The New Horizons Community Mental Health Center serves the diverse population of Miami, FL, which predominantly includes Hispanic, White American, African American, and Haitian clients. Patients with depression constitute a large part of the population that the Center serves, but the Center’s health providers have been reporting issues in determining the treatment for certain cases, especially mild depression. This problem is common since it is not clear whether psychotherapy or pharmacotherapy is more effective for mild depression (Reid, Cameron, & MacGillivray, 2014). As a result, the following research question should assist the case: in psychiatric patients with mild depression, what is the effect of psychotherapy on health compared with pharmacotherapy?
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The results of the study will provide the ground for the establishment of direct guidelines on depression management for the care providers of the Center, which will constitute the proposed change. The change is in line with the Center’s mission, which consists of providing high-quality care, and vision, which is to improve the mental health of the community. The culture of the Center is largely beneficial for the change since quality improvement is one of its values, but it is acknowledged that some resistance to change might take place because it is a common concern in change management (Anders & Cassidy, 2014). The issue is more likely to be encountered because all the providers of the institution will be involved in the change due to its significance; as a result, the engagement of the stakeholders will have to be carried out very carefully. Thus, the systems analysis of the settings is a requirement, and the present paper uses Kotter’s change model to this end.
The New Horizons Community Mental Health Center (Miami, FL) is a non-profit healthcare system that was established in 1974 to serve the economically disadvantaged and culturally diverse population of Miami-Dade County. Nowadays, the Center employs 180 staff members (including counselors, therapists, case managers, and nurses) and has about 5000 active clients. The services are provided to people of all ages and various ethnic backgrounds (predominantly African American, Hispanic, and Haitian); they range from prevention to rehabilitation.
Mission, Vision, and Values
Mission, vision, and values define an organization’s culture and strategy, which highlights their importance for the context analysis of the project (Ginter, 2013; Porter-O’Grady & Malloch, 2017). The Center’s mission is to provide comprehensive mental and substance abuse care services to the diverse population of the community of Dade County. The vision is to improve the wellness of the latter by creating an accessible care system. The values include inclusivity, cultural sensitivity, innovation, competence, comprehensiveness and quality of services, and empowerment. The mission, vision, and values of the Center are communicated to different groups of stakeholders through employee orientation activities, meetings, posters, and various handouts.
Interrelationships with other Systems
The review of the systems that the Center is connected to can clarify the context of the project (Vertakova & Vlasova, 2015). The major systems of the Center include those related to substance abuse care, mental health care, assistance to homeless and needy families, and juvenile justice. Moreover, the administrative system can be viewed as a separate subsystem. The latter factor is crucial to the project: to achieve success, it will need to ensure proper communication between the administration and healthcare providers.
One of the larger systems that the Center belongs to is the community. Moreover, the Center belongs to the system of federally managed agencies. The two systems affect the Center, which responds to the needs of the community while being formed and funded by federal efforts. The project needs to take into account these major influences on its context. Fortunately, the proposed change is of interest to the community (and, therefore, federal agencies) because it can improve its quality of life.
Organizational culture is a complex phenomenon that incorporates multiple features, including the vision and values that are translated into behaviors (Davis, Wehbe-Janek, Subacius, Pinto, & Nathens, 2015). Because of the above-mentioned values, the culture of the Center promotes continuous quality improvement and change (Banaszak-Holl, Castle, Lin, Shrivastwa, & Spreitzer, 2013; Wick et al., 2015). Moreover, the values of diversity, inclusivity, and competence make the organizational culture healthy (focused on the empowerment of stakeholders) (Davis et al., 2015). Similarly, the procedures of handling conflicts can also be viewed as healthy: the primary strategy employed by the Center is compromise (Labrague & McEnroe-Petitte, 2017). Despite being centralized, the power structure of the Center allows such conflict management because the Board promotes staff engagement in decision-making. A healthy organizational culture is important for the success of the Center and beneficial for information exchange and cooperation (Fernandez, 2015), which are helpful during a change. Thus, the culture of the Center is conducive to change, although it is relatively unlikely to take noticeable risks.
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Kotter Change Model Application
Kotter’s change model was not developed specifically for healthcare settings, but it has been used in them successfully and rather often (Anders & Cassidy, 2014; Small et al., 2016). The first step proposed by the model consists of creating a sense of urgency, which assists in “unfreezing” the situation and preparing the settings for change (Anders & Cassidy, 2014). The primary aim of this stage is to lead the change stakeholders to recognize the existing issues and opportunities, which provides motivation and informs future activities.
The status quo is unacceptable
Depression is a rather prevalent issue; for example, in 2014, 6.7% of the population of the US had a major depressive episode (Center for Behavioral Health Statistics and Quality, 2016, p. 3055). Depression is a significant health concern that has multiple negative outcomes for patients and their families (Olfson, Blanco, & Marcus, 2016). Also, depression presupposes healthcare expenses. However, the quality of care for patients with depression is reported to be suboptimal (Straten, Hill, Richards, & Cuijpers, 2015), and one of the relevant problems are medication over-prescription. Given the prevalence and consequences of the condition, this issue needs to be actively addressed.
It should be pointed out that over-prescription is a controversial matter. For example, Simon et al. (2015) demonstrate that antidepressants are used for mild depression relatively rarely and suggest that over-prescription is not a major concern. However, the effectiveness of antidepressant use for mild depression is not very well-documented, which is why it may be recommended to attempt non-pharmacological interventions before prescribing medications (Olfson et al., 2016; Reid et al., 2014; Spence, 2013; Straten et al., 2015). At the same time, the research on the effectiveness of psychotherapy for mild depression is also rather limited and inconclusive (Olfson et al., 2016). Olfson et al. (2016) suggest that more research is required to determine the relative effectiveness of psychotherapy and pharmacotherapy; for the time being, providers have to work with limited knowledge. It is apparent that the status quo is not acceptable: it is necessary to offer care providers more direct and clear guidelines to ensure the quality of care for mild depression (Spence, 2013). This fact can be used to create a sense of urgency.
A preliminary discussion with the stakeholders of the future change indicates that not all of them are aware of the problem of over-prescription, but relevant information attracts their interest, which should facilitate the process of creating a sense of urgency. The administration of the Center states that there are no clear guidelines in place to guide the prescription of drugs and psychotherapy for mild depression, and they admit that this fact is an issue. Providers point out that they prescribe both pharmacotherapy and psychotherapy for mild depression based on multiple factors. They report different preferences and suggest that additional data on the topic could better inform their actions, which indicates that they recognize the problem of insufficient evidence.
Concerning the patients, some of them report dissatisfaction with medication, believing that it might be detrimental to some aspects of their health, but many also express the belief that pharmacotherapy is more effective than psychotherapy. Therefore, patients are interested in inconclusive information on the relative effectiveness of pharmacotherapy and psychotherapy. This information about patients’ attitudes should help to establish a sense of urgency for the providers and administration while also serving as a motivation for the patients to participate in the study. In summary, the first stage of Kotter’s model applies to the project and can be employed to its benefit in planning the change.
The second step of the model presupposes creating a guiding coalition, which is a group of people who are going to lead the change (Anders & Cassidy, 2014; Small et al., 2016). The present project will engage four key members. The Director of the Outpatient Clinic, who is a Registered Nurse, possesses a position of power, credibility, well-proven leadership abilities, and expertise. Similarly, the Psychiatric Medical Director, who is a Doctor of Medicine, has a position of power, which comes with credibility and leadership experience, and is an expert in psychiatric matters. The two remaining members are a psychiatrist (Doctor of Medicine) and a nurse (Nurse Practitioner). Despite not having a formal position of power, both have used their leadership abilities when required, and their experience with the Center supports their credibility and expertise. In summary, the members were chosen for their position power, leadership abilities, credibility, and expertise, as well as the willingness to promote change and participate in the project.
All the mentioned members have been working together for at least two years, which has provided them with the opportunity to develop respect and mutual trust towards each other. The team has encountered some misunderstandings in the past, but they were resolved with the help of the well-established communication promoted by the Director. Currently, the team exhibits a notable level of understanding and is ready to address communication issues if required. Also, the members of the coalition recognize the importance of the concept of caring and extend it towards their colleagues. These factors are significant for the second step of Kotter’s model and can facilitate the coalition’s work.
The common goal of the guiding coalition consists of providing improved guidelines on the treatment of mild depression by establishing the relative effectiveness of psychotherapy and pharmacotherapy. This goal is in line with the Center’s vision and mission. Eventually, the coalition aims to improve the quality of care and patients’ safety while also facilitating the activities of the healthcare providers at the Center. Thus, the second step of Kotter’s change model is currently complete.
A meaningful vision
The third stage of Kotter’s model consists of developing the vision for the change (Spear, 2016). The process is complex but rewarding: it has been established that shared vision improves the ability of healthcare providers to work in a team and handle a change (Appelbaum, Degbe, MacDonald, & Nguyen-Quang, 2015; Somboonpakorn & Kantabutra, 2014). The proposed vision for the change can be stated as follows: the care providers of the New Horizons Community Mental Health Center will work together to develop and adopt guidelines for the use of pharmacotherapy and psychotherapy for the treatment of patients with depression while contributing evidence to the controversial topic of the relative effectiveness of the two approaches.
This vision is meaningful for all the healthcare providers of the Center. First of all, it is in line with the mission and vision of the Center. Indeed, the New Horizons Community Mental Health Center strives to provide comprehensive behavioral health services indiscriminately, envisioning an accessible care system that can improve the quality of life in the community of Miami-Dade County. The Board of the staff of the Center highlights the importance of the quality of care and the revision and update of the methods employed by the organization. Therefore, the update of the Center’s guidelines on the use of pharmacotherapy and psychotherapy is an activity that the administration and staff will consider helpful.
Secondly, since the Board directly approves of advanced evidence-based treatment, the staff is also likely to be interested in contributing evidence that can be employed to support better practices. As it was mentioned, the topic of the comparative effectiveness of pharmacotherapy and psychotherapy is still being researched (Olfsonet al., 2016). The problem of over-prescription makes it especially important from the perspectives of patient well-being, treatment effectiveness, and cost-efficiency (Spence, 2013; Stroka, 2015). Preliminary informal discussions with the staff demonstrate that the care providers of the Center recognize the fact that the lack of conclusive evidence prevents them from providing the highest-quality care to their patients, which makes the second part of the vision directly meaningful for the Center and healthcare in general.
Clarification, motivation, coordination, and autonomy
It can be suggested that the vision clarifies the direction of the change: it directly states the primary and the secondary aims of the project, emphasizing the direct outcomes that are to be expected. The specifics of the change are also described, including the exact guidelines that are to be developed. The secondary aim may be less specific since it does not specify the impact that the contribution to evidence can make, but that outcome cannot be assessed or estimated beforehand. Overall, the vision should be able to clarify the change in a concise way, which can help the staff to move in the right direction. The vision also highlights the significance of the topic, indicating that it is controversial and, therefore, requires the attention of healthcare providers. This factor seems to be a major advantage of the vision and should provide some motivation for the staff of the Center.
Apart from that, to motivate the people to take action in the right direction, the proposed vision focuses on the outcomes that they can enjoy as a result of the change, making the primary goal of the project tangible and directly helpful for the staff of the Center. Apart from that, the vision incorporates a secondary aim that may be less tangible but, at the same time, implies the possibility of making a change on a larger scale. Depending on a person’s traits and interests, the staff of the Center can be motivated by different factors, and the proposed vision employs two of them to be able to engage a larger group of people.
The vision directly supports the autonomy of the staff by stating that they will be carrying out the change and making a contribution to healthcare knowledge. It also highlights the fact that healthcare providers will be cooperating (working together) in order to achieve the outcomes of interest. As a result, the vision should be able to coordinate the actions of the staff while highlighting their autonomy and ability to make a difference.
Features of the vision
The vision is imaginable because it does not set unrealistic goals. In this respect, the inferior clarity of the secondary aim is beneficial since it avoids making statements about the specifics of the expected contribution, which makes its achievement more manageable. The development of guidelines on treatment is an imaginable goal that the Center has carried out before. The desirability of the vision is well-established and guided by the everyday needs of the organization and the gap in knowledge related to the two therapies (Spence, 2013). Given the fact that the Board of the Center supports evidence-based practice and related research activities, the vision is feasible and manageable from financial and organizational perspectives.
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As it was mentioned, the primary goal of the vision is very focused; the secondary one is less focused, but this feature is necessary to ensure its manageability. Moreover, this feature secures the flexibility of the vision; the primary aim is less flexible, although some changes could be made if required. As for the communicability, the vision can be easily communicated at the Center through multiple established and less established channels, especially due to the support of the Board and the interest of care providers. Thus, the considerations of the third stage help to assess and refine the vision, justifying its specific features.
Simplicity and language
The fourth stage of the model consists of communicating the developed vision (Pollack & Pollack, 2014), which has also been shown to be an essential instrument of a leader who promotes change in a healthcare environment (Somboonpakorn & Kantabutra, 2014; Spear, 2016). Several considerations are important in this regard. The proposed vision might be viewed as relatively complex because it has two aims, but the premise of both is rather simple and direct, and both aims can be expressed in a single sentence using simple language without jargon. Naturally, the process of communication will not be reduced to a single sentence, which is why the proposed vision does not include any literary devices or examples. Indeed, their introduction into the vision statement could make it more cumbersome and lengthy, which is not desirable given its relative complexity. However, when communicating the vision, it is possible to enhance it with metaphors, analogies, and examples to make it more animated and engaging. The examples can be taken from the personal practice of the staff; the preliminary discussion has demonstrated that the employees of the Center can provide the illustrations of the problems related to insufficient evidence and guidance on the use of pharmacotherapy and psychotherapy. Before using the examples, the members who can offer them will be asked for their consent.
Communicating the vision
The message will be communicated in multiple forms and rather extensively as required by Kotter’s model (Somboonpakorn & Kantabutra, 2014). In particular, the existing mechanisms of meetings and less formal encounters will be employed to this end. Apart from that, additional tools will be used, including newsletters and e-mails, which are occasionally used by the organization. Finally, the dissemination plan can be adjusted to include new mechanisms that will be deemed appropriate by the guiding coalition; they might consist of posters, banners, and flyers. As a result, the vision will be repeated multiple times and in various forms.
The guiding coalition includes care providers and administrators who are all going to be engaged in the change. As a result, they will have the opportunity to lead by example, which is especially appropriate for the providers who will be required to employ the developed guidelines in their practice. It does not seem that the vision has direct inconsistencies, but if they are discovered, they will be addressed specifically. This factor is connected to the fact that give-and-take will be central to the change: the communication of the vision will be two-sided, and the people who voice discontent or demonstrate resistance to change will not be silenced. Meetings will be the major vehicle for addressing inconsistencies and facilitate negotiations; apart from that, a messenger application will be used to examine the issues that may be very urgent or might need a discussion prior to a meeting. The specific messenger will be chosen depending on the participants’ preferences to satisfy the majority of them. In summary, the considerations that are relevant to the fourth stage of the model are helpful in planning the activities related to visual communication, which should assist the change.
The fifth stage of the model is predominantly concerned with the removal of obstacles or barriers to change in order to empower the participants (Spear, 2016). The issues that may be encountered during the proposed change include those related to training, personal resistance, and financial difficulties. Other typical barriers, including the inefficiency of formal structures, are less important for the proposed change.
Indeed, the formal structures of the New Horizons Community Mental Health Center are beneficial for change, which ensures a supportive environment for the project (Hanson et al., 2017). As has been mentioned, the values, mission, and vision of the Center are focused on the quality of care, which, among other things, is achieved through change. This fact is reflected in the structures and the general attitude of the administration and supervisors towards change. The project does not require the introduction of specific personnel systems since no hiring activities are needed, and the existing information systems should be able to support the change. In summary, these features do not appear to be challenging.
On the other hand, the typical issue of skills and training may be relevant and, therefore, should be addressed as required by the model (Ryan et al., 2015). The process of guideline development and change management can require specific skills. Fortunately, the Director of the Outpatient Clinic has had some experience in developing guidelines. Moreover, all the members of the coalition have participated in guideline adoption and change, and the majority of them have well-developed leadership skills. No specific skills are likely to be required for the rest of the participants, but the adoption of the new guidelines will involve relevant instruction to increase the speed of information dissemination. Thus, training will help to empower the participants.
The personal resistance barrier is common for change (Laker et al., 2014), and it is going to be addressed with the help of appropriate models (Hanrahan et al., 2015), as well as some of the interventions that are planned in accordance with Kotter’s model. The participants are expected to welcome the change, but it is also acknowledged that resistance is possible, especially if important concerns cause it. Examples of such concerns include the perceived difficulty of the new requirements or their relative advantages when compared to the previously used ones. These perceptions can be managed by leaders, for example, with the help of the theory of innovation diffusion by Rogers. The latter is shown to be effective in healthcare settings, and it is meant specifically for individual innovation adoption management (Pashaeypoor, Ashktorab, Rassouli, & Alavi-Majd, 2016). As a result, it is appropriate for handling personal resistance. Moreover, the communication activities that have been planned for the fourth stage of the model can also be employed to address resistance. Thus, the barrier can be destroyed.
Finally, financial constraints are a typical issue (Sadeghi-Bazargani, Tabrizi, & Azami-Aghdash, 2014). In the proposed change, an example of such restrictions can be seen in the current uncertainties related to the available communication channels: for instance, it is not clear if the guiding coalition will find the use of posters and banners feasible. However, the problem can be resolved due to careful budgeting. While certain options can be eventually deemed unavailable because of the financial constraints, this factor will push the coalition to use cheaper and more creative solutions. For instance, banners and posters can be included in e-mails rather than printed.
In summary, there exist barriers to the proposed change, including those related to training, resistance, and funding. However, the guiding coalition is aware of these issues due to the application of Kotter’s model, which provides the framework for reviewing them. As a result, it has developed plans that will help in bringing the barriers down to ensure the success of the change and empower the participants.
Short-term wins are the key elements of the sixth stage of the model (Casey et al., 2016; Spear, 2016). The primary aim of short-term wins is to demonstrate the fact that the change is occurring and motivate the participants to proceed with it (Spear, 2016). Also, the achievements can be used to influence the people who resist the change, which should result in bringing down one of the mentioned barriers as also recommended by the model. Thus, this stage is critical for gaining support, which is acknowledged by the guiding coalition and reflected in the plans for generating and promoting short-term wins.
Given the goals and the vision of the project, not all of its outcomes are likely to be immediately visible, but some of them are apparent and will be used as short-term wins. For example, the contribution of new evidence to the study of the relative advantages and psychotherapy and pharmacotherapy is likely to be a long-term outcome, and it is difficult to illustrate its achievement with short-term wins. However, the process of the development and introduction of the new guidelines would be expected to involve multiple milestones. Some of them can include the drafting of the guidelines, their finalization, and the beginning of their adoption.
The communication mechanisms that were employed during the fourth stage can also be used during the sixth one to demonstrate achievements and wins. For example, the weekly meetings will involve the praise and, if appropriate, rewards for compliance and contribution during the implementation process, which should be viewed as another form of short-term wins for a guideline adoption project. Similarly, newsletters and e-mails can include a section of accomplishments if the guiding coalition sees this approach as appropriate. Furthermore, if the posters are going to be employed, enhancing them with short-term wins seems to be an effective motivational strategy. These mechanisms will ensure the clarity and unambiguity of the short-term wins and connect them to the project.
In summary, the guiding coalition recognizes the importance of motivating the participants with short-term wins as recommended by the model. It appears that the first goal is more likely to generate them, for example, in the form of guideline development and adoption milestones. Eventually, these wins will be presented to the participants with the help of the Center’s communication channels which have been considered for stage four of the model.
Stage seven is concerned with the continuation of change, which is achieved by “consolidating” the gains and wins and by ensuring the production of more change (Spear, 2016, p. 60). The adoption of the new guidelines is the primary goal of the project. In order to achieve it, the coalition will focus on the improvement of the communication between the participants (to solicit their feedback and ensure the development of the guidelines) and the promotion of their compliance with the new guidelines (to ensure the usage of the guidelines). These features will be achieved through multiple activities, and the emphasis on the wins of the change and the destruction of the barriers to it will be the major contributors.
As has been mentioned, all the gains that can be described as wins will be highlighted and communicated to the participants. The information will be transmitted through multiple sources, and it will be coupled with rewards meant for the participants who contribute to the change either by providing important feedback or demonstrating exemplary compliance with the new guidelines. These measures should achieve multiple objectives, including the decrease of resistance to change, the retention of participants and attraction of new ones, the promotion of change and change-related activities (that is, the development and use of the new guidelines), and the prompting of the discussion of the change (especially relevant feedback). Thus, the development of active communication within the community is likely to help in consolidating the gains and keeping the momentum of change while promoting feedback and compliance.
Moreover, as the change progresses, the stakeholders will make progress in bringing down certain barriers. For example, the issue of skills, which is common for change management (Ryan et al., 2015), will definitely become less significant as the participants receive the required training. Similarly, the problem of resistance will be addressed with the help of multiple leadership-related activities and specific change management models, including that by Rogers (Hanrahan et al., 2015). Also, the process of guideline development presupposes their adjustment to the needs of the community. As a result, the change will encounter fewer issues with time, which should help it in gaining momentum and motivate and enable the participants to communicate and comply with the new guidelines.
In summary, the change will be consolidated due to the outcomes of the previous stages, especially those concerned with bringing down barriers and providing short-term wins. As a result of these activities, the participants will be motivated to contribute to the development of the guidelines and their usage. Apart from that, the change will be meeting less resistance and fewer barriers as it progresses. Thus, it will keep its momentum and ensure the production of more change.
Stage eight of the model is concerned with “institutionalizing” the change in the culture of the chosen organization (Anders & Cassidy, 2014, p. 145). The significance of culture for a change in a healthcare organization cannot be overestimated: it affects the staff’s motivation (Banaszak-Holl et al., 2013), changes resistance (Johansson, Åström, Kauffeldt, Helldin, & Carlström, 2014), and attitudes to change and quality improvement (Banaszak-Holl et al., 2013; Wick et al., 2015). As a result, it is necessary to plan to embed the new change in the culture of the targeted organization.
It is noteworthy that the culture of the New Horizons Community Mental Health Center is beneficial for change: quality and its improvement are directly included in the organization’s mission and vision. As a result, the staff is expected to have a relatively low resistance to change, and quality improvement should be viewed as a highly valued activity. Given the fact that the introduction of new guidelines for depression medication and psychotherapy is likely to be beneficial for the quality of care (Reid et al., 2014), it would be expected that the project is going to be easily aligned with the Center’s culture. As for the specific activities that are going to facilitate this outcome, they include the alignment of the mission and vision of the project with those of the Center and their promotion with the help of the multiple communication mechanisms that are going to be employed throughout the project. These activities should help to normalize the change from the perspective of the Center’s values. As for the adjustment of behavior, it will be achieved through the above-discussed system of rewards for compliance and contribution.
In summary, the project is going to enjoy the beneficial environment of the targeted organization, which will facilitate the process of embedding the change in the culture of the Center. This outcome is expected to be achieved with the help of the leadership activities that are already planned for the project as a part of the promotion of the change and its vision. Due to the apparent alignment of the visions and missions of the project and the Center, the promotional activities performed by change leaders would be expected to facilitate the achievement of the final stage of the model, ensuring a sustainable change.
Financial Costs of Project’s Implementation
Budgeting constraints are a major issue (Sadeghi-Bazargani et al., 2014), but the project does not presuppose substantial costs. No profit losses are expected from the change, and no direct compensation for participation is planned now since the results of the change will be beneficial to the stakeholders. Some of the existing communication mechanisms (meetings and e-mails) are also free of charge, and the use of electronic files instead of printed ones can limit printing expenses. Thus, as a non-profit organization, the Center can implement a change using a very limited budget, and it is possible to avoid costs completely. However, if the coalition decides that additional financing is in the interests of the Center, the extra money will be employed for participation compensations (meant for the subjects and care providers) and more costly means of communication (for example, posters).
The analysis of the system that will become the settings of the proposed change can provide the following conclusions. The Center is a complex system that exists within the community that it serves and the federal healthcare system. The mission, vision, and values of the organization are affected by its interrelationships with the larger systems, and the smaller ones need to be managed during the change. Kotter’s change model can assist in the process of subsystem management since it promotes effective communication within the system.
Currently, the need for the proposed change, which is the introduction of direct guidelines on the use of psycho- and pharmacotherapy, is acknowledged by the stakeholders, the change coalition is formed, and its vision is developed. The rest of the steps will employ the communication mechanisms that exist in the system to promote the change’s vision, advertise its gains, and bring down barriers. The understanding of the need for the proposed change is connected to the organization’s culture, which is supportive of the change. While the Center has some barriers, including those related to budgeting, their careful management, and Kotter’s model can help to institutionalize the change.
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