The Nursing Professional Development Change …...nursing publications, according to Tiffany et al. (1994), is Everett Rogers. His diffusion of innovation theory de-scribes the process

J O U R N A L F O R N U R S E S I N S T A F F D E V E L O P M E N T � Volume 24, Number 4, 176–184 � Copyright A 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

How many times have you watched a changeunfold and commented, ‘‘If only this had been

better planned?’’ Change will continue to be a majorfocus of nursing’s future, according to Nowicki (1996).Indeed, as nurses struggle with all of the stresses andproblems of progress, mergers, financial pressures,electronic documentation, emphases on customerservice, and patient safety, change is necessary tosucceed. To rest or to assume a posture of inertia, ifeven temporarily, invites failure for us and those underour watchful care.

One of the pressing issues for health care is anonstop rapid cycle environment. In a staff develop-ment position, the role of the educator as a changeagent includes ‘‘facilitating the initiation, adoption of,and adaptation to change’’ (American Nurses Associa-tion, 2000, p. 9). Articles, perspectives, advice, andtheories are numerous. Translation of those conceptsinto daily work is less clear.

Where the rubber meets the road, how exactly doesthe nursing educator implement change managementto be certain that the change is necessary, sound, wellplanned, and anchored? This article describes onenursing staff development department’s efforts to

delineate specific tools to use in consultation andintervention in change projects in a large acute careenvironment. Drawing from change literature, anexample from the nuclear power industry, andnumerous experiential incidents, a change processguideline and template are described.

REVIEW OF LITERATURE

Familiar words in sorting thorough literature on changeare resistance, fear, unfreezing, diffusion, denial,chaos, and integration. Many writings refer to ‘‘manag-ing’’ the reaction to change. Others address changewithin the individual. However, to provide consulta-tion and leadership as a change agent, it is alsonecessary to consider power, communication, relation-ships, and system-based thinking (Menix, 2001).Commonly referenced contributors to planned changeinclude Lewin, Rogers, Lippitt, and Havelock. Thefollowing discussion relates aspects of the models toacquired knowledge on change management and thetemplates developed.

Lewin

Tiffany, Cheatham, Doornbos, Loudermelt & Momadiin the 1994 survey of change management in nursingperiodical literature, report that 21% of theory citations

..........................................Keverne L. Lehman, MSN, RN-BC, is Director, Nursing Practice,Education, and Research, Spectrum Health, Grand Rapids, Michigan.

Change Management

Magic or Mayhem?

Keverne L. Lehman, MSN, RN-BC

................................................

The Nursing Professional Development

Educator role includes that of change agent.

Much of the literature addresses reaction to

change rather than purposeful guidance of

the process. This article describes the

development of a planned change template.

Distilled from change literature, experience

in change management, and wisdom from

the nuclear power industry, it can assist in

avoiding some of the common pitfalls that

thwart the success of change initiatives.

.................................................

176 July/August 2008

Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

allude to Lewin’s work. Often referred to as the forcefield analysis model, Lewin maintained that change isthe result of opposing forces in a field or environment(Bozak, 2003). Driving forces encourage the change tooccur; restraining forces attempt to maintain the statusquo. Lewin described the steps in change as ‘‘unfreez-ing’’ from the current state, ‘‘moving,’’ and ‘‘freezing’’(or ‘‘refreezing’’) at the new level.

Drawing from Lewin’s perspective, it is essential inany change initiative to fully understand and describethe current situation, need, or problem. According toSchein (2004), unfreezing involves creation of a‘‘dissatisfaction or frustration generated by data thatdisconfirms our expectations and hopes.’’ Perhapsfeedback from patients and their families is distressingor audit results indicate a picture of practice in conflictwith professional standards and nursing values. Newevidence-based practice information may illuminate adifferent path. These data or this information could stillbe ignored, unless it is connected to something valued.Staff require a clear, concise description of the ‘‘why’’of the change. If the why is not conveyed up front, itwill be the first question to be asked, or even worse,other hypotheses for the change will be generatedthat do not reflect the true situation. Lewin’s modelalso counsels us to fully understand the current statesurrounding the issue and investigate the forcescompelling the change as well as those that may actto curtail it.

The period of actual change is the ending of the oldand the beginning of the new. Feelings are especiallyparamount, and many articles address the stages andtheir manifestations and suggest intervention strategies.From the project management’s perspective, funda-mentals of the change period include maneuvering allelements of the change into place, supporting thechange with training and problem solving resources,and communication, communication, communication.

Refreezing involves alteration of the system ororganization to encourage the permanency of thechange. How many changes have you seen introducedonly to fade away, lose steam, or require ‘‘reeduca-tion’’? It is essential to implant an element of refreez-ing in any change project. Consider related policies orpractices that require alteration to support the newpractice. Design a mechanism for follow-up, outcomemeasurement, auditing, and accountability. Some au-thors portray this as the ‘‘handoff.’’

Lewin’s theory is incomplete, however, in thatchange is assumed to be introduced and directed bya person or group in authority and that the evaluationof the event occurs only as it relates to replanningstrategies (Tiffany et al., 1994). There is also noemphasis on specific stakeholder identification orinvolvement.

Rogers

The next most commonly used change theorist innursing publications, according to Tiffany et al. (1994), isEverett Rogers. His diffusion of innovation theory de-scribes the process through which an individual passesfrom having knowledge of an innovation, to forming anattitude toward the innovation, to making a decision toadopt or reject the new idea, and finally to confirmingthat decision. The change agent actively facilitates andregulates the diffusion process by recognizing andcapitalizing on group strengths and by identifyingand managing factors that impede the process. Rogers’theory is more a ‘‘change-watching theory’’ than a‘‘change-planning theory’’ (Tiffany et al., 1994).

Lippitt

A modification of Lewin’s theory, Lippitt identifies sevenphases of planned change: (1) diagnosing the problemin a complete form, (2) assessing system motivation andresources, (3) identifying the change agent and as-sessing the change agent’s motivation and resources,(4) identifying progressive objectives, often includinga pilot test, (5) choosing the appropriate role for thechange agent and delineating the chain of command,(6) diffusing and maintaining the change, and (7) ter-minating the helping relationship of the change agent(Geraci, 1997). Beneficial contributions to a workingchange template from Lippitt’s model include involvingthose affected by the change, paying attention to planningobjectives and time frames, considering a pilot event,establishing mechanisms for feedback, and anchoring thechange through formal systems such as policies.

Havelock

Havelock’s six phases of planned change also buildfrom Lewin’s unfreezing/change/refreezing model. Re-lationship building is an important part of the initialphase of change (Lane, 1992). Formal and informalleaders are identified, trust is built, and a planningcommittee is formed. Next, accurate and completediagnosis of the problem and acquisition of necessaryresources are addressed. This step includes thepossibility of a library search, which introduces thegathering of evidence-based practice as a source of in-formation about the situation. Phase 4 centers on choosingthe solution. Havelock also suggests a pilot implementa-tion, which provides helpful information contributing tosuccess of further execution of the change. Phase 5concentrates on the ‘‘people’’ part of the change:communication, staff response, education, support systemsduring implementation, and recognition. Finally, stabiliza-tion of the system, empowerment of staff, communicationof results, revisions, and lessons are undertaken.

JOURNAL FOR NURSES IN STAFF DEVELOPMENT 177


Bhola

Bhola’s theory of planned change emphasizes threeprimary considerations: systems thinking, dialecticalapproach, and constructivism. Regarding systemsthinking, Bhola stresses the understanding of therelationships among parts of the whole. Dialecticalprocesses involve placing opposing ideas together withdialogue (Schwartz & Tiffany, 1994) in which the resultis different and of more significance than what cur-rently exists. Another valued perspective of Bhola’splanned change theory is the constructivist viewpoint,in which the planner and adopters are equal partnersin change, are co-learners in the process, and are bothchanged by the interaction. This participative andcollaborative power structure of the model fits wellwith nursing’s worldview. ‘‘Change is seen not assomething given by P (planner) to A (adopter), but asmutually invented’’ (Bhola, 1994, p. 62).

Bhola further develops the planned change modelto delineate relationships among the participants andattends to the environment in which the changeoccurs. His ‘‘CLER’’ framework speaks to the config-urations (C) or relationships between the planners andadopters (individuals, groups, institutions, or cultures)and the linkages (L) or communication between them.It analyzes the environment (E) or systems importantto the change effort and also the resources (R)available to assist the planners to foster change andthe adopters to assimilate the change. These resourcesare evaluated in six areas: cognitive, influence, material,personnel, institutional, and time.

According to Bhola (1994),

change models dealing with living systems cannot promisethe model-user simplicity, clear causality, certainty andprediction. . .nor a set of formulas or exact steps to betaken. . .can be no more than a template for organizingavailable knowledge and material resources in relation toa particular social or educational change. (p. 59)

WISDOM FROM INDUSTRY:NUCLEAR POWER

Struggling to adjust to the increasingly and rapidlychanging acute healthcare environment and to trans-late change requisitions into plans that were bothsuccessful and inclusive of bedside staff expertise, ourstaff development department discovered a systematicchange management tool utilized by a local nuclearpower plant. Within that institution, management isexpected to participate in instruction on change man-agement. Completion of a toolkit is required with anyproposed change. This process was also employed forpersonnel changes. Comparing the nature of the in-dustries, both health care and nuclear power have

complex processes, are heavily regulated, and areentrusted with the safety of the public they serve. Evensmall errors can have drastic consequences. Changemanagement becomes not only desired, but essential.Menix (2001) advocates for prescribed tools in achange process, including activity plans, strategicplans, and planning worksheets. The nuclear facilityhad formalized many of these processes into a toolkit.Steps in the power plant’s blueprint deemed valuablefor consideration included a statement on alignmentwith the organization’s strategic goals. A stakeholderidentification list was also specified. Taking this onestep further, the template provided in this article listscommon stakeholders for consideration. The advan-tage of this specificity lies in consideration of affectedentities that the change planner may not have origi-nally envisioned.

An enlightening element of the nuclear powerplant’s plan was plotting the change on a ‘‘risk/complexity matrix.’’ It is worthwhile to consider anychange in light of the ‘‘complexities’’ involved, whichcan be anything from the number of roles, units, ordepartments affected, the extent of resources requiredby the change, or the intricacy of the steps of thechange itself. ‘‘Risk’’ can be defined as threat to pa-tients, staff, or potential for failure. In determining risk/complexity, we have informally classified the changesinto categories such as Level 1, ‘‘something a flyerwould take care of’’ to Level 3, ‘‘director involvementand mandatory education.’’ This classification also sug-gests appropriate support levels during the period ofthe change itself.

Contingency plans were another added step sug-gested by the nuclear facility’s plan. It is important toconsider the possible sources of failure, what theconsequences of that failure would mean to patientsand the project, and what backup plans may be im-plemented in case an unwelcome event occurs or theplan does not play out as expected. In the increasinglyfamiliar world of electronic documentation, this issummarized in one word: downtime.

The last major contribution from our industry part-ners is the attention to quality critique and incorpo-ration into organizational learning. Hardwiring anevaluation of the process also signals the handoff ofthe change process to system personnel or processes.

REAL-LIFE APPLICATIONS

When thinking of change, consider policies, processes,procedures, products, and personnel. All are worthy ofproper management. The Change Process Form in-cluded in this article can serve as a template to addressessential considerations in planning and implementinga change. Contemplate the implementation of new IV



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pumps in which all the stakeholders are not identifiedand included in the planing of the change process. Thefailure to identify specific tubing pressure needs ofcontrast injectors in the radiology department cancause a major disruption in patient care. Overlookingthe security department involvement with new facilityorientation during the evening hours can compromisethe safety of staff. Recognizing the medical staff asusers of new defibrillator equipment and visualizingthe underdeveloped communication channels to thatgroup would lead to special training sessions atconvenient times. Positioning a pulse oximeter productchange high on the risk (information accuracy essentialto patient care) and complexity (new technology,multiple staff roles, and interface with other clinicalequipment) axis of the matrix directs the team toacquire high-level management involvement to prob-

lem solve issues across departments and with thevendor. Initiation of a new computerized documenta-tion system or opening of a new patient care buildingimplies a support strategy worthy of 24-hour go-livesupport with predetermined escalated levels of re-sponse as necessary at a command post. Including theadopters of a new dress code will assist in the selectionof appropriate and useful styles as well as communi-cation of the new look. Even planned managerial orstaff changes may benefit from consideration ofelements of the change process.

It should be noted that this change processtemplate is not meant to extend, delay, or prolongchange. Our current healthcare environment grantslittle tolerance for prolonged projects. The toolsprovided here are meant to provide guidance to morerapidly move through the important and relevant



aspects of change management and to pilot the useraround common pitfalls. As Schwartz & Tiffany (1994)summarize:

Nurse planners must be open-minded and modest,learning from the realities of the change environment.They must make each change episode a learning event forthose who experience the change. . . Change does notjust happen when we think it should. We must carefullytheorize, plot plan, and communicate with those in theplanned change environment to make planned changesuccessful. (p. 61)

REFERENCES

American Nurses Association. (2000). Scope and standards of

practice for nursing professional development. Washington,

DC: Author.

Bhola, H. (1994). The CLER model: Thinking through change.

Nursing Management, 25, 59–63.

Bozak, M. (2003). Using Lewin’s force field analysis in imple-

menting a nursing information system. Computers, Infor-

matics, Nursing, 21, 80–85.

Geraci, E. (1997). Computers in home care: Application of

change theory. Computers in Nursing, 15, 199–205.

Lane, A. (1992). Using Havelock’s model to plan unit-based

change. Nursing Management, 23, 58–60.

Menix, K. (2001). Educating to manage the accelerated change

environment effectively: Part 2. Journal for Nurses in Staff

Development, 17, 44–53.

Nowicki, C. (1996). Twenty-one predictions for the future of

hospital staff development. Journal of Continuing Education

in Nursing, 27, 259–266.

Schein, E. (2004). Kurt Lewin’s change theory in the field and in

the classroom: Notes toward a model of managed learning.

Retrieved September 3, 2004, from http://www.solonline.org

Schwartz, K., & Tiffany, C. (1994). Evaluating Bhola’s con-

figurations theory of planned change. Nursing Management,

25, 56–61.

Spectrum Health. (2005). Change management toolkit. Grand

Rapids, MI.

Tiffany, C., Cheatham, A., Doornbos, D., Loudermelt, L., &

Momadi, G. (1994). Planned change theory: Survey of

nursing periodical literature. Nursing Management, 25,

54–60.

ADDRESS FOR CORRESPONDENCE: Keverne L. Lehman, MSN, RN-BC,Spectrum Health Blodgett Hospital, 1840 Wealthy SE, GrandRapids, MI 49507 (e-mail: [email protected]).



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The Nursing Professional Development Change …...nursing publications, according to Tiffany et al. (1994), is Everett Rogers. His diffusion of innovation theory de-scribes the process