Part 1:  The Hook

Rhonda is a new program director (PD) in a three-year Emergency Medicine training program in the United States. She has been PD for the past year and is leading the curricular conversion of the weekly conference day from traditional didactic lectures to a more interactive flipped classroom model. Although this change is supported by the literature, Rhonda is already hearing rumblings of discontentment from two separate stakeholder groups: the residents and the academic teaching staff.

Rhonda progressed to the PD role relatively early in her career. She has been consistently recognized for her attention to detail, tireless work on establishing strong program frameworks, and efforts to actively evaluate the successes and failures of her interventions. Despite this, she is feeling under-equipped to deal with a change management problem. She has astutely recognized that her ability to prepare the structural elements for this change may not be enough to convince either or both of these stakeholder groups.

Rhonda wishes she could find a framework that might help her understand which approach to change might be most useful for each of the stakeholder groups. She has recognized through conversation with these groups that they have different concerns and needs when applying the flipped classroom model. As such, she has recognized that addressing these concerns with explicit and deliberate change strategies might be the best approach.

Part 2:  The Meat

Overview

In 1984, Lee Bolman and Terrence Deal published their theory to describe methods for influencing and invoking change within an organization.1 They present four frames, or lenses, through which the mechanism of change can be viewed: structural, human resource, political, and symbolic. Factors in determining the appropriate frames to use in a given situation include the type of organization, the people undergoing the change, and the degree of change being implemented. A leader may show proclivity for one or two frames but may be resistant to using others due to lack of familiarity or comfort, resulting in recurrent use of less effective techniques. Success or failure of an attempted change movement can often be explained retrospectively via this model through the interpretation of the lenses used.

Background

Most organizations have a hierarchical system that places individuals in positions of leadership. Leaders and managers vary wildly in their skills, attributes, leadership styles, and interpersonal strengths. Recognizing different perspectives is a necessary skill in order to be an effective manager of individuals with various personality types. However, many people in supervisory positions are not well versed in reframing their perspective or are not aware how to do so.

In 1984, Bolman and Deal wrote Reframing Organizations: Artistry, Choice and Leadership, with the goal of defining four different perspectives, or frames, that can be used to assess organizations, leaders, and events.¹ Each frame is unique in its viewpoint and enlightens specific aspects of the case in question. A given person or situation may be better viewed through either one or multiple lenses in order to obtain a complete picture. Many people tend to use one or two frames preferentially, so being able to intentionally reframe in alternative perspectives is a valuable skill for effective problem solving.

Bolman and Deal’s Four Frames Model:

1. Structural

This frame focuses on the “how” of change. It primarily focuses on strategy; clarifying tasks and responsibilities; setting measurable goals and deadlines; and creating systems and protocols. This frame is well-suited for organizations and managers that deal in analysis and logic. Roles and goals are generally well-defined. The emphasis is on rationality, facts, and data. The organization itself can be thought of as a machine, requiring precision movements of many cogs. As such, the leader will need to be direct, focused, and methodical.

2. Human Resource

This frame is focused on the individual, their needs, and their value within the organization. The emphasis is on giving team members the power and opportunity to perform their jobs well. Interpersonal skills are critically important as coaching, motivation, guidance, and support of the individual are key in establishing the role and fit. The organizational goal is often empowerment and job satisfaction within the workforce.

3. Political

This frame emphasizes the importance of addressing conflicts between individuals or differing interest groups. The characteristics of an organization viewed through this lens include scarcity, power, allies, and deal-brokering. Leaders need advocacy, networking, and negotiation skills. The emphasis is on using any and all assets to maximize the benefits to the unit, organization, or workforce with the recognition that not all needs may be met.

4. Symbolic

This frame is often described as theatrical because the focus is on aligning individual goals with organizational goals to create a sense of purpose or meaning in one’s work. The manager must be a charismatic visionary with the ability to excite and motivate through storytelling and showmanship. The leader should ensure that there is a motivating vision and actively recognize excellent performance in their team members.

The four frames are guides that can be used to evaluate a complex situation and determine solutions. Reframing it with these lenses provides insights regarding the root causes behind an issue, possible paths for forward progress, and methods for achieving the desired goal. Analysis from a single viewpoint rarely offers the complete picture. Organizations and people are complex entities, requiring thoughtful analysis when evaluating, motivating, or initiating change. Using this organizational theory from Bolman and Deal will allow one to gain clarity of the task at hand and develop a roadmap for the most efficient and appropriate strategies for achieving success.

Modern takes or advances

Bolman and Deal have released six editions of their book. While their examples have changed to become more modern, there have not been many major advancements to the tenets or components of the theory.

Gwen Moran wrote an article in Fast Company that addressed utilizing reframing in the lives of individuals.² Pulling back the organizational component of Bolman and Deal, she focused on individuals and events. She discussed the benefits of reframing, include putting a positive spin on a generally negative situation and as a means of reassessing a task that may be idle or heading in the wrong direction.

Additionally, Bolman and Deal created a Leadership Orientation Survey, which measures individuals’ propensity toward leadership through each of the four frames. Completing the questionnaire results in a detailed analysis of which frames the survey-taker shows preference for, allowing for the identification of frames that they may be reticent in utilizing. The survey (available here) has been used by management to research leadership styles and frames of employees.

Other examples of where this theory might apply in both the classroom & clinical setting

Successfully enacting change requires buy-in from all of the involved parties. Being able to reframe an idea allows the change-maker to address concerns from different groups in a manner that will resonate at an individual level.

Patient flow modifications may create some anxiety among members of the healthcare team. For example, developing a Clinical Decision Unit (CDU) will impact physicians, nurses, and hospital administrators. A CDU is more akin to inpatient medicine and will require physicians to disposition patients after undergoing tests seldom ordered in an Emergency Department setting. Emergency nurses generally function with a high-acuity, rapid pace in the ED. However, in a CDU setting, the excitement is more limited, which may make the job less appealing. Hospital administration also needs convincing that CDU creation will increase the institution’s bottom line, while avoiding a negative impact on other hospital processes. Three groups with vastly different impetuses need addressing. The physician group may be best framed in the Structural model, while nursing may be best viewed using the Human Resources lens, and hospital administration evaluated with Political frame.

In the education setting, adopting an alternative method of evaluating learners is likely to cause some challenges, as well. End-of-shift evaluation forms, while common, are often seen as relatively low yield by faculty. Requiring faculty to complete the forms without understanding the potential benefit can lead to poor responses. Similarly, if learners do not see a value, they may be less likely to incorporate the feedback. Therefore, it is important to address this with both faculty and learners to ensure that there is proper support. This may involve one or more different frames.

Annotated Bibliography of Key Papers

Bleich MR. Job and Role Transitions: The Pathway to Career Evolution. Nurs Adm Q. 2017;41(3): 252-257.³

Bleich provides a summary of the four frames by Bolman and Deal and then uses this to guide readers regarding their readiness and need for change.

Gallos JV. Reframing complexity: A four-dimensional approach to organizational diagnosis, development, and change. Organization development San Francisco: Jossy-Bass. 2006.⁴

In this book, Gallos explores the frames developed by Bolman and Deal as a vehicle for diagnosis and change. She elaborates on how to directly apply each frame to real world organizational challenges and how to use the frames to create a culture of change.

Lieff SJ, Albert M. The Mindset of Medical Education Leaders: How do they conceive of their work? Acad Med. 2010 Jan;85(1):57-62.⁵

Leiff and Albert explore the use of each of Bolman and Deal’s four frames by medical education leaders. The authors determined that most leaders in medical education use all four frames, with the majority favoring the Human Resource frame. The article contains an excellent visual depiction of each frame and the themes in medical education in which to apply each frame.

Sasnett B, Clay M. Leadership styles in interdisciplinary health science education. J Interprof care. 2008; 22(6):630-638.⁶

Sasnett and Clay evaluate interdisciplinary health science education, including multiple areas within medicine. The authors discuss how different areas of medicine (eg, nursing, occupational therapy, medical residency directors, radiation therapy, interdisciplinary, and health information management) use varying frames. According to the article, the most prevalent frame across all areas of medicine is the Human Resource frame.

Swan-Sein A, Mellman L, Balmer DF, RIchards BF. Sustaining an advisory dean program through continuous improvement and education. Acad Med. 2012; 87(4): 523-528.⁷

Swan-Sein and colleagues discuss applying Bolman and Deal’s four frames with regard to the advisory dean program at the Columbia University College of Physicians and Surgeons. This article is a real-life example of applying the four frames to an academic medicine organization, including specific strategies associated with each frame.

Limitations

One limitation of this theory lies in the ability to choose a frame for a given situation. There is no blueprint for selecting which lens will result in the correct focus, and in some cases, multiple techniques may need to be considered and utilized in order to successfully integrate change. Picking the wrong frame to address a change may result in a significant error that could prematurely damage or destroy a potential initiative.

A second limitation of this theory is that it provides little guidance in environments with more distributed leadership. When multiple agents are simultaneously affecting change, it become less clear how to apply strategic changes through a variety of avenues.

Finally, this theory simplifies management styles into single approaches when in fact the application of many of these may be required to affect change.  These are further described in texts such as “Leading Change” by John Kotter and “7 Habits of Highly Effective People” by Stephen Covey.

Part 3:  The Denouement

After reading Bolman and Deal, Rhonda feels empowered to address the concerns of both groups.  Her change management strategy is now catered to the individual needs of the stakeholder groups.  She feels the following strategies will allow her to be more successful in the implementation of the change concept in her group.

With staff members, Rhonda heard a concern that prepared educational materials would have to be changed and that these individuals felt unprepared for this curricular change. Therefore, she decided to use a “structural” model with this group. Many of these individuals did not understand the meaning of “flipped classroom”.  As such, Rhonda stayed with her usual structured approach to change management. She established small group sessions with staff members who required more background and education surrounding the flipped classroom change. She disseminated a slide deck which underlined core principles of flipped classroom and used slide labelling to reinforce the flipped classroom model. She also devised a formal document which outlined the core reading list to be disseminated to residents for each session. Finally, she set up an automated email schedule of staff reminders for each step of the presentation and session preparation. Staff felt well-supported in their change to a flipped classroom model.

With the residents, Rhonda applied a different approach to change management.  Residents were concerned regarding the additional preparatory work that needed to be done before the educational sessions and balancing clinical requirements with this new work. With this group, Rhonda tried the “human resources” approach. She recognized that residents needed to have a clear and caring approach to this new change and required an open communication channel with the PD to discuss stressors, problems, and ongoing solutions. Specific residents were appointed to bring these concerns forward. Rhonda established a WhatsApp channel for all of the residents to engage in asynchronous discussion of any issues. Residents took part in the curricular design to ease the workload over the year and a quick discussion of any issues preceded each academic day.

After following the model discussed above, Rhonda feels that the change implementation was much smoother than she could have otherwise hoped. Although the change remained complex with ongoing operational and individual challenges, the overall impression of the conversion to the flipped classroom has been positive. Both teaching staff and learners are much happier with the new education model.

Don’t miss the 2nd post in the series, coming out Tuesday, April 16, 2019!