1. Lecturer – Olena Bidovanets

2.  Change is nothing new. In fact, it is often said that change is the only constant. Change, particularly in the health-care environment, is complex and is occurring at an unprecedented rate. Change is driven by many factors: the increasing cost of health-care delivery, the nursing shortage, the rapid advancements in technology and information management, and new expectations by the public to have a more active role in health-care decisions.

3.  Meeting the health-care needs of the world requires that the nurse be proactive and creative in guiding change. The ability to create and manage meaningful change is an essential skill for nurses in the 21st century.

4.  Change fosters growth and innovation; progress cannot occur without change. If nurses are to be leaders of change, it is imperative that they understand the changes occurring in the health-care arena, use political clout to have a hand in the changes, and master the change process. This chapter will introduce readers to the principles of planned change, barriers commonly encountered when introducing change, strategies for overcoming barriers, and the role of the nurse as the change agent.

5.  Change is an integral part of any organization, and the process can be uncomfortable and disturbing to those who are affected. An awareness of the elements common to the change process is important.

6.  Change means to be different, to cause to be different, or to alter. Change may be personal or organizational and can occur suddenly or incrementally. Change may be planned or unplanned. Unplanned change, or reactive change, usually occurs suddenly and in response to some event or set of circumstances. For example, an unanticipated rise in patient census may precipitate the need for a change in patient assignments.

7.  Decisions are made—and change follows—as a reaction to an event. Planned change, however, entails planning and application of strategic actions designed to promote movement toward a desired goal. Planned change is deliberate and proactive. For example, changing staffing patterns from extensive use of unlicensed assistive personnel to an all-professional staff requires time and planning.

8.  Specific strategies need to be developed and implemented before such a sweeping change is adopted. Generally, planned change is more likely to occur incrementally, over time. Planned change responds to anticipated events in the environment or community.

9.  Change may be initiated in response to internal or external forces. Internal forces stem from within the organization. Internal forces include organizational values and beliefs, culture, and past experiences with change.

10.  External forces come from outside the organization. These can be social influences, economic factors, or legislation.

11.  Assumption 1 Change of any kind represents loss. Even if the change is positive, there is a loss of stability. This loss of the familiar may produce anxiety and even grief in many individuals. The leader of change must be sensitive to the loss experienced by others.

12.  Assumption 2  The more consistent the change goal is with the individual’s personal values and beliefs, the more likely the change is to be accepted. Likewise, the more different the goal is from the individual’s personal values, the more likely it is to be rejected. The change agent needs to know and respect the values and beliefs of those most affected by the change.

13.  Assumption 3  Those who actively participate in the change feel accountable for the outcome. The more people who are involved in the process, the more the group will feel responsible for the outcome.

14.  Assumption 4  With each successive change in a series of changes, individuals’ psychological adjustment to the change occurs more slowly. It is for this reason that the leader of change must avoid initiating too many changes at once. Timing is important.

15.  Assumption 5  Power is important to the change process. Organizations with many layers of hierarchy between the initiator of change and the ultimate decision makers may have difficulty with implementing change. The shorter the distance the change proposal must travel from the initiator to the decision maker, the greater the likelihood that the change will be accepted. Conversely, the greater the distance, the more likely resistance will occur.

16.  Assessing readiness for change is generally the first step in any change project. Until participants are ready for change, little can be done to bring about change. According to Terry (1993), readiness for change is assessed by answering the following questions:

17.  1. What is the ultimate purpose of the action/ change?  2. Why might I lead or be involved in this change?  3. What is at stake if I lead or participate in this change action?  4. What structures are in place either to foster success or hinder the change?  5. Are the necessary resources available to achieve this change action?  6. What is the stakeholders’ level of commitment to the change?

18.  Those wishing to bring about change must develop strategies to foster change. Bennis, Benne, and Chin (1969), in their classic text, The Planning of Change, identified three strategies to promote change:

19.  rational-empirical,  normative-re-educative,  power-coercive.

20.  Decisions about which strategies to employ depend, to a great extent, on three factors:  the type of change planned,  the power of the change agent,  the amount of resistance expected. These strategies may be used independently or together. More often than not, some combination of strategies is indicated: the larger the change and the more resistance expected, the more strategies the change agent must employ.

21.  This strategy assumes that people are rational beings and will adopt a change if it is justified and in their self-interest. When using this strategy, the change agent’s role includes communicating the merit of the change to the group.

22.  If the change is understood by the group to be justified and in the best interest of the organization, it is likely to be accepted. This strategy emphasizes reason and knowledge. It presents those affected by the change with the knowledge and rationale they need to accept and implement the change.

23.  This strategy is most useful when little resistance to a change is expected. The power of the change agent is typically not a factor in changes amenable to this strategy. This strategy assumes that once given the knowledge and the rationales, people will internalize the need for the change and value the result.

24.  A second strategy takes into account social and cultural implications of change and is based on the assumption that group norms are used to socialize individuals. This strategy requires “winning over” those affected by the change. Success is often relationship-based; relationship, not information, is the key to this strategy.

25.  The success of this approach often requires a change in attitude, values, and/or relationships. Sufficient time is essential to the successful use of the normative-re-educative strategy. This strategy is most frequently used when the change is based in the culture and relationships within the organization.

26.  The power of the change agent, both positional and informal, becomes integral to the change process. For example, one of the most powerful changes in recent history occurred when the norm changed regarding when to wear surgical gloves for preventing the spread of infection. More than knowledge (rational- empirical) and administrative directives were needed to bring about this change: it took a change in cultural values that redefined the practice norms.

27.  This strategy is based on power, authority, and control. Political or economic power is often used to bring about desired change. The change agent “orders” change, and those with less power comply. This strategy requires that the change agent have the positional power to mandate the change.

28.  Change effected by this strategy is often based either on the followers’ desire to please the leader or fear of the consequences for not complying with the change. This strategy is very effective for legislated changes, but other changes accomplished using this strategy are usually short-lived if people have not embraced the need for the change through some other mechanism

29.  All changes have the potential for both gain and loss. It is important to identify all the potential barriers to change, to examine them contextually with those affected by the proposed change, and to develop strategies collectively to reduce or remove the barriers. Barriers most common to change within the health- care environment are discussed below, along with some strategies to overcome them.

30. Change requires movement, which, as physics indicates, is a kinetic activity that requires energy to overcome resistance. Also, as in physics, an object at rest (and that includes an organization) prefers to remain at rest. Movement over barriers requires an

31.  A number of theories exist to explain the change process. These theories provide a framework within which to guide change efforts. They are useful for planning both personal change and organizational change. Tiffany et al. (1994) surveyed 176 nurseauthored journal articles dealing with planned change. This study identified the type and frequency of planned change theories found in the nursing literature.

32.  Lewin’s Change Theory was most commonly used as a framework for change. Several other change theories were also frequently referenced. A brief description of Lewin’s theory, along with Lippitt’s Phases of Change, Havelock’s Six Step Change Model, and Rogers’ Diffusion of Innovations Theory, follows.

33.  These models of change are a mere sampling of change models. They provide a strong basis for understanding change theory. Before exploring the change theories, consider this brief discussion of change agents, an element in any change theory.

34.  A change agent is the individual or group that seeks to lead change. The change agent may be from inside or outside the organization. Change agents may have formal lines of authority or may be informal leaders. In either case, the change agent is responsible for moving those affected by the change through the process and implementing the change.

35.  Effective change agents are masters of change. They do three things correctly: they sense the right moment to initiate the plan, they find supporters for their ideas, and they have vision (Bruning, 1993).

36.  The successful change agent earns the respect and trust of the target system (individuals, groups, or organizations) by communicating openly and honestly, offering assistance, and demonstrating ability. A change agent’s success depends on communication and consultation style, interpersonal skills, and expert power. Ongoing communication is integral to the role of the change agent

37.  Change is an inevitable part of life; learning to lead change effectively is a skill that can be cultivated and mastered with practice. If you have been given the responsibility of leading an organizational change, there are several practical steps you can take to increase your chance for success.

38.  1. Begin by articulating the change vision clearly and concisely.  2. Select the change project team carefully.  3. Identify the formal and informal leaders who can help you implement the change successfully.  4. Stay alert to political forces, both for and against the change.  5. Develop communication skills. Keep communication lines open.

39.  6. Practice problem-solving skills.  7. Develop conflict resolution skills.  8. Learn to trust yourself and your project team. Functioning effectively as a change agent requires the nurse to have an understanding of the theoretical frameworks of change. A discussion of several classic, as well as emerging, theories of change follows.