RAK Medical and Health Sciences University

RAK College of Nursing BSN VII Semester

Nursing Leadership and Management Initiating and Managing change Vimala Edwin MBAHCS,MSN,PGDHM.

Senior Lecturer, RAK College of Nursing.

Learning objectives At end of the class the student will be able to1.Discuss nurse as a change agent2.Explain the Change theories3. Elaborate the change process4. Identify Change agent strategies5. Explain resistance to change6. List the guidelines to handle resistance7.Discuss the managers role in implementing

change

Introduction • In todays health care environment,

organizational change is essential for adaptation; creative change is mandatory for growth. Leaders initiate change ;followers strive it. Nurse managers must become skilled in implementing organizational change and in initiating change within the organization to strengthen nursing practice, provide quality care and create a better system.

1.The nurse as change agent• Change- the process of making something

different from what it was.• Change agent: one who works to bring about

change.• Nurses who can suggest changes to control

costs, improve quality or offer new services will be in great demand especially for management position.

• Being an effective change agent requires expert planning skills.

• This includes planning for changing needs.• The failure to reassess goals proactively and

initiate these changes results in misdirected and poorly used fiscal and human resources.

2.Change theoriesA.Lewins force field model• Lewin provides a social –psychological view of

the change process.• He sees behaviour as a dynamic balance of forces

working in opposing directions within a field(such as an organization)

• Driving forces- facilitate change because they push participants in the desired direction

• Restraining forces- behaviours that impede change by discouraging participants from making specified changes.

Lewin (1951) identified three phases• Through which the change agent must

proceed before a planned change becomes part of the system: unfreezing, movement, and refreezing.

• Unfreeze – motivate participants by getting them ready for change. Build trust and recognition for the need to change. To soften attitudes ,actively participate in identifying problems and generate alternative solutions.

• Movement - In movement, the change agent identifies, plans, and implements appropriate strategies, ensuring that driving forces exceed restraining forces. Whenever possible, change should be implemented gradually.

• Refreezing - During the refreezing phase, the change agent assists in stabilizing the system change so it becomes integrated into the status quo.

• If refreezing is incomplete, the change will be ineffective and the pre-change behaviors will be resumed.

• For refreezing to occur, the change agent must be supportive and reinforce the individual adaptive efforts of those affected by the change.

B.Lippitt’s Phases of change• Lippitt, Watson, and Westley (1958) built on Lewin’s

theories in identifying Seven phases of planned change:1. The patient must feel a need for change. Unfreezing

occurs.2. A helping relationship begins between the change agent

and his or her patients. Movement begins. 3. The problem is identified and clarified. Data are

collected.4. Alternatives for change are examined. Resources are

assessed.5. Active modification or change occurs. Movement is

complete.6. Refreezing occurs as the change is stabilized.7. The helping relationship ends, or a different type of

continuing relationship is formed.

• Murphy (1999), in a more contemporary model, suggests that there are four predictable stages that people pass through when exposed to any change:

• Resistance• Confusion• Exploration • and Commitment

3.Havelocks model• Havelock described a six step process, also a

modification of Lewins model. He describes an active change agent as one who uses a participative approach.

Havelock emphasizes the unfreezing or planning stage as

• Building a relationship• Diagnosing the problem• Acquiring resources

This stage is followed by the moving stage• Choosing the solution• Gaining acceptanceRefreezing referred to as:• Stabilization• Self-renewal

4.Rogers diffusion of innovations• His frame work emphasizes the reversible

nature of change :participants may initially adopt a proposal but latter discontinue it, or the reverse-they may initially reject it but adopt it at a later time.

The five steps are• Knowledge –the decision –making unit is

introduced to the innovation and begins to understand it

• Persuasion- a favorable attitude toward the innovation forms

• Decision-activities lead to a decision to adopt or reject the innovation

• Implementation –the innovation is put to use and reinvention or alterations may occur.

• Confirmation-the individual or decision making unit seeks reinforcement that the decision was correct. If there are conflicting messages or experiences the original decision may be reversed.

• Rogers stresses two important aspects of successful planned change: Key people and policy makers must be interested in the innovation and committed to making it happen.

3.The change processThe change process follows the same path as

the nursing process: Assessment, planning, implementation and evaluation

A. Assessment: Identifying the problem or the opportunityCollect data-once the problem or opportunity

has been clearly defined, the change agent collects data external and internal to the system.

Analyze data: the change agent should focus more energy on analyzing and summarizing the data than on just collecting it.

B. Planning – planning the who, how, and when of the change is a key step. What will be the target system for the change? Members from this system should be active participants in the planning stage.

C. Implementation- The plans are put into motion. Interventions are designed to gain the necessary compliance .

• The change agent creates a supportive climate acts as energizer, obtains and provides feedback and overcome resistance.

D. Evaluation At each control point the operational

indicators established are monitored. The change agent terminates the helping relationship by delegating responsibilities to target system members. The energizer role is still needed to reinforce new behaviours through positive feedback.

4.Change agent strategiesA.Power coercive strategies• It is based on the application of power by

legitimate authority, economic sanctions and political power.

• Changes are made through law, policy or financial appropriations.

• Those in control enforces changes by restricting budgets or creating policies.

• When much resistance is anticipated ,time is short and the change is critical for organizational survival ,power coercive strategies are necessary.

B. Empirical –Rational model- of change strategies the power ingredient is knowledge. The assumption is that people are rational and will follow their rational self interest if that self interest is made clear to them.

• Empirical rational strategies are often effective when little resistance to the proposed change is expected and the change is perceived as reasonable.

• Introduction of new technology that is east to use cuts nursing time and improves quality of care would be accepted readily after inservice education and perhaps a trial use.

• Well structures ,cost effective technology can be implemented using these strategies.

C.Normative –Re educative strategies- of change rest on the assumption that people act in accordance with social norms and values.

• Information and rational arguments are insufficient strategies to change peoples patterns of actions; the change agent must focus on behaviour as well.

• Peoples roles and relationships, perceptual orientations, attitudes and feelings will influence their acceptance of change.

• The change agent should have skill in interpersonal relationship and collaboration.

• Normative re-educative strategies are well suited to the creative problem solving needed in nursing and health care today.

• When there is adequate time or when group consensus is fundamental to successful adoption of the change, the manager is well advised to adopt this framework.

Resistance to change• Response to change varies from ready

acceptance to full-blown resistance. Rogers identified six response typologies:

• Innovators love change and thrive on it• Less radical, early adopters are still receptive

to change• The early majority prefers the status quo ,but

eventually accept the change.• The late majority are resistive, accepting

change after most others have.

• laggards dislike change and are openly aggressive

• Rejecters actively oppose and may even interfere with change.

When handling resistance, the manager must first identify the need to reduce it. Remain rational, stick to the problem solving change process and proceed with the following guidelines:

a. Communicate with those who oppose the change.b. Get to the root of their reasons for oppositionc. Clarify information and provide accurate feedbackd. Be open to revisions but clear about what must

remaine. Present the negative consequences of resistance .f. Emphazise the positive consequences of the change

and how the individual or group will benefit.

g.Keep resisters involved in face to face contact with supporters. Recognize valid objections and relive unnecessary fears.

h.Maintain a climate of trust, support and confidence.

i.Divert attention by creating a different disturbance. When members perceive a greater environmental threat they tend to unify internally.

7.The managers role in implementing change• Making change is not easy, but it is a

mandatory skill for managers.• The ability to combine ideas from

unconnected sources• The ability to energize others by keeping the

interest level up and demonstrating a high personal energy level.

• Skill in human relations; well developed interpersonal communication, group management and problem solving skills.

• Integrative thinking ;the ability to retain a big picture focus while dealing with each part of the system

• Sufficient flexibility to modify ideas when modification will improve the change, but enough persistence to resist nonproductive tampering with the planned change.

• Confidence and the tendency not to be easily discouraged

• Realistic thinking

• Trustworthiness: A track record of integrity and success with other changes

• The ability to articulate a vision through insights and versatile thinking

• The ability to handle resistance• A cardinal rule of change is : don’t try to

change too much or too fast.

If resistance continues ,two options should be considered:

• The change is not workable and should be modified to meet the strongest objections.

• The change is fine-tuned sufficiently, but change must proceed now and resistance must be overcome.

• If the latter option is selected ,energy is focused on overcoming resistance. Supporters are mobilized and constant ,consistent pressure is exerted to move ahead

References: 1.Sullivan, E. Ducker, effective leadership and

management in nursing,2009,7th edition, pearsoninternational.