Employee buy-in to innovation and change is more important than ever in the success of any healthcare organization... Change and challenge are our constant companions. Employee buy-in to innovation and change is more important than ever in the success of any healthcare organization as it changes in response to internal and external threats and opportunities. Additionally, the more buy-in employees demonstrate in support of the change, the more likely the change will be successful and sustained over time. If change cannot be sustained to meet the threats and opportunities an organization faces, then the change turns out to be an expensive exercise in futility, and it has the potential to negatively impact the short-term and long-term strategic trajectory of the organization (Paterson, 2000; Robertson & Cooper, 2010; Xu & Cooper-Thomas, 2011).

Leaders must be careful not to label the activities of the past as inadequate, but rather as adequate for the time... Change involves learning something new and simultaneously letting go of the past. In the uncertainty and ambiguity of today’s healthcare system, we must try new ways of providing care, and in doing so, we must take risks. During this process, staff may feel as though they are letting go of things that have served them well and have great meaning to them as part of their routine. Leaders must be careful not to label the activities of the past as inadequate, but rather as adequate for the time, realizing that the activities of the past will not produce the desired outcome within the new context of healthcare. The leader oftentimes is the first to identify the value and purpose of the new way of doing things and must do so in such a way as to increase the likelihood of staff buy-in (Geisler, 2012).

Shared governance, introduced by Porter-O’Grady and Finnigan (1984), is a strategy that can facilitate point-of-service nursing staff buy-in because it allows nurses greater control and autonomy over their practice, rather than having their practice controlled by senior nurse executives. Many healthcare leaders have sought to enhance nurse participation in various organizational initiatives through nursing shared governance structures. However, as Hess (2004) pointed out, shared governance structures are demanding and challenging to design and maintain; they require an investment on the part of the organization, its leaders, and point-of-service staff. Although some nurses will actively engage in the work of change, others may be content to play a passive role during times of change.

While buy-in may be implicitly understood during some organizational change processes, leaders in organizations that are experiencing problems with employee participation in shared governance, or with sustainability of initiatives, may benefit from seeking a greater understanding of the complexities of buy-in. Doing so will help them to more effectively engage employees in carrying out the organization’s mission, vision, values and strategic trajectory.

Paterson (2000) noted that although many leaders do not understand the importance of making buy-in a priority in their change strategies, the idea of buy-in does not have to be an elusive matter. However, achieving buy-in does require timely, accurate and credible communication, as well as a thorough understanding of what is important to the employees on whom any strategy depends. Credibility, vital to any form of communication, stems from being frank, honest, and up-front about the conditions that have stimulated the need for a change in direction or strategy. The purpose of this article is to identify prerequisites to buy-in, which, when cultivated, may positively influence nurse engagement and buy-in. In this article we will discuss the concept of buy-in, identify prerequisites for buy-in, consider factors for enhancing buy-in, and present scenarios of what happens when buy-in happens, when it almost happens, and when it fails.

The Concept of Buy-In

It is important to understand the concept of buy-in before trying to convince others to participate in a given activity. In this section, we will discuss both what buy-in means and what buy-in looks like.

What Buy-in Means

...buy-in involves one’s tangible or intangible return on one’s investment. An astute student need not study long before recognizing that buy-in is rooted in the act of an individual or group giving something in return for something else. In other words, buy-in involves one’s tangible or intangible return on one’s investment. To buy-in could include “to purchase shares in a company” or “to buy goods and securities on the open market against a defaulting seller” (Buy in, 2013 para 2-3), to purchase a part of something that is also partly owned by others (Buy in to something, 2013), or for an individual or group to purchase an organization in-order-to become its new owner (Management buy-in, n.d.). In the world of gaming, buy-in is the payment required to participate in poker or other gaming activities (Buying in poker, 2013). An online slang dictionary used down, cool with, game, and dig as alternatives to buy-in (Buy in slang, 2013).  A commonly understood definition of buy-in, particularly as related to shared governance structures, is “to agree with; to accept an idea as worthwhile” (Buy in to something, 2013, para 2).

What Buy-In Looks Like

If nurses were asked to list characteristics of buy-in, they may respond with descriptors, such as agree, commit, willing to do, or I’m in. The phrase throwing my hat in the ring may also resonate with many as the way in which buy-in is manifested. Buy-in, in many interpretations of the term, signifies a form of payment in exchange for something tangible or the opportunity to obtain something tangible by acting in a certain manner.

Buy-in is considered to be a personal and professional commitment to actively engage in a process, task, or initiative. Buy-in is considered to be a personal and professional commitment to actively engage in a process, task, or initiative. Without buy-in, employees are more likely to go through the motions and not commit to a level of change which results in active engagement. There are several prerequisites nurses consider before buying-in to any initiative, including shared governance. Think of the large colored circles on the famous Twister^® game mat as similar to the situations, culture, work climate, attitudes and beliefs that nurses encounter or espouse. Similar to Twister participants evaluating which arm or leg to move to keep themselves from toppling over and failing the Twister challenge, nurses carefully evaluate risks versus benefits as they determine how much to personally invest in the latest initiative. The factors influencing nurses as they evaluate how much, if anything, to personally invest in a new way of behaving are prerequisites to nurses buying in to, and subsequently actively engaging in, a new activity or initiative. Those prerequisites are individual and personal. In shared governance, or any other worthwhile initiative, buy-in is a critical element to success.

Prerequisites for Buy-In by Front-Line Staff

Of equal importance to what buy-in looks like is how buy-in is measured and what precedes the act of buying-in. From our experience, buy-in is demonstrated in a number of ways, including participation through voluntary attendance, verbalization, vote, show of hands, or formal application. A review of the literature resulted in few objective measures of buy-in. When the term is used, it is most often implied to just happen, without discussion of what factors led to the act of buying-in. Additionally, psychological states may play a role in an individual’s willingness to buy-in to an initiative. These prerequisites can be considered predictors, offering a feel for the front-line staff’s degree of readiness for implementing an initiative. They can help nurse leaders anticipate the ease, or lack of ease, regarding facilitating a given change process. These prerequisites can also serve to facilitate buy-in to the extent that leaders are able to adapt the proposed change to the workers’ psychological state(s). Each of these prerequisites will be considered below.

Objective Measures

Thomson, de Chernatony, Arganbright, and Khan (1999) evaluated employee commitment (emotional buy-in) and understanding (intellectual buy-in) as influencers on brand and business performance. They created a Likert-scale questionnaire with six statements characteristic of emotional buy-in and five statements characteristic of intellectual buy-in. The questionnaire was administered to 350 British managers. These authors concluded from their literature review that the higher the emotional and intellectual buy-in, the better the performance of the individual. They constructed a two-dimensional emotional-intellectual matrix to visualize levels of commitment and understanding. Their findings substantiated their literature review in that the higher the commitment and understanding of the individual, the stronger an advocate that person is for the growth of the organization.

Psychological States

Hackman and Oldham (1980) introduced a model of work re-design, which, if done properly, will lead to high internal work motivation and consequently increase employee engagement. To reach the outcome of high internal work motivation, the following three critical psychological states must result from one’s work: (a) seeing work as meaningful; (b) taking full responsibility for the outcomes of one’s work resulting from increased autonomy over defining the work; and (c) having concrete knowledge of the results of one’s work. Feedback about the outcomes of one’s work is a major component of defining the work as meaningful and motivating.

In the early 1990’s, Kahn (1990) extended the work of Hackman and Oldham and posited that there are three specific psychological conditions that directly lead to employee buy-in and eventual engagement. These three internal conditions are described in the Table.

Kahn defined meaningfulness as the employees’ awareness that they will be adequately rewarded for their personal investment in the work of the organization. Meaningfulness should be evaluated in terms of the immediate efforts employees must expend to be fully supportive of the change as well as the efforts required to sustain the change. Leaders must identify both the short-term and long-term benefits of any proposed change.

If for any reason someone must hide an aspect of self, that employee is not truly present with the work. Psychological safety is the personal awareness that the employee feels knowing that one’s whole self can be brought to the role without adverse consequences to self-image, status, or career ambitions within the organization. In other words, one can be authentic about self in the workplace, and thereby bring one’s entire self to one’s work (Kahn, 1990). If for any reason someone must hide an aspect of self, that employee is not truly present with the work. Creating a work place that inspires meaningfulness and safety will lead to employee availability and ultimately employee buy-in.

Psychological availability is the personal awareness that an employee has the necessary psychological, emotional, and physical resources to invest in the role. Psychological availability is impacted by the employee’s life outside of the organization, and is influenced by whether or not that person’s life, with its many distractions and challenges, leaves ample psychological, physical, and emotional resources to invest in the organization (Kahn, 1990).

Employees often bring themselves into and out of organizational life as their life circumstances change. Psychological availability is the condition least under the influence and control of the organization and its leaders and is often the most difficult to facilitate. Employees’ life circumstances can change over time, having a profound impact on role performance. Early recognition that high performing employees’ personal circumstances have changed and are negatively impacting their role performance can assist both managers and employees in making appropriate assignments. Employees often bring themselves into and out of organizational life as their life circumstances change. Most employees have times in their outside life when they must retreat somewhat from organizational life. The astute leader understands that temporary disengagement is much different from chronic disengagement. For the chronically disengaged, the best approach may be to separate that employee from the organization because that individual often has a negative impact on the performance of the team and organizational effectiveness (Kahn, 1990).

Factors to Enhance Buy-In

As an extension of Kahn’s work, we believe there are additional factors that can either hamper or facilitate employee buy-in. When leaders attend to these factors, they can cultivate buy-in. For any initiative, whether establishing a shared governance structure or promoting employee-led initiatives in an established shared governance model, making the effort to assess and evaluate the current status of each of these factors, and strengthen these factors as needed, may enhance staff members’ level of buy-in. It is important that organizations recognize that these initial factors (employee engagement, trust, balance of options, personal connection and adequate time to engage in an initiative) are all necessary for buy-in when the organization needs to make a planned, systematic change. Pausing to assess and attend to these factors is a vital step in successful change. The following discussion will consider each of these factors.

Initial Engagement

The initial engagement prerequisite may often be expressed in the question, “What’s in it for me?” Initial engagement is the “hook” that grabs the attention of the nurse. Vestal (2012) documented foundational elements established by leaders that she believed to influence employee engagement. They included clearly articulated and relatable desired outcomes and goals to reach those outcomes, establishment of relationships with employees, promotion of employee work-life balance, creation of a supportive environment, and demonstration of leader engagement in organizational outcomes. Initial engagement can be piqued through effective communication (Thomson et al.,1999) and a sense of urgency that disrupts the status quo and overcomes complacency (Kotter,1996). Because all organizational change essentially consists of personal behaviors, effective leaders understand that the way they communicate the need for change is most effective when presented in a way that speaks to all employees (Crow, 2006). The initial engagement prerequisite may often be expressed in the question, “What’s in it for me?” Nurses compare the incentive(s) to buying in to an initiative like shared governance to the cost of committing.

Trust

Trust, including trust in the process, in the competence and experience of those implementing the process, and in those participating in the process, is another important factor in promoting buy-in (Bowles, Cunningham, & De La Rosa, 2007; Dooley & Fryxell, 1999). Trust is evaluated based on the competence and loyalty among those participating in the decision-making process (Dooley & Fryxell, 1999). Dwyer, Schurr, and Oh (1987) and Morgan and Hunt (1994) noted that it is important for leaders to understand employees’ degree of trust when assessing expectations for cooperation.

Balance of Options

as the number of current initiatives increase, individual interest begins to decrease. Porter-O’Grady and Malloch (2011) identified the need for managers to create a "culture of buy-in" (p. 109) to engage employees in the ongoing initiatives of the organization. They observed that as the number of current initiatives increase, individual interest begins to decrease. Many leaders have witnessed how too many competing priorities have led to frustration and burnout in their nursing staff. Additional research is warranted to understand how to find the balance between having an appropriate number of options to stimulate engagement, yet not overwhelm an already busy nursing workforce.

Personal Connection and Consequences

Buy-in does not occur until the individual’s goals and core beliefs align with those of the organization. Buy-in does not occur until the individual’s goals and core beliefs align with those of the organization (Porter-O’Grady & Malloch, 2011). According to Maitlis and Ozcelik (2004), individuals take into account potential positive and negative consequences based on personal preferences and expectations prior to making a decision regarding a change. Nurses who believe an initiative to be in conflict with their personal values and/or to lead to negative consequences are unlikely to buy-in to an initiative. The process of buying-in includes a personal review of the emotional, psychological, and/or physical motivation individuals have to connect them to the project. The concept of personal connection and consequences directly links to Kahn’s (1990) concept of psychological availability reviewed earlier in this article. Nurse leaders facilitate this connecting when they help employees consider the extent to which the consequences may strengthen their personal values.

Time

Employees know that new initiatives are a function of time and money. When employees feel that they are not allotted adequate time to safely provide quality, cost effective, and goal directed patient care because the budget will not allow it, while at the same time the organization is introducing initiative after initiative, it is easy to understand why they feel like management is not listening to their concerns.

Without a structure and process, such as shared governance, where issues can be aired in an environment of trust and respect, management should not be surprised when employees seem to be just going through the motions. Therefore, adequate time to both solve the day-to-day problems faced by clinical staff and to develop a new initiative is vital to the success of any organizational change. Without adequate time, buy-in for future initiatives is not likely to be successful, causing most initiatives to fall short of the intended goal.

Without time to evaluate the risks and benefits of participating, as well as time to focus on quality nursing care, a nurse may choose to simply ignore a new initiative. Légaré, Ratté, Gravel, and Graham (2008) reviewed 38 studies of barriers and facilitators to shared decision-making implementation. Time constraints were the most frequently cited reason for not implementing shared decision-making in clinical practice. While the type of shared governance structure described by Légaré et al. (2008) is specific to shared decision-making between physician and patient, the importance of time for the process of shared decision-making is equally relevant to nursing shared governance structures. Without time to evaluate the risks and benefits of participating, as well as time to focus on quality nursing care, a nurse may choose to simply ignore a new initiative.

When Buy-in Happens, Almost Happens, and Fails

Three scenarios are provided below to demonstrate Kahn’s (1990) prerequisite psychological states and our extension of Kahn’s work to include initial engagement, trust, balance of options, personal connection, and time. For ease of reference, each reviewed prerequisite is identified in parentheses in each scenario.

Buy-in Happens

Charge Nurse Susan, a 10-year veteran on a busy medical-surgical inpatient unit, had been reading in the local hospital paper about a rise in pressure ulcers throughout the hospital. A recent letter from the Chief Nursing Officer (CNO) called for all nurses who were interested in discussing the prevalence of pressure ulcers to attend a discussion forum the following day (stimulating commitment through initial engagement). Susan was intrigued, as she had cared for two patients in the past month with hospital-acquired pressure ulcers (initial engagement and personal connection through motivation to help her own patients). The next day Susan and approximately 30 other nurses from various departments in the hospital attended the discussion forum. The CNO began the session with one simple statement: “As nurses, each of us is here to provide the absolute best care possible for our patients. The data show that we’ve experienced an increase in pressure ulcers, and we need your help (psychological safety) to understand why the numbers are increasing and what we can work on together to make a change” (initial engagement through a clearly articulated vision and relatable outcomes). The CNO’s statement led to an hour of productive dialogue among the nurses in attendance, with the CNO and other leaders actively listening and asking key questions throughout the conversation (creating a sense of trust).

...[Susan] felt that the nursing leaders truly valued the input of the group (personal connection). Susan was impressed with the atmosphere in the room. Her nursing colleagues shared her passion for patient care (psychological meaningfulness and availability), and she felt that the nursing leaders truly valued the input of the group (personal connection). The consensus of the group was that the current, antiquated hospital beds were ineffective in supporting patients long-term, despite various nursing interventions to prevent pressure ulcers. The CNO reported to the group that she had suspected the beds may be a cause for the prevalence of pressure ulcers, but she had chosen to reserve her opinion until she heard from bedside nurses who cared for the patients (trust).

...senior leaders selected two beds that would fit into the budget and asked the taskforce to organize informational sessions for their nursing colleagues and facilitate a nursing vote on the best option. The discussion group transitioned into a small taskforce of nurses charged with reviewing evidence-based best practice resources to identify and recommend three bed options for senior leaders to review. The CNO committed to the group that their shifts would be covered while participating in the work (stimulating commitment through time). She also assured group members that while they all were already working on other important patient care initiatives, they were empowered to focus their time and energy on the successful completion of this project (balance of options and time). Within two weeks the taskforce, under Susan’s leadership as chair, made three recommendations to senior leaders. Much to the group’s surprise, senior leaders selected two beds that would fit into the budget and asked the taskforce to organize informational sessions for their nursing colleagues and facilitate a nursing vote on the best option. Manufacturer representatives were brought on-site to conduct informational sessions. The risk of transitioning to the new bed, as identified by the nursing taskforce, was that if nurses did not use the technology appropriately, there might not be a reduction in pressure ulcers. Taskforce members were present at each of the sessions and facilitated the question-and-answer session with their colleagues. A hospital-wide vote was held to select the bed replacement. There was over 98% nursing attendance at around-the-clock instructional sessions, led by the taskforce nurses, as the new beds were installed on each unit. Over the course of one year, the hospital experienced a reduction in the total number of pressure ulcers by 85%. Through the incorporation of each prerequisite to buy-in and factors to facilitate buy-in, this model scenario demonstrated a successful, employee-led initiative.

Buy-in Almost Happens

Hospital leaders were tasked by the Board of Directors to significantly decrease the rate of pressure ulcers. At the end of an executive meeting, hospital leaders decided that the best approach would be to change the beds. Within a few days they had selected a replacement. A handful of charge nurses, including Susan, were invited to attend an informational session hosted by the manufacturer (initial engagement). The technology impressed the charge nurses in attendance and they were excited to get the new beds installed (personal connection and psychological meaningfulness). The nurses were asked to spread the word and encourage their nursing colleagues to attend three upcoming educational sessions to be held during normal business hours.  The charge nurses had already been tasked with a patient satisfaction initiative, and despite their best intentions, only had time to speak with a couple of nurses on each unit. Attendance at the educational seminars was low.

Some nurses were excited about learning the new beds, but many saw the technology as an impediment to their already hectic shifts. When the beds were installed, the charge nurses did their best to help their nursing colleagues understand the new technology. Some nurses were excited about learning the new beds, but many saw the technology as an impediment to their already hectic shifts. Over the course of the year, the hospital saw a slight reduction in the rate of pressure ulcers, but not to the extent hospital leaders had expected.

While inclusive of some of the factors to enhance buy-in, other factors, such as time, trust, and a balance of options were missing. In addition, Kahn’s (1990) psychological safety and availability were also missing, resulting in an initiative that was not as successful as leaders had hoped.

Buy-in Fails to Happen

Without cultivating any of the prerequisites for, or promoting factors to enhance buy-in, initiative failure is more likely to happen. Susan returned to the nursing unit for her first night shift after being off for several days. As she walked into the nurse report room, she noticed a message from her nursing supervisor written on the whiteboard. It stated, “Our new beds are in. The rep was here at 2 pm today for a demo. Make sure you know how to use them because your annual review will be impacted by our unit goal to decrease pressure ulcers by 50%.” Shortly into her shift Susan started to hear grumbling from her nursing colleagues. No one knew the beds were coming and staff were only given one-day notice for the training. Most were unable to attend this training. Two hours into her shift, Susan had arrived at the conclusion that the beds were impossible to learn. She pushed a couple of buttons on the bed interface monitor and hoped for the best as she returned to other tasks at hand. After a year’s time, the rate of pressure ulcers in the hospital remained the same. Without cultivating any of the prerequisites for, or promoting factors to enhance buy-in, initiative failure is more likely to happen.

Future Directions

Employees may find themselves reviewing what stimulated them to buy-in so-as-to ensure that those influencers are still relevant and worthy of continued involvement in the initiative. Buy-in is the difference between an engaged nursing staff and employees who are disengaged or are just going through the motions. The act of buying in to shared governance, or any other initiative, is not a straightforward process. Employees may find themselves reviewing what stimulated them to buy-in so-as-to ensure that those influencers are still relevant and worthy of continued involvement in the initiative. Further study and research is needed to substantiate and elaborate on the prerequisites and factors related to buy-in identified in this article and to measure the effects of buy-in on initiative success and sustainability. Future research related to buy-in could include evaluating the relationship between employee buy-in and organizational success; employee buy-in and profitability; employee buy-in and succession planning; and employee buy-in and staff tenure.

Nursing leaders can maximize their efforts to ensure buy-in by: (a) promoting psychological meaningfulness, safety, and availability and (b) spurring initial engagement and trust, helping employees understand the balance of options faced by the organization, creating positive personal connections built on mutual trust, and making time available for initiative success. Leaders have the obligation to ensure that employees have the necessary knowledge, skills, abilities, and time to meet the complex needs of the patients and families they serve.

Patients and families come to the hospital because they need nursing care. In today's healthcare environment, both management and employees benefit from being equally knowledgeable about how internal and external threats and opportunities impact daily operations and future directions. For any healthcare organization to continue to be a reliable community resource, employees and management must work cooperatively to meet the needs of both patients and families they serve and also nurses who provide the care. 

Author

Matthew French-Bravo, MSN, RN
Email: mfrench-bravo@kumc.edu

Mr. French-Bravo is a PhD student at the University of Kansas School of Nursing in Kansas City. He earned his Bachelor of Science and Master of Science in Nursing degrees from Wichita State University in Wichita, KS. Mr. French-Bravo facilitated a staff-led team to establish a nursing shared governance structure at Via Christi Hospitals in Wichita, KS, and personally has experienced the importance of buy-in for establishing shared governance. In his current work as a risk manager, he continues to collaborate with staff on quality, safety and satisfaction initiatives, all of which are significantly influenced by buy-in. Mr. French-Bravo has had clinical experience in the areas of trauma and surgical intensive care, urgent care, and adult home healthcare. These experiences and his experience in shared governance, have spurred his interest in the role of effective communication on the sustainability of nursing initiatives.

Gregory Crow, EdD, RN
Email: crow.vnp@usfca.edu

Dr. Crow is professor emeritus from California State University in Sonoma, and is currently Senior Consultant at Tim Porter-O’Grady Associates. He earned his Diploma in Nursing from Samuel Merritt School of Nursing in Oakland, CA, his Bachelor of Science and Master of Science in Nursing degrees, as well as his Doctorate of Education, from the University of California, San Francisco. His clinical experience includes psychiatric and cardiac critical care nursing. Dr. Crow is adjunct professor and Director of the Vietnam Nurse Project at the University of San Francisco (USF), School of Nursing and Health Professions. The Vietnam Nurse Project is an international education and practice partnership between the USF School of Nursing and Health Professions and the Bach Mai School of Nursing, An Khanh School of Nursing, and Thanh Nhan Hospital in Ha Noi, Vietnam.