, Social Development Department Mimeo, London: ODA. July 1995 (www.enterprise-impact.org.uk/informationresources/ toolbox/stakeholderanalysis.shtml). • Resources for home-based and small businesses, Networking Skills and Strategic Alliances (www.4hb.com/0205index.html). • Wisconsin Public Health Association, Tools to build effective relationships with policy makers (www.wpha.org/legtoolkit.pdf). • World Bank, 2002 Social Analysis Sourcebook, Social Development Department, World Bank, Washington, DC, 2002 (www.worldbank.org/ESSD/essdext.nsf/ 61DocByUnid/5F37FA51B653935E85256BCF0064FFBA?Opendocument). 1 4 MODULE 2: Identifying and analysing the stakeholders and establishing networks SKILL SHEET 2.1 SELF-LEADERSHIP There are a few simple things that you can focus on to assist you to recognize and further develop your self-leadership skills, and they are: Use your gifts We all have gifts, talents, and abilities but are you using them? The only way a person can realize their full potential as a leader is to use their gifts and talents (e.g. patience, compassion, oratory skills, etc.) regularly. This requires a disciplined approach. Do you know what your gifts are? Are you using your gifts every day? Without discipline, the gifts that you have will not reach their maximum potential. Self- leaders develop their gifts with discipline. Reflect and forward your life Self-leaders understand the power of reflection and what it means to their growth potential. To reflect means to step back and learn from what life is revealing to you. This could come in the form of information that you already know or, more importantly, it is information and feedback that comes from other sources. Rather than be quick to defend your position, consider using the gift of feedback to your advantage. Serve others Self-leaders understand the power that is generated from serving and helping others. This can apply to those we serve on the job as well as family members, friends, neighbours, etc. 1 5 MODULE 2: Identifying and analysing the stakeholders and establishing networks Listen Self-leaders capitalize on the power of listening. They listen to what people say, what they do not say, and what they would like to say but do not know how to put into words. When is the last time that you were either involved in or observed a situation in which there was a cost due to a listening breakdown? Be honest Holding back how we “really” feel when communicating with others does more damage to ourselves, as well as to the relationships we have with others. It takes courage and practice to be honest with others in a non-aggressive and non-judgmental manner. Self-leaders have developed the ability to give unconditional and constructive feedback. This is the foundation for an integrity-based style of living. Take calculated risks and focus on success Self-leaders are risk takers. The word “failure” is not part of their vocabulary. They focus on succeeding rather than on not failing. 1 6 MODULE 2: Identifying and analysing the stakeholders and establishing networks SKILL SHEET 2.2 DEVELOPING AND MAINTAINING RELATIONSHIPS In general terms the following is a good guide for developing and maintaining relationships: Make yourself visible to the relevant stakeholders. You should be known and if you are not, get involved with various groups and issues. The more you do, the more contacts you will have. Build personal relationships. Remember that you are dealing with people, not just agencies or organizations. These people will be stronger allies if they know and like you as a person. And keep in mind that building a strong relationship takes time and energy; it will not happen overnight. Focus first on understanding other people’s needs and priorities. Do not start off with what you need. Listen carefully so that you can understand what drives the person or organization you want to enlist for support. Start with the individual — what personally motivates him or her. Similarly, what is the organization’s focus? Think of ways your needs mesh with others’ needs. Look for win-win opportunities. Think of how being involved with your issue can be good for both you and your allies. Keep people informed. People tend to get annoyed when they feel that they have not been adequately informed. Call people, write to people, send out notices — whatever it takes. Avoid surprising people. An added benefit is that when you let people get involved in something at the beginning, they are more likely to want to contribute and continue their involvement. Build a “bank account” of trust and goodwill — and do not make too many “withdrawals”. Keep your word, and do favours for people when asked, if it’s not too burdensome. It’s been said that “what goes around comes around.” If you do what you say you are going to do when you say you are going to do it, people notice. If you help someone out even in a small way, especially if that person is in a difficult situation, they will be likely to return the favour. 1 7 MODULE 2: Identifying and analysing the stakeholders and establishing networks Thank anyone and everyone. Send thank you letters, make phone calls, and recognize your contributors. When in doubt, give people more credit than they deserve. Be polite and patient, even if you have to be persistent. “You can catch a lot more flies with honey than with vinegar.” Civility counts, and is essential for a good relationship. Know who has the power to solve the problem. Often, when people seem to be unresponsive, it is simply that they really can not do anything about the issue you are raising. Unfortunately, people do not always explain that. So be sure to ask if there is anyone else that you (or the person you are talking to) can deal with in order to solve the problem. 1 8 MODULE 2: Identifying and analysing the stakeholders and establishing networks SKILL SHEET 2.3 NETWORKS AND NETWORKING Types of networks Formal: A professional group designed to promote networking among its members. Informal: Personal relationships you have developed over time and can rely on for support. Internal: Professional relationships and contacts developed in the workplace. External: Professional relationships and contacts developed outside the workplace. Preparing yourself to network Assess your skills. What do you have to offer to individuals, groups or organizations? What are your skills, knowledge, and abilities? Believe in yourself. How confident are you in your technical competence? If you were to write a 60 second commercial about yourself, what would you list as your strongest assets? Have clear goals. What are your goals? Are you able to say clearly how a network could support you in reaching your personal or professional goal? Know your style and personality. How comfortable are you in meeting new people? Are you able to talk about your strengths and skills in a confident manner? What environments make you most comfortable meeting and talking with new people? Do you prefer to communicate with people in person, on the telephone or in writing? Do you tend to meet people and not follow up with them? What would help you to keep in contact with each other? 1 9 MODULE 2: Identifying and analysing the stakeholders and establishing networks How to build a network List your personal and professional goals. Write down your goals. Practice saying them aloud so that you are comfortable talking about them with others. List key contacts. Make a list of (1) people who can help introduce you to people who could assist you in meeting your personal or professional goals, (2) people who are doing the type of work you want to do, and (3) people who could possibly offer you work in your professional area. Identify professional organizations. Find out what groups or organizations are already formed that are linked to your professional goals. Find out when meetings occur and check it out for interest. Consider how the goals of the organization or the membership could support you and help you to grow. Demonstrate your expertise. Show people what you are capable of doing. Be willing to volunteer for projects that allow you to demonstrate your knowledge, experience or skill. Demonstrate how you can contribute. Keep business cards current. Keep business cards in an easily accessible place and check periodically for accuracy of information. Set goals to meet and contact new people. Set monthly goals for yourself to meet new people who can expand your network. How to maintain your network Keep in contact often. Let your network know that you are there. Contract with individuals to contact with them monthly, bi-monthly, etc. Give as well as receive. Find out how you can help the members of your network. Networking should involve both giving as well as receiving. Follow up when activity takes place. Be sure to keep your network informed when events of interest take place. Also make sure that you let people know that you are aware of actions they may have taken on your behalf. Show appreciation. Send thank you notes or show your appreciation in other ways when your network does something to help you reach your goals. 2 0 MODULE 2: Identifying and analysing the stakeholders and establishing networks Networking tips Set “networking goals.” Who do you want to add to your network? Why? How will you contact these individuals? Plan on meeting your contacts regularly for breakfast, lunch, dinner or after-work drinks. When you approach a busy individual and ask them to have lunch with you, have an agenda in mind. Be specific about what you want. If they ask what you need to talk about, have a clear and concise response in mind. Create a system for keeping track of your network connections. Keep notes on information gathered and the people who gave it. Make notes about small talk. For example, “What were the results of the mentoring program you developed?” “How did the examinations go for your son?” This makes people feel remembered and engaged when they talk to you. Be generous with your time and information. Networking is a system of IOUs. If people have been helpful to you, be helpful to them and others. Recommend and exchange resources. Pass along book reviews, articles, reports and programme materials. Introduce your contacts to each other and let others know you are interested in meeting new people. Practice mingling and the art of small talk. When attending social functions, do not limit your interaction to one or two people. Do not linger in the corner or stay in one spot. Read newspapers and magazines. Arm yourself with information - facts, opinions, or quotes - that will spark an exchange. Observe networking etiquette. Respect confidentiality. Do not take information you have received and pass it on recklessly. Before giving the name and number of a contact to another person, always ask permission of the third party. Respect other people’s time. When connecting by phone, always ask “Is this a good time to talk?” Remember the rule of “No’s”. The Rule of No’s states that if we ask for what we want, we will get turned down sometimes. Do not take it personally if someone turns down your request for an information meeting or cancels an appointment with you. It is important to be persistent, but not overly so. If you do not get your phone calls returned after three times, or if someone has cancelled a meeting more than once, take them off your list. 2 1 MODULE 2: Identifying and analysing the stakeholders and establishing networks FACILITATOR’S GUIDE – STAKEHOLDER ANALYSIS Facilitator’s Preparation time: 90 minutes Exercise time: 90 minutes Resources: Module 2 and Exercise Sheets 2.1 - 2.6 Butcher paper, white board or black board Pens/pencils/paper Instructions: • The exercise is preferably done with no more than 20 people. • Read Module 2 and go through each of the exercises. • Familiarize yourself with the Exercise Sheets. • Ensure you have enough copies of the Exercise Sheets for each participant in your group and that you have the resources you need, e.g. pre-prepared butcher paper. • Introduce the topic and explain the objectives of the exercise. • Ensure that everyone in the group has a full understanding of the case study being considered for the stakeholder analysis. • Begin with Exercise Sheet 2.1. Using the brainstorming technique, ask participants who they think the stakeholders might be and list all the stakeholders on the butchers paper, white board, or black board. Do not forget to use the checklist provided. • Next go to Exercise Sheet 2.2 and list the interest each of the stakeholders might have in the project. Use the questions on the Exercise Sheet to help the group participants. • Then go to Exercise Sheet 2.3 and rate each of the stakeholders level of interest and influence on a scale of 0 (unknown) to 5 (very influential/critical player). 2 2 MODULE 2: Identifying and analysing the stakeholders and establishing networks • Then go to Exercise Sheet 2.4 and, using the results of Exercise 2.3, place the stakeholder in the appropriate quadrant. • You have now prioritized the stakeholders and you can discard all the stakeholders who are in quadrant D. • Omit Exercise Sheet 2.5 and go to Exercise Sheet 2.6. • For each of the remaining stakeholders, develop a programme of how to include them in each of the advocacy steps. Indicate whether they should be informed, consulted or partnered and the strategies for achieving the outcome. This completes Module 2, Session 3 2 3 MODULE 2: Identifying and analysing the stakeholders and establishing networks EXERCISE SHEET 2.1 STAKEHOLDER LISTING TOOL What is it? The Stakeholder Listing Tool guides the documentation of stakeholders who may have an interest in the project/policy. Who uses it? An individual or group – preferably done with a small group. Why use it? To make a list of those people who either directly or indirectly have an interest in or may be affected by the project/policy. How to use it: • Explain the objective of the exercise to the group. • Clarify the problem/issue/policy/plan/project you will be discussing. • Brainstorm (See Exercise Sheet 1.2) the stakeholders you think have an interest in the project/policy. • Use the checklist below to ensure that you have a comprehensive list. Checklist for identifying stakeholders: • Have all people of organizations who have an interest in the problem or issue been listed? • Have all potential supporters and opponents of the project been identified? • Has gender analysis been used to identify different types of female/male stakeholders? (see Module 5.) • Have the interests of vulnerable groups been identified? • Are there any new stakeholders that are likely to emerge as a result of the project? 2 4 MODULE 2: Identifying and analysing the stakeholders and establishing networks Stakeholder list • Now proceed to Exercise 2.2. Stakeholder Analysis Documentation Sheet Number Stakeholders Stakeholder Stakeholder Stakeholder Degree interest influence importance of risk 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 2 5 MODULE 2: Identifying and analysing the stakeholders and establishing networks EXERCISE SHEET 2.2 STAKEHOLDER INTEREST TOOL What is it? The Stakeholder Interest Tool guides the documentation of interest each of the listed stakeholders might have in the project/policy. Who uses it? An individual or group – preferably done with a small group. Why use it? To assess the impact that stakeholders may have on the project/ policy and the impact it might have on the stakeholders. How to use it • Explain the objective of the exercise to the group. • Brainstorm (See Exercise Sheet 1.2) the interests which you think relate to the problem/issue. • Clarify the responses using the checklist below. Checklist for drawing out interests • What are the stakeholder’s expectations of the problem/ issue? • What benefits are there likely to be for the stakeholders? • What resources will the stakeholder wish to commit (or avoid committing) to the project? • What other interests does the stakeholder have which may conflict with the project? Stakeholders Interest • Now proceed to Exercise 2.3. 2 6 MODULE 2: Identifying and analysing the stakeholders and establishing networks EXERCISE SHEET 2.3 STAKEHOLDER INFLUENCE AND IMPORTANCE TOOL What is it? The Stakeholder Influence and Importance Tool guides you in assessing how powerful a stakeholder is in relation to your project/ policy. Who uses it? An individual or group – preferably done with a small group. Why use it? To determine the extent to which a stakeholder may impact on the process and/or outcomes of the project/policy. How to use it: • Explain the objective of the exercise to the group. • Brainstorm the influence/importance which you think the stakeholders might have on the project/policy according to the following rating scale:1 Influence Importance 1=Little/No influence 1=Little/No importance 2=Some influence 2=Some importance 3=Moderate influence 3=Moderate importance 4=Significant influence 4=Very important 5=Very influential 5=Critical player No. Stakeholders Interest Influence Importance 1 2 3 4 • Now proceed to Exercise 2.4. 1 Influence is the power which stakeholders have over a project - to control what decisions are made, facilitate its implementation, or exert influence which affects the project negatively. Influence is perhaps best understood as the extent to which people, groups or organizations (i.e. stakeholders) are able to persuade or coerce others into making decisions, and follow certain courses of action. Importance indicates the priority given by you to satisfying stakeholders’ needs and interests through the project. Importance is likely to be most obvious when stakeholder interests in a project converge closely with your objectives. 2 7 MODULE 2: Identifying and analysing the stakeholders and establishing networks EXERCISE SHEET 2.4 STAKEHOLDER CLARIFICATION TOOL What is it? The Stakeholder Clarification Tool guides the documentation of all the risks associated with a problem/issue/policy/plan/project and assists in determining the degree of probability of a risk occurring and the extent of the impact. Who uses it? An individual or group – preferably done with a small group. Why use it? To determine the best course of action to take given the priorities diagnosed. How to use it: • Explain the objective of the exercise to the group. • Using the rating scores applied in Exercise Sheet 2.3 for ‘influence’ and ‘importance’ place the number of the stakeholder in the appropriate quadrant e.g. if stakeholder number 1 rated 5 importance and 2 influence they would be placed as shown below. If stakeholder number 2 rated 2 importance and 4 influence they would be placed as shown. Continue until all the stakeholders have been placed in a quadrant. 2 8 MODULE 2: Identifying and analysing the stakeholders and establishing networks • Now proceed to Exercise 16. Quadrant A Stakeholders of high importance to the project, but with low influence. This implies that they will require special initiatives if their interests are to be protected. Develop a strategy for working with these stakeholders. Quadrant B Stakeholders appearing to have a high degree of influence on the project, and who are also of high importance for its success. This implies you will need to construct good working relationships with these stakeholders, to ensure an effective coalition of support for the project. Develop a strategy for working with these stakeholders. Quadrant C Stakeholders with high influence, who can therefore affect the project outcomes, but whose interests are not the target of the project. This conclusion implies that these stakeholders may be a source of significant risk, and they will need careful monitoring and management. Develop a strategy for working with these stakeholders. Quadrant D Stakeholders in this box, with low influence on, or importance to project objectives may require limited monitoring or evaluation, but are of low priority. They are unlikely to be the subject of project activities or management. Remove these from your stakeholder list A D C B 5 1 3 5 1 2 4 4 2 1 2 Influence Importance f c 2 9 MODULE 2: Identifying and analysing the stakeholders and establishing networks EXERCISE SHEET 2.5 STAKEHOLDER RISK ASSESSMENT TOOL What is it? The Stakeholder Risk Assessment Tool guides in recording the relative risk associated with each of the stakeholders. Who uses it? An individual or group – preferably done with a small group. Why use it? To determine the risk levels of the key stakeholders. How to use it: • Explain the objective of the exercise to the group. • Brainstorm (See Exercise Sheet 1.2) the risks which you think relate to each of the stakeholders. • Clarify the responses using the checklist below. Checklist for drawing out assumptions about (and risks deriving from) stakeholders • What is the role or response of the key stakeholder that must be assumed if the project is to be successful? • Are there negative responses which can be expected, given the interests of the stakeholder? • If such responses occur what impact would they have on the project? • How likely are these negative responses to occur, and are they major risks? • In summary, which views about stakeholders support or threaten the project? 3 0 MODULE 2: Identifying and analysing the stakeholders and establishing networks Stakeholder Degree of Risk Example Example - 0 + Stakeholder Degree of Risk - 0 + 1. Clients - 2. Clients families - 3. Local community - 4. Staff – Nursing — 5. Staff - Others 0 6. Management of centre ++ 7. Local politician ++ • The results of this exercise help you workout what strategies you need to put in place to reduce the risks of involving or not involving your stakeholders. • High risk stakeholders need special attention and targeted strategies. • Now proceed to Exercise 2.6. 3 1 MODULE 2: Identifying and analysing the stakeholders and establishing networks EXERCISE SHEET 2.6 SUMMARY STAKEHOLDER PARTICIPATION MATRIX TOOL What is it? The Summary Stakeholder Participation Matrix Tool guides you the documentation the level and nature of involvement you want each of the key stakeholders to have in the project/policy. Who uses it? An individual or group – preferably done with a small group. Why use it? To determine the involvement you want each stakeholder to have so that you can prepare yourself and them for that desired level of involvement. How to use it: • Explain the objective of the exercise to the group. • Brainstorm (See Exercise Sheet 1.2) the proposed level and nature of involvement of the each key stakeholder from the analysis you have completed for the change you want to achieve. • Place a in the box which indicates the highest level of communication, e. g. if partnership is required then it goes without saying that you will need to inform and consult. So you do not need to these boxes. Key stakeholder Inform Consult Partnership Planning Implementation Monitoring and evaluation 3 3 3 2 MODULE 2: Identifying and analysing the stakeholders and establishing networks Key stakeholder Inform Consult Partnership Planning Implementation Monitoring and evaluation Example Key stakeholder Inform Consult Partnership Planning Implementation Monitoring and evaluation Inform: One-way information on the plan and progress. Consult: Seeking the views on the planning, implementation and evaluation. Partnership: This requires joint, active involvement in planning, implementation and/or evaluation. 3 3 3 3 3 MODULE 2: Identifying and analysing the stakeholders and establishing networks FACILITATOR’S GUIDE – NETWORKING Facilitator’s preparation time: 45 minutes Group exercise time: 60 minutes Resources: Exercise Sheets 2.7 - 2.9 Skill Sheets 2.1 - 2.3 Butcher paper, white board or black board Pens/pencils/paper Instructions: • The exercise is best done with no more than 20 people. • Read Module 2, Session 4 and go through each of the exercises. • Familiarize yourself with the Exercise Sheets and Skill Sheets. • Make sure you have enough copies of the Exercise Sheets for each participant in your group. • Make sure that you have the resources you need, e.g. pre-prepared butcher paper. • Introduce the topic and explain the objectives of the exercise. • Make certain that everyone in the group has a full understanding of the case study being considered for stakeholder analysis. • Begin with Exercise Sheet 2.7 and complete the self- leadership skills audit. This will assist the participants to understand their strengths and weaknesses and what action they might need to take. • Then go to Exercise Sheet 2.8 to develop strategies for fostering relationships by applying the list of stakeholders developed in the previous session. • Then go to Exercise Sheet 2.9. This exercise will assist the group to plan the action needed to strengthen networks. This completes Module 2, Session 4 3 4 MODULE 2: Identifying and analysing the stakeholders and establishing networks EXERCISE SHEET 2.7 SELF-LEADERSHIP SKILLS AUDIT TOOL What is it? The Self-leadership Skills Audit Tool guides you in assessing your self-leadership strengths and weaknesses. Why use it? To determine what skills you have and which skills you need to develop. When to use it? At anytime, but particularly before, during and after advocating. How to use it: • Complete a self assessment by ticking the relevant column – be very honest. • Ask a close friend or colleague to use the tool to assess you. • Cross check and validate the results. Leadership attributes Always Frequently Sometimes Never Acts with integrity and in accordance with values, principles and commitments made, even when challenged. Respectfully listens to others Is responsible for own words and actions Commits to working with others Collaborates with diverse groups and individuals Manages and resolves conflict Provides constructive feedback to 3 5 MODULE 2: Identifying and analysing the stakeholders and establishing networks individuals and/or groups Leadership attributes Always Frequently Sometimes Never Recognizes and acknowledges the contributions of others Synthesizes information to bring distinct clarity to a group discussion Proposes creative solutions to problems Communicates clearly and simply Engages in ongoing self-assessment by identifying personal strengths and weaknesses Acknowledges and integrates formal education with experiential learning Integrates continual improvement into all processes Distinguishes risk taking from risky behaviour Teaches, coaches and mentors others • List your 3 greatest strengths and your 3 greatest weaknesses below. Strengths: 1 Weaknesses: 1 2 2 3 3 It is important that you maintain your strengths while you are reducing your weaknesses. Action to be taken _______________________________ _______________________________________________ _______________________________________________ 3 6 MODULE 2: Identifying and analysing the stakeholders and establishing networks EXERCISE SHEET 2.8 RELATIONSHIP AUDIT AND PLANNING TOOL What is it? The Relationship Audit and Planning Tool guides you in targeting those individuals or groups with whom you need to have a relationship. Why use it? To develop a clearly defined set of strategies for developing and maintaining the appropriate relationships. When to use it? Upon completion of a stakeholder analysis and as part of your overall plan of action. How to use it: • Complete a stakeholder analysis (Exercise Sheets 2.1 – 2.6). • List below those stakeholders considered to be of high importance and high influence as well as those who are high risk. • Develop strategies for developing relationships with these stakeholders. Stakeholders Strategies for developing relationships 3 7 MODULE 2: Identifying and analysing the stakeholders and establishing networks EXERCISE SHEET 2.9 NETWORK AUDIT TOOL What is it? The Network Audit Tool assists you assess the extent of stakeholder networks. Why use it? To determine the extent of stakeholder networks and your involvement in those networks. When to use it? When you need to know what networks you need to access in order to influence the appropriate individuals and groups. How to use it: • Complete a stakeholder analysis (Exercise Sheets 2.1 – 2.5). • Take results of the stakeholder analysis and list below those stakeholders you have highlighted as being of high importance and high influence and those who are high risk. • Document the networks they are likely to belong to. • In the INVOLVED column indicate whether you are involved in the network or not. • Document the action you need to take to strengthen your networking with each of your stakeholders. Stakeholders Networks Involved Action to be taken 3 8 MODULE 2: Identifying and analysing the stakeholders and establishing networks
i MODULE 1: Identifying the problem and the desired outcome i i MODULE 1: Identifying the problem and the desired outcome i i i MODULE 1: Identifying the problem and the desired outcome CONTENTS MODULE 1: IDENTIFYING THE PROBLEM AND THE DESIRED OUTCOME Objectives 1 Session 1 2 Introduction to this module 2 The problem 2 Problem description 3 Analysing the problem 4 Prioritizing the problem 5 Assessing your strengths and weaknesses (SWOT) 6 Force field analysis 7 Session 2 8 Introduction to gathering evidence 8 The evidence 8 Accessing information: search focus 10 Search preparation 11 Case development 12 Potential source of information: the information 14 sources audit Appraising the evidence 15 Applying the evidence 16 References 17 Information sheet 1.1 - Data sources 18 Facilitator’s Guide - Defining the problem 22 Exercise sheet 1.1 - Problem description tool 24 Exercise sheet 1.2 - Brainstorming 26 Exercise sheet 1.3 - Prioritization matrix tool 28 i v MODULE 1: Identifying the problem and the desired outcome Exercise sheet 1.4 - SWOT analysis 30 Exercise sheet 1.5 - Force field analysis 32 Facilitator’s Guide - Gathering evidence 34 Exercise sheet 1.6 - Search focus tool 36 Exercise sheet 1.7 - Search preparation tool 37 Exercise sheet 1.8 - Case development tool 39 Exercise sheet 1.9 - Information source audit tool 41 Exercise sheet 1.10 - Information analysis tool 43 Exercise sheet 1.11 - Case documentation tool 45 1 MODULE 1: Identifying the problem and the desired outcome MODULE 1 IDENTIFYING THE PROBLEM AND THE DESIRED OUTCOME Objectives Upon completing this session, the reader should be able to: Identify and define the problem Use a problem solving approach to generate a solution Carry out a force field and SWOT analysis Find, appraise and apply the evidence 5 5 5 5 MODULE 2 Identifying and Analysing the Stakeholders and Networks MODULE 5 Managing Communication and the Change Process MODULE 3 Understanding the Contextual Environment MODULE 1 Identifying the Problem and the Desired Outcome MODULE 6 Monitoring and Evaluating the Project MODULE 4 Understanding the Policy, Political and Decision- Making Processes T T T T T T 2 MODULE 1: Identifying the problem and the desired outcome Session 1 Introduction to this module Defining a problem so that it is relevant to decision-makers begins with awareness that a problem exists or, more specifically, that there is a difference between the actual and desired state of affairs. It is essential for the advocate for change to be very clear about what the problem really is. To go forward not being clear or not having analysed the problem will send you, the advocate for change, on the wrong solution path. Following an analysis of the problem, you will be ready to consider the range of solutions available to you. This task will be aided by the use of a number of tools and this module will provide you with some examples and exercises. The problem Problem identification is not a simple task. Also, one person’s problem is another person’s satisfactory state of affairs. A problem occurs when there is a difference between “what should be” and “what is”, between the ideal and the actual situation. A problem: • expresses the difference between the hoped for and the actual situation; and • is directly or indirectly related to the health of the population. Before something can be said to be a problem, you have to: • be aware of the discrepancy; • be under pressure to take action; and • have the resources necessary to take action. How do you become aware you have a discrepancy? You have to make a comparison between the current state of affairs and some standard. What is that standard? It can be past performance, previously set goals, or the performance of some other unit within the organization or in other organizations. The problem must also be such that it puts some type of pressure to act. Pressure might include organizational policies, deadlines, financial crises, complaints, expectations from management, a proposed change or a continuing community demand. DEFINITION: A problem is a discrepancy between an existing and a desired state of affairs. 3 MODULE 1: Identifying the problem and the desired outcome Finally, you are not likely to describe something as a problem if you think that you do not have the authority, budget, information or other resources necessary to act on it. When you believe you have a problem and are under pressure to act, but feel you have inadequate resources, you usually describe the situation as one in which unrealistic expectations are being placed on you. Problem description Before attempting to solve a problem, you need to describe it in detail. You do this so you can understand how the problem affects the process being examined, such as delivery of a health service to a community. (See Exercise Sheet 1.1) Example: Health Centre Case Study A health centre receives complaints from users regarding the quality of the services. A discrepancy exists between the numbers of complaints currently being received in comparison to the previous year. The number of complaints is now reaching a volume that is unacceptable. How frequently does the problem occur? Verbal and written complaints are being received on a daily basis. When does it generally occur? It appears to have started following a reduction in staffing levels. Where does it generally occur? The location is not relevant to this situation. Who is most affected? Obviously the users are, but so are the staff as they are becoming quite agitated by the complaints and the workload they are experiencing. The problem can therefore be summarized as: Patient dissatisfaction, affecting both patients and staff, which appears to have started following a reduction in staff. Exercise Consider a problem that you have experienced recently and using the Problem Description Tool (Exercise Sheet 1.1) describe the problem more accurately. 4 MODULE 1: Identifying the problem and the desired outcome Analysing the problem Now that you have described the problem, you can move on to analysing it. To act most effectively, you should analyse its causes and prioritize the most important factors. Acting on those critical causal factors will solve most of the problem. It is suggested that you use the brainstorming technique. (See Exercise Sheet 1.2). Example: You are concerned about the quality of services provided at the health centre in which you work. You need assistance in defining and analysing the problems. As a first step in identifying the problems that are affecting the quality of the services offered through a health centre, you can conduct a brainstorming session with users chosen randomly from the health centre. You are in charge of the brainstorming session. Put some users in a room together with members of staff, and ask them the following question: “In your opinion, what are the problems of quality that the health centre is facing?” You ask them to take a few minutes to think to themselves about this issue, and assure them that there are no right or wrong answers. Next, each participant states his or her ideas, one at a time, and you write the ideas on a large piece of paper so everyone can see them. The participants add to the list when new ideas come to mind during the discussion. You group all the ideas together, and ask the group to clarify ones that are not clear. After the list of ideas is finished, the group discusses the ideas together. You lead them to consensus on which ideas to keep and which to eliminate. The result of the brainstorming session is a final list of the problems that are impacting the quality of the services provided at the health centre. The list included: • no appointments on Tuesdays or Wednesday afternoons • not enough chairs in the waiting room • the waiting area is noisy and crowded • delays in registering on arrival • not enough nursing staff • have to wait too long to get an appointment • long waiting time at appointments • patients feel that they are not treated with respect Exercise Taking the problem you have described in the previous exercise, use the brainstorming technique to assess the causes of the problem. Use the Brainstorming Tool (Exercise Sheet 1.2) and if you cannot access a group, try brainstorming on your own. 5 MODULE 1: Identifying the problem and the desired outcome Prioritizing the problem Once you have analysed the causes of a problem you can use a Prioritization Matrix to prioritize the important causes (see Exercise Sheet 1.3). By using this method of prioritizing problems, you are able to look at the data and determine which problems are most important according to this group of patients and staff. The general view of the group is that the lack of nursing staff is a widely perceived problem. The second most important problem is perceived as being the long wait to get an appointment and the third most important problem is the long waiting time at the appointment. Below is an example of the results you might achieve when you have completed Exercise Sheet 1.3. Example Problem Frequency Importance Feasibility Total points No appointments on Tuesday afternoons 69 24 45 138 Not enough chairs in the waiting room 25 37 86 148 The waiting room is noisy and crowded 32 26 74 132 Delays in registering on arrival 52 42 48 142 Not enough nursing staff 76 88 35 199 Long waiting time at appointments 41 69 46 156 Long wait to get an appointment 55 79 48 182 Exercise Taking the problem you have accurately described and analysed in the previous exercise, use the Prioritization Matrix Tool (Exercise Sheet 1.3) to prioritize the important causes. You have now described and analysed your problem, and prioritized the causes. The next step is to start planning your way forward. Given that you have decided to be the change agent and advocate for change, it is useful to assess your strengths and weaknesses and consider where your opportunities and threats are going to come from. 6 MODULE 1: Identifying the problem and the desired outcome Assessing your strengths and weaknesses (SWOT) SWOT analysis is a very effective tool for identifying your strengths and weaknesses, and for examining the opportunities and threats you may face. Carrying out an analysis using the SWOT framework will help you to focus your activities on areas where you are strong, and where the greatest opportunities lie (see Exercise Sheet 1.4). Below is an example of the results you might achieve when you have completed Exercise Sheet 1.4. Example: When applying the questions to oneself the following might apply: Strengths: • I have a good knowledge of the health system and the health service • I have credibility as a practitioner • I have good interpersonal skills • I have the support of my professional peers Weaknesses: • I have no advocacy experience • I have little knowledge of financial systems and processes Opportunities: • The professional association will take an interest in staffing issues and can provide support Threats: • External budgetary constraints/controls • The health centre not seen as a priority for funding In summary, I have professional credibility and peer support but I lack knowledge relating to financial systems. I can harness the expertise of the professional association to get the issue on the decision-makers agenda. Given this assessment, there is sufficient evidence to indicate that I have or can get the capacity to proceed. Exercise Using the SWOT Analysis Tool (Exercise Sheet 1.4), complete a SWOT analysis on yourself. Having completed a SWOT analysis on yourself, you should now complete a Force Field Analysis. 7 MODULE 1: Identifying the problem and the desired outcome Force field analysis Force field analysis is a method used to get a complete view of all the forces for and against a plan so that a decision can be made which takes into account all interests. In effect, this is a method of weighing both the pros and cons (see Exercise Sheet 1.5). Below is an example of the results you might achieve when you have completed Exercise Sheet 1.5. Example Forces for change Plan Forces against change 4 Peer support Budget constraints 5 5 Community support Not seen as priority 5 4 Support of professional No advocacy experience 3 association 3 Supportive data Do not know decision- 3 accessible makers 16 16 In this case the forces for and against are even, so there is a 50/50 chance of success. I need to determine whether I should proceed or not. It will depend on the significance or importance of the issue. Exercise Using the Force Field Analysis Tool (Exercise Sheet 1.5), complete a force field analysis on the problem you have been working on in the previous exercises. 8 MODULE 1: Identifying the problem and the desired outcome Session 2 Introduction to gathering evidence Now that you have a clearly defined problem, and a plan to address the problem, you can prepare yourself to advocate for change. Data and research are essential for making informed decisions when choosing a problem to work on, identifying solutions to the problem, and setting realistic goals. The following section will address: • means by which you can find evidence; • how to analyse the usefulness and appropriateness of the evidence; and • how to use the evidence in advocating. The evidence Your ability to provide evidence-based arguments to advocate for change depends on finding the best available data, information or research. Good data can be the most persuasive argument. What data can be used to best support your arguments? Given the data, can you realistically reach the goal? You can use data to: • identify issues for policy action; and • widen the range of possible solutions to a problem. Data can also be used to: • affect what is considered changeable or achievable in a policy process; • choose an advocacy goal; and • directly influence decision-makers (the primary audience of an advocacy programme). However access to data is variable. Many organizations still have manual data collection methods which make it difficult to summarize the data or report on trends. Many nurses still do not have access to electronic sources of data such as the Internet. DATA Quantifiable facts usually represented by figures. INFORMATION A collection of facts and data. KNOWLEDGE Theoretical or practical understanding from the sum of what is known. RESEARCH Critical inquiry of a subject. 9 MODULE 1: Identifying the problem and the desired outcome Libraries may be situated long distances from the work place and professional associations may not have the resources to respond to calls for assistance to gather data or information. However, often where this occurs the policy developers and decision-makers also have limited information resources. So one should not be deterred. Information can be provided in the form of ‘stories’ or case studies which provide a description of the situation as described by those who either experienced it or observed it. This form of evidence is legitimate and can often be very persuasive. Example Data: Number of women in Columbia using a contraceptive. Information: Percentage of women in rural Colombia using a contraceptive. Knowledge: 97.8% of women know of modern methods and 93.3% of women know a source for a modern method, but only 30.8% of women are using a modern method. Research: A research study has indicated that it is the desire for more children which is the reason why 37.4% of women do not use a contraceptive method. Any investigation will require resources and takes up the time and energy of respondents, interviewers and decision- makers. It is therefore important that these resources are used cost-effectively and not wasted collecting a lot of information which is never used. This requires that the process be carefully focused on particular practical or policy issues. Realistic possibilities for change may not be immediately obvious from statistical analysis. It may also require careful analysis of particular cases of success or failure and/or consultation regarding what different stakeholders see as possible ways forward. Example To investigate the percentage of women in a rural area of Columbia using a contraceptive, you would use a combination of local health clinic data and perhaps a survey of the women in the area. To investigate the extent of the women’s knowledge of modern methods and the source of such methods, you would conduct a survey but also support this with focus group meetings and interviews. 1 0 MODULE 1: Identifying the problem and the desired outcome Accessing information: search focus The main objective of the search for information is to be able to put together a strong case against the current situation and a strong case in support of the change you are proposing. The list below indicates the types of information you need at a high level in order to develop your proposal. Case against the current Case in support of the proposed situation change Document current adverse Show the positive outcomes responses to current of change that have occurred situation. elsewhere. Identify people who have Show that change makes been adversely affected economic sense. by the current situation. Demonstrate the conse- Demonstrate that it is quences of inaction. feasible to reach the goal of the proposed change. Note the benefits of the change to health sector development and infrastructure building. So where do you start in developing your case? What type of question should you ask to facilitate your search? (See Exercise Sheet 1.6) To provide yourself with a manageable approach to your search, you need to break the question down into meaningful segments. For example: • Client • Intervention • Outcome 1 1 MODULE 1: Identifying the problem and the desired outcome Example Using the Case Study of the Health Centre, the problem of “Insufficient nursing staff to meet client needs” needs to be segmented. This can be done by breaking it down into: • meeting client needs (client) • nursing staff ratios (intervention) • improved client services (outcome) You can now use these segments to pose questions you may wish to ask. For example: • What level of nursing staff is required to meet client needs? • What ratio of nursing staff to client is used by similar health clinics that do meet client service standards? • How do I determine the appropriate level of nursing staff to meet our client needs? • What standards exist for setting appropriate nursing staff to client ratios? The common words in most of these questions are “nursing staff ratios” which can now be used as the basis for the search. Exercise Using Search Focus Tool (Exercise Sheet 1.6), establish the focus for your search. Search preparation There is a set of questions which, when answered, provide you with a way forward, while also highlighting the risks associated with your search. • What do we want to know? What does this imply for the main focus of the investigation? What level of detail is required? • Whom do we ask? What does this imply for the types of questions which can be asked? What is the best timing of the investigation? • What methods are to be used? What are the potential advantages and disadvantages of each? • Who is to be involved in the investigation? Which parts of the investigation are best conducted by external researchers, programme staff, or grassroots groups? (See Exercise Sheet 1.7) 1 2 MODULE 1: Identifying the problem and the desired outcome Example Using the Health Centre Case Study and applying the questions, the answers might be as follows: Questions Answers What do we want to know? What Nurse ratios for the health centre does this imply for the main focus of which meet client needs the investigation? The level of detail required? Whom do we ask? What does this The organization imply for the types of questions The staff and clients whichcan be asked? The timing The central authority of the investigation? Professional associations What methods are to be used? Search of routine data sites What are the potential advantages Literature searches: libraries/ and disadvantages of each? professional association resources/InternetInterviews/ focus groups: staff/clients/others Who is to be involved in the SelfInterested other staff investigation? Which parts of the of the organizationStaff of the investigation are best conducted by professional associationOther external researchers, programme contacts, e.g. librarians staff, or grassroots groups? Exercise Using the Search Preparation Tool (Exercise Sheet 1.7), prepare questions to a search you want to carry out. Case development Having become clear about the focus of the questions to be asked and having developed your search plan, you are now ready to begin gathering information to develop your proposal (“case”) using the outline provided at the beginning of this module (see Exercise Sheet 1.8). 1 3 MODULE 1: Identifying the problem and the desired outcome Example Using the Health Centre Case Study Case against the current situation Type of information required Document adverse responses to Staff turnover current situation. Client complaints Waiting times and numbers Identify people who have been Clients and their families adversely affected by the current Staff situation. Other health services Demonstrate the consequences Increased staff turnover of inaction. Increased illness profile of clients Increased waiting times and numbers Increased client discontent Potential adverse media response Show the positive outcomes of Examples of best practice from change that has occurred elsewhere. the literature and other health services Show that change makes economic Cost of high staff turnover sense. Cost of increased illness (transfer cost to acute care) Cost of having to react to community and media discontent Demonstrate that it is feasible to Consider different staff mix reach the goal of the proposed Example of innovation and best change. practice elsewhere Note the benefits of the change to Increased efficiency without health sector development. impacting negatively on client outcomes and without adverse community and media reactions. Exercise Using the Case Development Tool (Exercise Sheet 1.8), determine the type of information you will require. You now have a focus for your search and an indication of the information required. But where and how will you find the information? If you are familiar with the appropriate data sources available, then proceed to the next section. If not, before proceeding go to Information Sheet 1.1. 1 4 MODULE 1: Identifying the problem and the desired outcome Potential sources of information: the information sources audit (See Exercise Sheet 1.9) Example Type of information required Potential sources Staff turnover Health centre reports Client complaints Departmental reports Waiting times and numbers Increased staff turnover Health centre reports Increased illness profile of clients Departmental reports Increased waiting times and numbers Increased client discontent Potential adverse media response Examples of best practice from the Literature literature and other health services Cost of high staff turnover Health centre reports Cost of increased illness (transfer Departmental reports cost to acute care) Cost of having to react to community and media discontent Consider different staff mix Literature Example of innovation and best practice elsewhere Increased efficiency without impacting Literature negatively on client outcomes and without adverse community and media reactions Exercise Using the Information Source Audit Tool (Exercise Sheet 1.9), apply the questions to a search you want to carry out. 1 5 MODULE 1: Identifying the problem and the desired outcome Appraising the evidence The quality of data includes its accuracy, completeness, timeliness, relevance, and transferability in the context of its “fitness for use.” In other words, is the quality of the data “good enough” for its intended purpose? The first level of appraisal of any data or information can proceed as follows: • Does the data set contain the necessary data elements to answer the business question? • Are the data relevant enough given the intended use? • Are the data accurate enough given the intended use? • Are the data complete enough given the intended use? • Are the data timely enough given the intended use? If an answer is no, then what will it take (time, cost, effort) to make it fit for the intended use? Are you able to access the resources? • If not, are there alternative data sources? • If not, are you willing to incur the cost to create the data source? • If not, should you change the question to match the data? The second level of appraisal should consider the following: Authority and currency What are the credentials and credibility of author; data collection system; organizations; individuals? What is the status of publisher? What is the date of collection; publication? Objectivity and reliability Is the information fact, opinion or propaganda? Is the information valid? How reliable are the results/ outcomes? Are the ideas/arguments logical? Is the language free of emotion? 1 6 MODULE 1: Identifying the problem and the desired outcome Coverage Does it extensively or marginally cover the issue being searched? Is it a primary or secondary source of information? Applicability What is the intended audience? Are the results/outcomes transferable? Exercise Using the Information Analysis Tool (Exercise Sheet 1.10), apply the questions to a search you want to carry out. Applying the evidence It is now time to go back to the elements of the case that is to be presented. You have completed your search. You have analysed the usefulness of the information to your case. Now it is time to summarize the relevant useful information according to the particular aspects of the case you will be putting together. Case against the current Summary of Source of situation evidence evidence collected Document adverse responses to current situation. Identify people who have been adversely affected by the current situation. Demonstrate the consequences of inaction. Show the positive outcomes of change that has occurred elsewhere. Show that change makes economic sense. Demonstrate that it is feasible to reach the goal of the proposed change. Note the benefits of the change to health sector development. 1 7 MODULE 1: Identifying the problem and the desired outcome Exercise Using the Case Documentation Tool (Exercise Sheet 1. 11), summarize and classify the information you have searched and analysed and found useful to your case. Also record the sources of the information. But what if you have not been able to find the evidence to support your case? You may have to set up and conduct your own research. If you have found sufficient evidence then proceed. References • Australian Continuous Improvement Group Force Field Analysis. www.acig.com.au/ Library/forcefield.PDF. • Brassard M. (Editor), The Memory Jogger: A Pocket Guide of Tools for Continuous Improvement Goal/QPC, 1989. • Cave C., Techniques for Creative Thinking. Brainstorming, Creativity Web: Resources for Creativity and Innovation, 1988 (http://www.ozemail.com.au/ ~caveman/Creative). • United States Department of the Interior, Decision Process Guidebook: How to get things done. United States Bureau of reclamation, Washingtong D.C., 1996, (www.usbr.gov/pmts/guide). • Gartland G., Thunderbolt Thinking. 2001(www.thunderboltthinking.com/ jumpstart.htm). • Harris R., Creative Thinking Techniques, 2002 (www.virtualsalt.com/crebook2.htm). • Kibbe DC; Smith PP; LaValle R; Bailey D; Bard M., A guide to finding and evaluating best practices health care information on the Internet: the truth is out there? Journal of Nursing Administration, 1998 Jul–Aug (7–8): pages 21–26. • Marketing Teacher (www.marhetingteacher.com/Lessons/lesson_swot.htm). • Mindtools (www.Mindtools.com). • Wujec T., Five Star Mind: Games and Exercises to Simulate Creativity, Doubleday New York, USA, 1995. 1 8 MODULE 1: Identifying the problem and the desired outcome INFORMATION SHEET 1.1 DATA SOURCES Routine data collection Failure to build upon existing information wastes the time and resources of all involved. It is likely that those involved will rapidly become tired of answering similar questions in different assessments unless the usefulness of doing so is clearly apparent to them. This will seriously affect the reliability of any information obtained. Reviewing existing information includes looking at obvious sources like programme records and statistics. Non-routine data collection Collecting non-routine data tends to be both time and resource consuming and should only be used when routine data are not available or there are significant gaps in the data. The most useful and used tools are: • Participant observation • Interviews • Focus groups • Service exit surveys • Household/population surveys Libraries Libraries can be accessed personally, by telephone, e-mail or the Internet. They can be your most useful resource. Upon completing Module 1, you should be able to give the librarian clear instructions for your search. If you are doing the search in the library yourself: 1. Use keyword searching for a narrow or complex search topic. Use subject searching for a broad subject. Print or write down the citation (author, title, etc.) and the 1 9 MODULE 1: Identifying the problem and the desired outcome location of information (call number and library). Note the circulation status. When you pull the book from the shelf, scan the bibliography for additional sources. Watch for book-length bibliographies and annual reviews on your subject; they list citations to hundreds of books and articles in one subject area. 2. Use periodical indexes and abstracts to find citations to articles. The indexes and abstracts may be in print or computer-based format or both. Choose the indexes and format best suited to your particular topic. Ask at the reference desk if you need help figuring out which index and format would be best suited for your needs. You can find periodical articles by the article author or title by using the periodical indexes in the library catalogue. When you have recorded or printed out the citation from the index, locate the library that owns the periodical you want by looking up the title of the periodical in the library catalogue. Professional organizations/unions If you have a professional association, union or registration authority they can be an invaluable resource. They are likely to have a common interest and to be a supporter of your case. Many have their own libraries or can access libraries for you. It is also more than likely that they will have Internet access and be able to assist you with your search. The Internet The Internet is increasingly becoming available to health professionals, so it is worth detailing the process for accessing information on the Internet. Search engines Search engines, like any other tool, are much more effective when you learn to use them well. This chapter will introduce the basic concepts involved with searching on the Internet, and provide some general tips about how to use these tools. 2 0 MODULE 1: Identifying the problem and the desired outcome There are over 800 million separate web pages on the Internet. Even the most inclusive Internet search engine only provides access to 160 million pages, which is why a good researcher is familiar with more than one search engine, for example: Search engine URL Northern Light northernlight.com Alta Vista altavista.com Inktomi yahoo.com, msn.com Fast alltheweb.com Google google.com Infoseek infoseek.com Excite excite.com Lycos lycos.com Basic search concepts and tips for searching Most search engines have both “basic” search forms and “advanced” search forms. The basic search forms are what you are most likely to see on the search engine’s home page. It usually provides a handful of basic search tools, such as the use of AND, OR and “phrase searching”. Somewhere on that same home page, you will probably find a link to an advanced search form that allows more sophisticated search tools, such as the use of “wildcard” characters and the ability to search for terms that are close to each other (often called “proximity searches”). Using the best search terms The key to effective searching involves the ability to think of appropriate search terms. Start with the general and move to the specific. You will be searching through hundreds of millions of web pages, so you need to narrow your focus, but not by too much. Generally, it is better to use more than one term. Using multiple search terms, on the other hand, will narrow the focus of your search and return fewer, but more relevant, results. 2 1 MODULE 1: Identifying the problem and the desired outcome Using the right search tools While no two search engines function identically, most are similar enough that a few basic rules apply almost universally. The basic tool set comprises a few Boolean operators (AND, OR and NOT) and quotation marks (“”). The AND operator If you are searching for two or more keywords, you should use the “AND” operator. Almost all search engines allow the use of the shorthand notation “+” for the “AND” operator. Place the “+” in front of any word or phrase that must be included. (i.e. +nurse+ratios). Some search engines require that you spell out the word “and”, and among these some require that you use the all capitals version “AND”. If you do spell out this operator, the best strategy is to always use the “all caps” version. The OR operator If you need to cast a broader net, use the OR operator. This will retrieve pages that contain any one of your search terms. This is useful if there are alternative ways of describing a topic. A good example would be searching for information about ‘nurse ratios’ which could also be referred to as ‘nursing ratios’: “nurse OR nursing ratios”. The NOT operator Sometimes a search term you use will also be associated with a different topic. To exclude pages that are not related to your search, use the NOT operator. Most search engines allow the use of the “-” sign as short-hand for the NOT operator. Quotation marks Use quotation marks for phrases. If you are searching for a phrase like “community health”, use double quotation marks (“”) to distinguish it from a search for either one of those two words. 2 2 MODULE 1: Identifying the problem and the desired outcome FACILITATOR’S GUIDE – DEFINING THE PROBLEM Facilitator’s preparation time: 45 minutes Group exercise time: 60 minutes Resources: Exercise Sheets 1.1 - 1.5 Butcher paper, white board or black board Pens/pencils/paper Instructions: • The exercise is best done with no more than 20 people. • Read Module 1, Session 1 and go through each of the exercises. • Familiarize yourself with the Exercise Sheets. • Make sure you have enough copies of the Exercise Sheets for each participant in your group. • Make sure that you have the resources you need, e.g. pre-prepared butcher paper. • Introduce the topic and explain the objectives of the exercise. • Begin with Exercise Sheet 1.1 and use it to help the group define the problem clearly by answering the questions provided. Then summarize the results to form a ‘problem statement’. • Now go to Exercise Sheet 1.3 and prioritize the causes of the problem. Follow the instructions in the sheet. • By now you will have defined the problem and prioritized the causes. • Next go to Exercise Sheet 1.4 to determine what are the internal strengths and weakness of the group and what are the external opportunities in dealing with the problem. You may not always need to complete this exercise as sometimes it is enough just to do the ‘force field’ analysis in Exercise Sheet 1.5. 2 3 MODULE 1: Identifying the problem and the desired outcome • Then you can use Exercise Sheet 5 to assess the forces for and against change that have to be addressed. Exercise Sheet 1.2 can be used at any time when you need to use the brainstorming technique to collect people’s collective views on an issue. This completes Module 1, Session 1 2 4 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.1 PROBLEM DESCRIPTION TOOL What is it? The process of describing the problem using the Problem Description Tool assists you to understand how the problem affects the process being examined. Who uses it? Any person or group who identify a discrepancy between “what is’ and “what should be” and want to rectify the discrepancy. Why use it? To identify the problem and clearly articulate it so that the plan will consist of the right solutions. How to use it? • Explain the objective of the session to the group. • Write the problem on a board or large sheet of paper. To help you describe the problem, you should try to answer certain questions about the problem, such as: How frequently does the problem occur? When does it generally occur (for example, at a particular time of the year, on a set week, on a specific day)? Is the problem related to time? Where does it generally occur (for example, is it limited to a particular area, or is it everywhere)? What relationship does the problem have to location? Who is most affected (for example, individuals or families, people of different gender, race, age, or socio-economic status)? 2 5 MODULE 1: Identifying the problem and the desired outcome • Answer the questions set out below and summarize the outcomes. How frequently does the problem occur? When does it generally occur? Where does it generally occur? Who is most affected? Finally, summarize the problem and confirm it with the group. Problem statement: _______________________________ _______________________________________________ _______________________________________________ 2 6 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.2 BRAINSTORMING What is it? Brainstorming is a technique that helps a group generate as many ideas as possible in a short time period. Who uses it? Any group, of any number, who has an interest in the problem. If you invite people with different perspectives to brainstorm, you are more likely to see innovative ideas generated by the group. Why use it? To identify problems, analyse causes, select alternative solutions, do strategic planning, generate ideas for marketing change, and handle many other situations. How to use it: 1. Explain the objective of the session: for example, to select problems, analyse causes, or generate ideas. 2. Explain the technique to the group. Tell them that you are looking for a lot of ideas, and that you want their thoughts and ideas to flow freely. There is no right or wrong answer. The idea of brainstorming is to produce as many innovative ideas as possible. 3. Silent reflection: Ask the participants to think about the proposed objective or topic for a few minutes. (Time: approximately 5 minutes.) 4. Brainstorm: The participants call out their ideas and add those that come to mind during the discussion. Write down the ideas using the words of the speaker. Ask for clarification only if the meaning is not clear. (Time: approximately 20 minutes.) 2 7 MODULE 1: Identifying the problem and the desired outcome 5. Once the list is finished, discuss it with the group to: • Clarify the meaning of some ideas • Combine similar ideas that are worded in different ways • Eliminate those ideas which are not related to the objective of the session. Issues At the end of this stage, you will have reduced the list of ideas to those that represent most of the major ideas of the group. (Time: 5-15 minutes.) 2 8 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.3 PRIORITIZATION MATRIX TOOL What is it? A Prioritization Matrix is a useful technique you can use to achieve consensus about an issue. The matrix helps you rank problems or issues (usually generated through brainstorming) by a particular criterion. Then you can more clearly see which problems are the most important to work on solving first. Who uses it? Members of your team, or a group of users, can participate in the process. Why use it? To determine what your users or your team members consider to be the most pressing problem with your programme or health service. When to use it? When you need to prioritize problems, or to achieve consensus about an issue. How to use it: Fill out the Prioritization Matrix chart with the group: Issues Frequency Importance Feasibility Total points 2 9 MODULE 1: Identifying the problem and the desired outcome 1. In the first column, write down the problems that were mentioned in the brainstorming session. 2. In the second to fourth columns, use the following questions to give a rating: • Frequency: How frequent is the problem? Does it occur often or only on rare occasions? • Importance: From the point of view of the users, what are the most important problems? What are the problems that you want to resolve? • Feasibility: How realistic is it that we can resolve the problem? Will it be easy or difficult? 3. Each participant gives a score out of 5 (1 being the least and 5 the most) for each box 4. You add together the scores for each box (If there are 10 in attendance the highest score in a box is 100) then total the row for each issue. 5. The totals help you see clearly how to prioritize the problems. The higher the score the higher the priority. Example: Issues Frequency Importance Feasibility Total points No appointments on Tuesday 69 24 45 138 Not enough chairs in waiting room 25 37 86 148 Long wait to get an appointment 55 79 48 182 Delays in registering on arrival 52 42 48 142 Not enough nursing staff 76 88 35 199 Long waiting time at appointments 41 69 46 156 3 0 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.4 SWOT ANALYSIS What is it? You can use a SWOT analysis to identify and analyse the Strengths and Weaknesses of your organization, as well as the Opportunities and Threats revealed by the information you have gathered on the external environment. Who uses it? The team members and the managers. Why use it? To develop a plan that takes into consideration many different internal and external factors, and maximizes the strengths and opportunities while minimizing the impact of the weaknesses and threats. How to use it: 1. Explain the objectives of the session and the process: 2. Internal analysis: Examine your/group capabilities. This can be done by analysing your/group strengths and weaknesses. Strengths: What are your advantages? What do you do well? What do other people see as your strengths? Consider this from your own point of view and from the point of view of the people you deal with. Do not be modest - be realistic Weaknesses: What could you improve? What do you do badly? What should you avoid? Again, consider this from an internal and external basis - do other people seem to perceive weaknesses that you do not see? Are your competitors doing any better than you? It is best to be realistic now, and face any unpleasant truths as soon as possible. 3 1 MODULE 1: Identifying the problem and the desired outcome 3. External analysis: Identify those events, issues, trends, evidence that pose opportunities for your organization/ group, and those that pose threats or obstacles to performance. Decide whether the answers or the data collected reveal external opportunities or threats. Opportunities: Where are the good opportunities facing you? What are the interesting trends you are aware of? Where are your support networks? Where is the evidence to support your case? Threats: What obstacles do you face? Do you have access to the information you need? Who is likely to oppose your position? 4. Enter the information you have collected in steps one and two into a table as illustrated below: Internal strengths Internal weaknesses External opportunities External threats 5. You can use this information to help you develop a strategy that uses the strengths and opportunities to reduce the weaknesses and threats, and to achieve the objectives of your organization/group. 3 2 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.5 FORCE FIELD ANALYSIS What is it? Force Field Analysis is a technique based on the premise that change is a result of a struggle between forces of resistance (forces that impede change) and driving forces (forces that favour change). By using Force Field Analysis, you can learn which course of action will be the best one to implement because it will have the most driving forces and the least resistant forces. Who uses it? The team members, the managers, the users. Why use it? To determine the best course of action to take. How to use it 1. Explain the process to the group. Define the problem or issue you will be discussing. 2. Create a chart on newsprint or chalkboard with two headings: forces for change and forces against change 3. Have the group brainstorm which forces belong in each column. Forces for change are characteristics of the issue that make it easy to take place; forces against change are characteristics of the issue that make it difficult to take place. 4. Rate each force on a scale of 1-5 with 1 weak and 5 strong. Total the scores and evaluate the chart together. Forces for change Forces against change 3 3 MODULE 1: Identifying the problem and the desired outcome Example Forces for change Forces against change 4 Peer support Budget constraints 5 5 Community support Not seen as priority 5 4 Support of professional No advocacy experience 3 association 3 Supportive data accessible Don’t know decision makers 1 16 14 5. If the score for the forces against change are greater than the score for forces for change, you might have to reconsider the feasibility of proceeding. Success is likely to be very difficult. If the score for forces for change are highest then you can proceed but develop strategies for reducing the negative impact of the forces against change. 6. Now summarize and develop strategies for overcoming or reducing or weakening the impact of the forces against change. Issues Strategies 3 4 MODULE 1: Identifying the problem and the desired outcome FACILITATOR’S GUIDE – GATHERING EVIDENCE Facilitator’s preparation time: 45 minutes Group exercise time: 90 minutes Resources: Exercise Sheets 1.6 - 1.11 Information Sheet 1.1 Butcher paper, white board or black board Pens/pencils/paper Instructions: • The exercise is best done with no more than 20 people. • Read Module 1, Session 2 and go through each of the exercises. • Familiarize yourself with the Exercise Sheets and the Information Sheet. • Make sure you have enough copies of the Exercise Sheets for each participant in your group. • Make sure that you have the resources you need, e.g. pre-prepared butcher paper. • Introduce the topic and explain the objectives of the exercise. • Begin with Exercise Sheet 1.6 and use this to establish the focus of the search you need to do to gather the evidence to support your case. You may not need to do this exercise if your ‘problem statement’ gives you sufficient focus for the search. • Go to Exercise Sheet 1.7. This exercise will help the group prepare the right questions for searching the evidence required. • Now go to Exercise Sheet 1.8. This exercise will guide the group in deciding what information is needed once the group is clear about what questions they need to ask. 3 5 MODULE 1: Identifying the problem and the desired outcome • Next go to Exercise Sheet 1.9, which will assist the group to select the appropriate sources of information available. Given that this is a learning exercise, the group will not be able to actually get the information but you can give them some instructions so that they could proceed on their own. • Using Exercise Sheet 1.10, take the group through the process for making sure that any information they do get is useful, reliable and valid. Again the group cannot do this, but they can develop an understanding of what they would need to do. • Now go to Exercise Sheet 1.11 and use it to show how the group could document the case for change from the information they would have gathered. This completes Module 1, Session 2 3 6 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.6 SEARCH FOCUS TOOL What is it? The Search Focus Tool guides you in developing the question should you ask to facilitate your search for evidence. Who uses it? Any person or group wanting to embark on a well planned search for information. Why use it? To ensure that you take a cost-effective approach to your search. How to use it: • If you are working with a group, explain the process and rationale for the exercise. • State the problem or issue you will be clarifying prior to carrying out a search for evidence. • Break down the problem statement into the focus areas listed below. Potential focus areas Client/problem (e.g. meeting client needs; quality care) Intervention (e.g. staffing levels; skill mix of staff) Outcome (e.g. improved client services) Now use these focus areas to pose questions you may wish to ask. __________________________________________ _________________________________________________ The common words in most of these questions are: (e.g. nursing staff ratios)____________________________ These words can now be used to search for evidence to support your case. 3 7 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.7 SEARCH PREPARATION TOOL What is it? The Search Preparation Tool assists in clarifying the parameters of the search and helps minimize the time and energy spent on the exercise. Who uses it? Any person or group wanting to embark on a well planned search for information. Why use it? To identify the potential risks, strengths and weaknesses of the information search. How to use it: • If working with a group explain the process and rationale for the exercise. • Using the search statement you have agreed to in Exercise Sheet 1.6 to answer the following questions. Search statement ________________________________________________________ Questions Answers Examples What do we want to know? Nurse ratios for the health centre What does this imply for the main which meet client needs focus of the investigation? The level of detail required? Whom do we ask? The organization What does this imply for the types The staff and clients of questions which can be asked? The central authority The timing of the investigation? What methods are to be used? Search of routine data sites What are the potential advantages Literature searches: Libraries/ and disadvantages of each? professional association database Who is to be involved in the Self investigation? Which parts of the Interested other staff of the investigation are best conducted by organization external researchers, programme Staff of the professional association staff, grassroots groups? 3 8 MODULE 1: Identifying the problem and the desired outcome The result of the exercise will tell you: • Who should assist with the search • What methods you could use 3 9 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.8 CASE DEVELOPMENT TOOL What is it? The Case Development Tool guides you in determining your information needs to put your case together. Who uses it? Any person or group wanting to embark on a well planned search for information. Why use it? To ensure that you access information sources appropriate to your particular search need. How to use it: • If you are working with a group explain the process and rationale for the exercise. • State the problem or issue you will be clarifying. • Break down the problem statement into the segments listed below. Case against the current situation Type of infor- Example mation required Document adverse responses to Staff turnover current situation. Client complaints Waiting times and numbers Identify people who have been Clients and their families adversely affected by the current Staff situation Other health services Demonstrate the consequences Increased staff turnover of inaction. Increased waiting times and numbers Show the positive outcomes of Examples of best practice from the change that has occurred elsewhere literature and other health services Show that change makes economic Cost of high staff turnover sense Cost of increased illness (transfer cost to acute care) 4 0 MODULE 1: Identifying the problem and the desired outcome Case against the current situation Type of infor- Example mation required Demonstrate that it is feasible to Consider different staff mix reach the goal of the proposed Example of innovation and best change. practice elsewhere Note the benefits of the change to Increased efficiency without health sector development and impacting negatively on client infrastructure building. outcomes and without adverse community and media reactions. You now have a focus for your search and an indication of the information you require and where to get it. 4 1 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.9 INFORMATION SOURCE AUDIT TOOL What is it? The Information Source Audit Tool guides you in determining the appropriate information sources to target in your search. Who uses it? Any person or group wanting to target their information search. Why use it? To ensure that you access information sources appropriate to your particular search need. How to use it: • If you are working with a group explain the process and rationale for the exercise. • List your information needs in the left column and then list in the right column the sources for each information need. Type of information required Potential sources 4 2 MODULE 1: Identifying the problem and the desired outcome Health unit databases • Clinical management data – information regarding clients, services and programmes • Resource management data – information regarding staff, finances, supplies and capital Departmental (regional/national) databases • Morbidity and mortality • Epidemiological • Demographic • Resource utilization Rapid assessment procedures • Participant observation • Interviews • Focus groups • Service exit surveys • Household surveys Library • Journals • Dissertations/Theses • Research • Reports Professional associations Policies Guidelines Standards Case studies The Internet 4 3 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.10 INFORMATION ANALYSIS TOOL What is it? The Information Analysis Tool guides you in assessing the integrity and usefulness of the information you have collected. Who uses it? Any person wanting to critically analyse data sets and information extracted from a search. Why use it? To ensure that you access information sources are useable. How to use it: • First record the details of the information source. • Apply the questions set out below to the information source you are analysing. Data/information source 1 Comments Authority and currency What are the credentials and credibility of author; data collection system; organiszations; individuals? What is the status of publisher? What is the date of collection; publication? Objectivity and reliability Is the information fact, opinion or propaganda? Is the information valid? How reliable are the results/outcomes? Are the ideas/arguments logical? Is the language free of emotion? Coverage Does it extensively or marginally cover the issue being searched? Is it a primary or secondary source of information? Applicability What is the intended audience? Are the results/outcomes transferable? 4 4 MODULE 1: Identifying the problem and the desired outcome • Do not use any information that does not meet the criteria above. • Repeat the exercise for each information source you have collected. Data/information source 2 ________________________ _________________________________________________ _______________________________________________ 4 5 MODULE 1: Identifying the problem and the desired outcome EXERCISE SHEET 1.11 CASE DOCUMENTATION TOOL What is it? The Case Documentation Tool guides you in developing the evidence-supported case against the current situation and for the proposed change. Who uses it? Any person wanting to put an evidenced supported case for change. Why use it? To ensure that an evidence based approach is used to support a case for change. How to use it: • Document a summary of the evidence collected from your search. • Then document the details of the information sources. Case against the current situation Summary of evidence Source of evidence collected Document adverse responses to current situation Identify people who have been adversely affected by the current situation Demonstrate the consequences of inaction Show the positive outcomes of change that has occurred elsewhere Show that change makes economic sense Demonstrate that it is feasible to reach the goal of the proposed change Note the benefits of the change to health sector development 4 6 MODULE 1: Identifying the problem and the desired outcome Example Case against the current situation Type of information required Document adverse responses to Staff turnover current situation. Client complaints Waiting times and numbers Identify people who have been Clients and their families adversely affected by the current Staff situation. Other health services Demonstrate the consequences Increased staff turnover of inaction. Increased illness profile of clients Increased waiting times and numbers Increased client discontent Potential adverse media response Show the positive outcomes of Examples of best practice from the literature change that has occurred and other health services elsewhere 4 7 MODULE 1: Identifying the problem and the desired outcome 4 8 MODULE 1: Identifying the problem and the desired outcome
i i i WHO Library Cataloguing in Publication Data Health service planning and policy-making : a toolkit for nurses and midwives. 1. Delivery of health services -- organization & administration. 2. Policy making. 3. Nurses. 4. Midwifery ISBN 92 9061 186 3 (NLM Classification: W 84.7) © World Health Organization 2005 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Or- ganization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: publications@wpro.who.int i i i PREFACE In the complex and turbulent world of today’s health care systems the roles nurses and midwives play in those systems are changing rapidly. The contribution of nurses to future health care systems is likely to be even more complicated than it is today. Nurse leaders and managers face the tremendous challenge of shaping the nursing profession to meet the rapidly changing health care needs of the future. Nurse leaders everywhere need to foresee and respond to changes so that the nursing profession can continue to effectively carry out its key role in providing health care services. Real and lasting progress in nursing will be impossible unless nurses in leadership positions are able to set clear priorities, plan strategically, advocate for and manage change and effectively participate in and influence health care planning and policy-making. As the largest group of health care personnel, nurses and midwives continue to play a significant part in the delivery of health services, yet their participation in health policy development and strategic planning has been limited. Nurse leaders and managers should be able to fully contribute to policy formulation, health service planning, programme development, resource management, implementation of action plans, and monitoring and evaluation of outcomes. Recognizing the important role that nurses and midwives play in primary health care, in 1989 the World Health Assembly passed a resolution (WHA 42.27) on strengthening nursing and midwifery in support of strategies for health for all. The resolution urged Member States of the World Health Organization (WHO) to encourage and support the appointment of nursing/midwifery personnel in senior leadership and management positions and to facilitate participation in planning and implementing their country’s health service strategies. The Global Advisory Group on Nursing and Midwifery highlighted the need for nurses and midwives to formulate health care policy at country, district and sub-district levels for improving national health services. It recommended that to ensure the appropriate involvement of these personnel in policy formulation and health service planning, WHO and Member States should prepare nurses and midwives to deal with policy issues through leadership development and participation in policy forums. i v At the 54th World Health Assembly, resolution 54.12 was passed, recognizing the significant and cost-effective health system contributions provided by nurses and midwives and urging Member States to take the lead in identifying mechanisms for involving nurses and midwives in the framing, planning and implementation of health policy at all levels. Hence this toolkit on health care planning and policy- making for nurses and midwives was developed. The toolkit extracts the core strategic planning and advocacy skills essential in addressing nursing, midwifery and health system issues and in implementing policy decision-making processes. It is organized into six modules. Module 1 on Problem Identification provides a conceptual overview of the process of identifying, describing, analysing and prioritizing problems. Module 2 focuses on how to do Stakeholder Analysis. Modules 3, 4 and 5 each focus on particular policy-making and advocacy methods and strategies—Understanding the Contextual Environment, Understanding the Policy, Political and Decision-Making Processes, and Managing Communication and the Change Process, respectively. Module 6 examines how all these methods and strategies are used in Monitoring and Evaluating the Project. Each module in the toolkit has objectives and reference lists and provides definitions, examples, exercises and accompanying guiding exercise sheets. Additional supportive materials are provided in Information and Skills Sheets. The impetus for this publication was the lack of a practical guide for nurses and midwives to strengthen their skills and knowledge in policy formulation and strategic planning. The publication has been designed for use by nurse and midwifery leaders and managers at all levels who have interests in advocacy, change management and impacting policy decision-making. Toolkit users may find one module that is particularly relevant to their needs and may choose to use that module as a stand-alone guide or to concentrate on only a few sections of greatest relevance. We encourage you to add your own experiences and exercises to the toolkit and welcome feedback from users of the toolkit. Shigeru Omi, M.D., Ph.D. Regional Director WHO Regional Office for the Western Pacific vACKNOWLEDGEMENTS The toolkit, prepared by Professor Carol Gaston, Project Consultant, was made possible through the many thoughtful ideas, contributions, experiences and suggestions of a number of different people who took part in two-years of reviews and pilot experiences. The production process was undertaken in collaboration with Ms. Kathleen Fritsch, Regional Nursing Adviser and Project Coordinator. vii CONTENTS Preface iii Acknowledgements v Introduction 1 Background 1 Purpose 1 Audience 2 Structure of toolkit 2 Using the toolkit 3 Advocacy 4 What is advocacy? 4 What is the basis for advocacy? 4 Who should advocate? 5 What are the characteristics of a nurse/ 5 midwife advocate? What are the principles of advocacy 5 References 6 Example: Advocacy Workshop Programme 7 Individual Booklets Module 1 : Identifying the problem and the desired outcome Module 2 : Identifying and analysing the stakeholders and establishing networks Module 3 : Understanding the contextual environment Module 4 : Understanding the policy, political and decision-making processes Module 5 : Managing communication and the change process Module 6 : Monitoring and evaluating the project 1 INTRODUCTION INTRODUCTION Background The need to further strengthen nursing and midwifery services was moved to the forefront by WHO and its Assembly by the passing of Resolution 45.5 in 1992. This resolution recommended that Member States and WHO’s Director General undertake a number of initiatives to strengthen nursing and midwifery services for primary care. In response, a Global Advisory Group was formed by the WHO Director General to look closely at how to best strengthen nursing and midwifery services. The Global Advisory Group, over its four-year term (1992-1996), provided WHO and its Member States with a number of important recommendations in this regard. At the 49th World Health Assembly, held in 1992, Resolution 49.1 was passed which urged Member States to: Involve nurses and midwives more closely in health care reform and in the development of national policy. The 54th World Health Assembly, held in May 2001, reinforced its position by urging Member States to: Further the development of their health systems to pursue health sector reform by involving nurses and midwives in the framing, planning and implementation of health policy at all levels. Purpose The purpose of this toolkit is to provide nurses and midwives with tools to effectively participate in and influence health care planning and policy-making. This is the first of two toolkits, the second being a resource to strengthen nurses and midwives capacity to evaluate nursing’s contribution to health system performance. These toolkits were developed by the WHO Regional Office for the Western Pacific to support effective implementation of Resolutions 49.1 and 54.12 2 INTRODUCTION Audience This toolkit has been designed for use by any nurse or midwife who has an interest in advocating for change in their work environment. This includes chief nurses and midwives who are in a position to impact policy decision-making at a country level, as well as clinical nurses and midwives advocating for funds to carry out a community development programme at the clinic level. Structure of the toolkit This toolkit includes the following: • Six modules, each with one or more sessions (nine sessions in total) • Each module has a set of objectives to be achieved and a reference list for further information • Each session provides definitions, examples and exercises and accompanying exercise sheets • Additional supporting materials are provided in the information and skills sheets. MODULE 5 Managing Communication and the Change Process MODULE 3 Understanding the Contextual Environment MODULE 4 Understanding the Policy, Political and Decision- Making Processes T T T MODULE 2 Identifying and Analysing the Stakeholders and Networks MODULE 1 Identifying the Problem and the Desired Outcome MODULE 6 Monitoring and Evaluating the Project T T T 3 INTRODUCTION Using the toolkit The toolkit can be used: • alone or with a colleague or small group • self-directed • as a train-the-trainer tool • with a trainer • when wanting to advocate or just to develop skills such as ‘change management’ for other purposes. It is advised that the user reads through each of the modules before beginning any of the exercises. Assess your own knowledge against each of the module objectives. For example, the objective of Module 1, Session 1, is to ‘carry out a force field and SWOT analysis’. If you are familiar with these skills, then there is no need for you to proceed with this particular session (unless you want to refresh your knowledge and skills). Following is an outline of the components of the toolkit. The time allocated for each topic is indicated, which is an indication only, however the activity should not take any longer than the time suggested. Topic Module Session Information Skills Exercise Time Sheets Sheets Sheets Defining the problem 1 1 - - 1.1 - 1.5 120 mins Gathering the evidence 1 2 1.1 . 1.6 - 1.11 120 mins Stakeholder analysis 2 3 - - 2.1 - 2.6 180 mins Networking 2 4 - 2.1 - 2.3 2.7 - 2.9 90 mins Assessing contextual 3 5 3.1 - 3.2 - 3.5 120 issues: values, ethics, mins traditions, gender, and risks Understanding the policy 4 6 4.1 - 4.2 - 4.1 - 4.6 120 development processes mins Understanding the 4 7 4.3 - 4.7 - 4.9 90 decision-making mins processes Change management 5 8 5.1 - 5.4 5.1 - 5.10 5.1 - 5.5 120 mins Monitoring and evaluation 6 9 6.1 - 6.2 - 6.1 - 6.2 120 mins Total 18 hrs 4 INTRODUCTION To complete the full course, three days should be allocated. This will allow adequate time for introductions and explanations, as well as summary sessions and future planning. An example of a programme is provided. Advocacy Why advocacy? The role of nurses and midwives in advocacy is to mobilize all interested parties around an issue which evidence shows will have a positive impact on the performance of the health system. Nurses and midwives need to build relationships in order to gain access to, and to be able to effectively communicate with, decision-makers about the need to take action, what actions are possible, and what benefits can be gained from the actions. What is advocacy? Some people see advocacy as organizing marches and demonstrations. Others see advocacy as involvement in political campaigns or lobbying in the corridors of power, while still others see it as an editorial comment in the mass media. Advocacy may require all of these tools. Advocacy is a combination of individual and social actions designed to gain political and community support for a particular health goal or programme. Action may be taken by, or on behalf of, individuals and groups to create living conditions which promote health and healthy lifestyles. What is the basis for advocacy? Advocacy by nurses and midwives should involve securing political action which will improve health outcomes and health system performance. A critical starting point for advocacy is knowledge – that is, having a good understanding of the problem and the appropriate responses. So, advocates for nurses and midwives should understand: • How the problem or issue is experienced; • Both common and uncommon experiences; • The extent to which cultural, social and economic forces have an impact on the problem; and • Appropriate solutions which are effective given diverse cultural, social and economic conditions. 5 INTRODUCTION Who should advocate? Advocacy is required at all levels of the health system. Whether it be registered nurses or midwives in remote clinics needing to advocate for funding for a particular community development programme; nurses or midwives in hospital settings requiring new technology or a different staff mix; directors of nursing in hospital or community settings requiring additional funding to manage increased demand; or simply advocating for a change of practice among colleagues. What are the characteristics of a nurse/midwife advocate? • Personal leadership skills • Interpersonal skills • Knowledge about the issue • Passion • Energy and commitment What are the principles of advocacy? Advocacy requires sustained action with multiple players and needs to be well planned. In fact, there are a number of important facets of advocacy which include: Be focused and relevant • Be clear about what you are advocating for • Establish common themes and messages • Do not stray from your message • Make it local and keep it relevant Work in partnership • Target individuals and organizations that can get your message across • Get involved in other peoples forums and use them for your own • Recruit corporate allies • Develop media contacts (including those outside medicine) 6 INTRODUCTION Be credible and appealing • Know the facts and the numbers • Do your homework and document your findings • Find ‘attractive’ spokes-people • Use icons who have credibility • Use interesting stories Be tactical • Start by assuming the best of others • Do not take ‘no’ for an answer • Be passionate and persistent • Set realistic goals • Plan for small wins • Take principled positions • Be opportunistic and creative • Employ multiple strategies • Be willing to compromise This toolkit will help you develop the skills required to advocate but also keep in mind the principles of advocacy as outlined above. Enjoy the experience of using this toolkit! References Burg, M.A., Health problems of sheltered homeless women and their dependent children. Health and Social Work, 19(2), 1994, pages 125-131. Chiarella, M., Advocacy in nursing: nonsense or necessity? ACORN Journal, 7(4), 1994, pages 21-22. Gaylord, N. and Grace, P. , Nursing advocacy: an ethic of practice, Nursing Ethics: an International Journal for Health Care, 2(1), 1995, pages 11-18. Heyman, S.J., ‘Health and Social Policy’ in L. Berkman and I. Kawachi (eds), Social Epidemiology, Oxford University Press, Oxford, 2000:375. Mallik, M., Advocacy in nursing – perceptions of practicing nurses. Journal of Clinical Nursing, 6(4), 1997a, pages 303-313. Mallik, M., Advocacy in nursing – a review of the literature, Journal of Advanced Nursing, 25(1),1997b, pages 130-138. Rafael, F. , Advocacy and empowerment: Dichotomous or synchronous concepts?, Advances in Nursing Science, 18(2), 1995, pages 25-32. Tschudin, V. and Hunt, G., Editorial Nursing Ethics: an International Journal for Health Care, 2(1), 1995, pages 1-2. World Health Organization, Health Promotion Glossary, WHO, Geneva, 1998, page 5. 7 INTRODUCTION EXAMPLE: ADVOCACY WORKSHOP PROGRAMME Day 1 Time Topic Resources 08:00 – 08:30 Introductions and explanations Overheads on advocacy 08:30 – 10:30 Defining the problem Module 1 Session 1 Exercise sheets 1.1 - 1.5 10:00 – 10:30 Tea break 10:30 – 12:30 Gathering the evidence Module 1 Session 2 Info sheet 1.1 Exercise sheets 1.6 - 1.11 12:30 – 13:30 Lunch break 13:30 – 16:30 Stakeholder analysis Module 2 Session 3 Exercise sheets 2.1 - 2.6 16:30 – 17:00 Summarize the days activities and outcomes Day 2 Time Topic Resources 08:00 – 08:30 Summarize the previous days outcomes 08:30 – 10:00 Networking Module 2 Session 4 Skill sheets 2.1 - 2.3 Exercise sheets 2.7 - 2.9 10:00 – 10:30 Tea break 10:30 – 12:30 Assessing contextual issues: Module 3 Session 5 values, ethics, traditions, Info sheet 3.1 gender, and risks Exercise sheets 3.2 - 3.5 12:30 – 13:30 Lunch break 13:30 – 15:30 Understanding the policy Module 4 Session 6 development process Info sheets 4.1 - 4.2 Exercise sheets 4.1 - 4.6 15:30 – 17:00 Understanding the decision- Module 4 Session 7 making process Info sheet 4.3 Exercise sheets 4.7 - 4.9 8 INTRODUCTION Day 3 Time Topic Resources 08:00 – 08:30 Summarize the previous days outcomes 08:30 – 10:30 Change management Module 5 Session 8 Info sheets 5.1 - 5.4 Skill sheets 5.1 - 5.10 Exercise sheets 5.1 - 5.5 10:00 – 10:30 Tea break 10:30 – 12:30 Monitoring and evaluation Module 6 Session 9 Info sheets 6.1 - 6.2 Exercise sheets 6.1 - 6.2 12:30 – 13:30 Lunch break 13:30 – 15:30 Summarize the outcomes of the workshop and plan next steps