A different look

March 1, 2000
Is change an enemy or ally? Perhaps a `beginner`s perspective` will lead to some startlingly good ideas. Why can`t it be the hygienist who sparks change?

Is change an enemy or ally? Perhaps a `beginner`s perspective` will lead to some startlingly good ideas. Why can`t it be the hygienist who sparks change?

Cindy Quinn, RDH, BS

Virtually all of us have experienced change during our tenure as a dental hygienist. Emerging technologies change procedures. Fellow staff members are replaced. A personal decision is reached to try working in a new office. We can relate to the bittersweet feelings of anything new. With a new job, we deal with the sense that things will be "better" at the new place, even though the scribbles from the previous hygienist make one`s eyes cross and the dilapidated autoclave spits!

During the first month, one usually faces the classic "fight or flee" response on several occasions, second-guessing that decision. If the values and philosophy of the office are in sync with personal convictions, most hygienists choose to stay. But they must either downplay or ignore problems, or seek to rectify uncomfortable situations.

Fortunately, they are properly armed as the master managers of change - if they`ll give it a try. No matter whether it`s the radiographs or the receptionist who`s changing, a dental hygienist has the pivotal, yet precarious, role to manage change during a transition.

Change takes many forms in a dental office. Sometimes a "situation" arises that affects hygiene responsibilities directly. For example, a mandate will require four-minute fluoride treatments to all patients during recall visits - without using additional chair time. Other examples include managing office dynamics and policies that affect one indirectly, such as a feud between two co-workers. The advent of high technology in dentistry has also generated changes from the vantage point of remaining up-to-date, sorting through manuals, and literally learning on the job. Probably the most critical, and often overlooked, issue to manage is one`s own career development.

Changes in an existing practice often result in changes in attitude, sometimes positively and sometimes not. Hygienists need to evaluate the impact of all changes that occur and work to optimize the outcome. Conversely, when hygienists initiate the change, they need to identify and address the obstacles that lie ahead before problems arise.

The author of Managing Transitions: Making the Most of Change, William Bridges, feels the key to capitalizing on change lies in understanding the cycle of challenge that is brought about by disrupting the status quo, as well as one`s response to it. He cites historian Albert Toynbee`s A Study of History as demonstrating that "great civilizations have risen to power not because of their advantages, but because they treated their disadvantages as challenges to which they discovered creative responses."

Whether responding to change or initiating it, "a beginner`s perspective" handles change with a clear sense of purpose and an openness to look beyond currently accepted procedures. This ensures that nothing is merely taken for granted, and areas of improvement are easily seen.

Isn`t that what clinical practice is all about? Hygienists are trained to look beyond dental anatomy and see areas where improvements in hygiene or access to an interproximal area are necessary. It`s the same brain wave! It is invaluable to periodically look at a dental office from a beginner`s perspective (see related article), whether as a hygienist beginning in practice for the first time or, more likely, as an experienced professional viewing an existing practice.

Dare to ask the "dumb" questions, even if only in private, because the answer may lead to a solution that saves time or money. Not only will the sacred cows surface and the familiar ruts of routine become evident, but even the visual impact of the office equipment and décor may change. The day-to-day stains, smells, and dirty cushions that the staff looks at regularly may debut as a negative form of communication to patients.

Bear in mind that there is no perfect dental office. As a practice coordinator for a state-supported tobacco-cessation program, I have the opportunity to visit more than 200 dental offices within a short span of time. I have enough discussion with some of them to understand the interplay of personalities and office hierarchies. They vary greatly. I will ask, "Who should I contact in this office to follow up on this?" The manner in which the answer is handled speaks volumes about each office. I can tell which offices put energy into working together vs. which show up to collect a paycheck.

Many offices do things differently from the expected - but "different" doesn`t translate to "bad." It feels awkward or uncomfortable, perhaps, but I`ve seen some innovative solutions come from those willing to be different. I`ve never seen a "perfect" office where there are no problems, inequities, or inefficiencies - and I doubt that one exists.

Much like patients who balk at the thought of floss, office personnel often are reluctant to embrace change. According to Kriegel and Brandt in their book Sacred Cows Make the Best Burgers, change is uncomfortable, unpredictable, and unsafe. People view it as fraught with uncertainty and always harder than it looks. That`s simply human nature. Methods for handling resistance and motivating people will be addressed later in the article.

To do battle with human nature, hygienists must follow the ground rules for implementing change. In order, these include:

- "Sell" the problem, not the solution. Once a problem or opportunity is viewed from the "beginner`s perspective" exercise discussed earlier, it is crucial to "sell" the problem to demonstrate a reason for change. People who understand the real problem on the front end don`t have to be re-educated after the fact. All staff members are educated about the importance of the problem. They begin to tackle the problem from the same side of the field, eliminating the polarity that`s often created when people choose sides in ignorance. When everyone recognizes the problem, it usually is solved faster.

Finally, to quote William Bridges` book: "Selling problems implicates everyone in the solution. It says, in effect, `If you want to be part of the solution, get involved. If you don`t, don`t complain.` "

- Create urgency for resolution. The change manager must create a sense of urgency to make the change, once a sense of buy-in exists. This converts the situation from a topic of complaint or blame to one of action.

Dental offices witness evidence for the need to create urgency on a weekly basis. Think of patients with diagnosed caries who put off tackling the problem until the tooth breaks or aches. That, too, is human nature. Similarly, a change in an office procedure will be put off until something aches or breaks, unless urgency is generated. It must be supported with a written, realistic timeline for action - including accountability to specific individuals - and gentle, but persistent, reminders.

- Develop a migration plan. With the groundwork described above completed, a migration path to the desired outcome is provided. As James Belasco, Ph.D. states in Teaching the Elephant To Dance, "(People) learn by copying. Little boys watch their fathers for the `correct` male behavior and imitate them ... Successful executives model their behavior after a successful boss." At the onset, at least two well-respected members of the office should consistently model the appropriate behavior to bring about the desired change.

- Take time for all three transition steps to occur. The next rule for implementing change involves a three-stage transition process, outlined by Bridges. He writes, "There can be any number of changes, but unless there are transitions, nothing will be different when the dust clears." The starting point for transition is not the outcome desired from the change, but rather the psychological ending one has to make to leave the old situation behind.

This is best explained through an example. When parents have their first child, they must mentally put an end to life as it used to be, letting go the routines of regular sleep, extra money, or the spontaneity of going somewhere when you feel like it. The next stage in the transition process is called the "neutral zone," according to Bridges. It`s the limbo land when the old way is gone but the new way doesn`t yet feel comfortable. People often feel confused, frightened, and try to escape. If given time (where failures are forgiven and repetition breeds familiarity), revitalization occurs and people evolve into the third stage, a new beginning of a procedure or change in services rendered.

- Reinforce new behaviors. Any newly adopted behavior must be reinforced to have lasting effects. In Managing Transitions, the author suggests four ways to continually refocus energies in new directions, reinforcing new beginnings. They include:

> The use of a consistent message

> Restoring self-confidence

> Symbolizing the change

> Celebrating a successful outcome

The first way to reinforce behavior is to be consistent with the message, the desired change, and the corresponding behavior that is required. Bear in mind that if people are asked to, for example, process five additional forms without removing anything from their existing list of tasks, it sends an inconsistent message if one`s focus is efficiency. It is also inconsistent to ask people to act in new ways and then reward them for old behaviors. This often happens when an office encourages teamwork on a project and then rewards individual contributions. To properly reinforce, people must feel they are better off for having changed their attitude and behavior.

People asked to make a change often feel less confident, particularly in the neutral zone of transition. They usually feel less productive and competent, so they are likely to need to see some fairly immediate successes to restore their self-confidence. Thus, the second rule to reinforce behavior is to ensure success by setting initial goals in situations with little risk of failure or with ongoing efforts where success is pretty much in the bag.

Bridges` third rule requires "symbolizing" the change. Apparently, small things can take on enormous significance as people work through a change. Think about the stickers, stars, and toothbrushes used to encourage proper behavior from young dental patients! The symbol itself does nothing to contribute to the successful leap of change, but it brings change to a level of importance.

Finally, one must celebrate the successful outcome of the change. When a majority of the office has become comfortable with the new procedure and has regained their confidence, it`s time for a fun break from the routine and a note of thanks.

Pockets of resistance

But just like those patients who know they need to floss faithfully, people are often resistant and require motivation to implement a change. It is wise to evaluate staff members` attitudes when initially selling the problem to the office and take the appropriate action early. As Kriegel and Brandt put it, "Resistance is the hump in the road that few leaders know how to get people over. Most think all they have to do is reward or threaten people. Or they hope resistance will simply disappear once the change is imposed. These are half-measures, like putting on a clean shirt when what you really need is a shower." The authors feel one needs to uncover the real cause for resistance from office members and suggest that it usually originates from fear, feeling powerless, or inertia.

Fear is the most common cause of resistance, as well as the most powerful. Everyone has fears, but no one is ready to admit them. The current pace of change in the world also heightens anxiety, because nothing stays predictable for very long.

Most fears, however, are exaggerated and irrational, easily offset by a good reality check. The best way to diminish the fears of staff members who resist change is with the following two questions, according to Kriegel and Brandt: First, what`s the worst thing that could happen if the situation doesn`t work out? Secondly, on a scale of one to 10 - if 10 equals certainty - what are the chances of your fears being realized?

By allowing discussion of these questions, people usually realize that the chances of the imagined disaster are much less than they first thought. It also helps to pattern one`s fearful self-talk as "if-then" statements (If the printer jams, then I`ll hand-write the bill), rather than "what if" worries (What if the printer won`t work?). A savvy change manager can gently make those reminders.

Many people resist change when they feel powerless. This usually occurs when they are told what specific action to take, rather than allowed to give input prior to the decision. To successfully implement any change, employees must also be empowered to make choices, take action, and give feedback. As Kriegel and Brandt state it, "Employees want to feel like participants, not bench-warmers."

As mentioned earlier, some people view a change as extra, unnecessary work. This creates resistance in the form of inertia. No matter what timeline is established, they distort the amount of effort that will be required and put off action. The best way to deal with these people is to break the project down to manageable increments, using concrete demonstrations that correct these distortions and reduce the quantity of new material to be learned. People also distort how much change is truly involved in change. Sometimes they distort that a change to one process means the entire system will change. In that case, the hygienist should not only point out what will be altered but what will remain the same.

The rewards

Once resistance is countered, it`s on to motivation. In Sacred Cows Make the Best Burgers, the authors offer a great contrast, "Overcoming resistance is about neutralizing negativity. Motivation is about lighting a fire." They go on to say, "When people are burning with enthusiasm, they`ll take risks, go the extra mile, and fully commit themselves to change."

We have to motivate and remotivate to inspire progress. Motivating people is much more than exhorting people to jump on the bandwagon. It also involves giving clear responsibility for execution and a powerful rationale for action. We have to understand what motivates each member on the team and use that knowledge to create commitment. Look for natural leaders in the office - people who others look to for cues about how to react to change - and convince them about the need for the change.

Building and maintaining enthusiasm for the change is a learned behavior, so don`t expect it to happen overnight. However, enthusiasm is the single most important factor differentiating "outstanding" from "good" performance, according to research cited by Kriegel and Brandt. People get inspired by possibilities, not probabilities. So it is best to create a vision that makes people feel their contributions are making a difference in the office. This vision doesn?t have to be global; it can appeal to people?s personal hopes, dreams, and aspirations instead.

No discussion on motivation would be complete without the topic of rewards. Corporate America has taken incentive plans to such new heights that many personnel think like children: OWhat will I get if I do it?O

The two ways to motivate people with rewards are extrinsic and intrinsic. Extrinsic incentives include money, gifts, and titles. They often are not necessary to accomplish change that benefits the entire office. Intrinsic incentives are intangibles such as fairness, flexibility, freedom, and recognition. They also include belonging, acceptance, and identification ? rewards that fulfill social needs particularly when working as a team. Needless to say, if the initiator of change develops and fosters intrinsic incentives, the office remains motivated.

By now, the skeptics should be asking, OWhat?s in it for me?O Why should a hygienist take the time to look at the dental office from a beginner?s perspective; identify problems that lead to unfairness, inefficiency, or compromised patient care; and become a manager of change to improve the situation? Why bother dealing with the resistance along the way and the cheerleading necessary to motivate and remotivate?

The answer is that people ? staff, dentists, and patients ? appreciate progress and respect those who contribute to solving problems and fleshing out opportunities. In fact, others in the office more readily notice one?s expertise in these areas than clinical skills because everyone gains from them. That creates bargaining power at raise time!

Managing change within the dental office also contributes to the challenge needed for professional growth and dilutes the monotony sometimes found with 10 prophys per day. More importantly, the development of change management skills allows hygienists to move forward from the ruts created in both their personal and professional lives, a challenge of nonsensical sacred cows, and the confidence to take risks.

So are ya ready for a change? With a little practice, you betcha!

Cindy Quinn, RDH, BS, works as a practice coordinator for Tobacco-Free Ways, a grant-funded tobacco-cessation program that enlists the cooperation of health care providers in Tucson, Arizona.

A "beginner`s perspective"

Begin practicing on a very simple, ordinary item such as a saucer. Sit in a quiet spot without interruptions, and imagine that you`ve never seen the item before. Remove all preconceived notions from your thinking, something difficult to do without practice. Now write down as many uses for it as you can. When finished, look at the end of this article to see how your answers compare. Once you`re comfortable with ordinary items, switch to dental office items.

You can also borrow from the re-engineering gurus to practice with processes and services, rather than tangible items. The answer to the sample of questions listed below may surprise you when answered from a beginner`s perspective:

> How do patients want to deal with us?

> What would the practice look like if created today?

> What worthwhile purpose does it (specific service or procedure) serve?

> Why is that procedure scheduled that way?

(From a beginner`s perspective, a saucer could be a sunshade, hat, paper clip dispenser, paperweight, doorstop, etc.)