1. PLANNING FOR CHANGE Change occurs over time, often fluctuating betweenintervals of change then a time of settling and stability. Change managemententails thoughtful planning and sensitive implementation, and above all,consultation with, and involvement of, the people affected by the changes. If youforce change on people normally problems arise. Change must be realistic,achievable and measurable. These aspects are especially relevant to managingpersonal change.DefinitionPlanning: ―Planning refers to thinking ahead of time and formulation ofpreliminary thoughts‖ .Planned change: ―Planned change entails planning and application of strategicactions designed to promote movement towards a desired goal‖ .o ―Planned change is a change that results from a well thought out and deliberateseffort to make something happen. It is the deliberate application of knowledge andskills by a leader to bring about a change‖ . Tappen, 1995Change agent: ―A change agent is one who generates ides, introduces theinnovation, and works to bring about the desired change‖ .Change agent A change agent is someone who deliberately tries to bring about achange or innovation, often associated with facilitating change in an organizationor institution. To some degree, change always involves the exercise of power,politics, and interpersonal influence. It is critical to understand the existing powerstructure when change is being contemplated. A change agent must understand thesocial, organizational, and political identities and interests of those involved; mustfocus on what really matters; assess the agenda of all involved parties; and plan foraction. The change agent should have the following qualities; The ability to combine ideas
2. The ability to energize others Skills in human relations Integrative thinking Flexibility modify ideas Persistent, confident and has realistic thinking Trustworthy Ability to articulate a vision, and Ability to handle resistanceAssumptions regarding change Change represents loss. Even if the change is positive, there is a loss of stability.The leader of change must be sensitive to the loss experienced by others. The more consistent the change goal is with the individual‘s personal values andbeliefs, the more likely the change is to be accepted. Likewise the more difficultthe goal is from the individual‘s personal values; the more likely it is to berejected. Those who actively participate in change process feel accountable for theoutcome. Timing is important in change. With ea successive change in a series of chchanges, individual‘s psychological adjustment to the change occurs more slowly.And for this reason the leader of change must avoid initiating too many changes atonce.The key principles driving the elements of the Change Management are: 1.Targeted Commitment Levels 2. Executive Ownership 3. Visible, sustained
3. sponsorship 4. Deployment/Implementation Support and Monitoring 5. EmployeeSupport 6. Post Deployment Preparation Strategies for planned change Ingeneral, three categories of change models exist: empirical-rationale, power-coercive, and normative-educative model. (Bennis, Benne and Chin , Theplanning of change) Rationale- empirical: This strategy emphasizes reason and knowledge.People are considered rational beings and will adopta change if it is justified and intheir self- interest. Here the change agent‘s role is communicating the merit of thechange to the group. If the change is understood by the group to be justified and inthe best interest of the organization, it is likely to be accepted. This strategy isuseful when little resistance to change is expected. It is assumed that once if theknowledge and rationales are given, people will internalize the need for change andvalue the result. Normative- re-educative: This is based on the assumption that group normsare used to socialize individuals. The success of this approach often requires achange in attitude, values, and/ or relationships. This strategy is most used whenthe change is based on culture and relationships within the organization. The powerof the change agent, both positional and informal, becomes integral to the changeprocess. Power- coercive: This approach is based on power, authority, and control.Desired change is brought about by political or economic power. It requires thatthe change agent have the positional power to mandate the change. The outcome ofchange is often based either on follower‘s desire to please the leader or fear of theconsequences for not complying with the change. This strategy is effective forlegislated changes, but other changes using this strategy are often short- lived.
4. Barriers to change and strategies to overcome It is important to identify allpotential barriers to change, to examine them contextually with those affected byproposed change, and to develop strategies collectively to reduce or remove thebarriers. Change requires movement, which as physics indicates, is a kineticactivity that that requires energy to overcome resistance.
5. Types of changes Hohn (1998) identified four different types of change: Changeby exception, Incremental Change, Pendulum Change and Paradigm Change. Change by Exception: This occurs when someone makes an exception to anexisting belief system. For instance, if a client believes that all nurses are bossy,but then experiences nursing care from a much modulated nurse, they may changetheir belief about that particular nurse, but not all nurses in general. Incremental Change: A change that happens so gradually, that an individual isnot aware of it. Pendulum Changes: Are changes that result in extreme exchanges of points ofview. Paradigm Change: Involves a fundamenta rethinking of premises and lassumptions, and involve a changing of beliefs, values and assumptions about howthe world works.Change Theories in Nursing Change theories are used in nursing to bring aboutplanned change. Planned change involves, recognizing a problem and creating aplan to address it. There are various change theories that can be applied to changeprojects in nursing. Choosing the right change theory is important as all changetheories do not fit every change project. Some change theories used in nursing areLewin‘s, Lippitt‘s, and Havelock‘s theories of change. The characteristics ofchange theories areProblem identification Plan for innovation Strategies to reduce innovation Evaluation plan
6. Kurt Lewin‟ s change theory: The theoretical foundations of change theory arerobust: several theories now exist, many coming from the disciplines of sociology,psychology, education, and organizational management. Kurt Lewin (1890 – 1947)has been acknowledged as the ―father of social change theories‖ and presents asimple yet powerful model to begin the study of change theory and processes.He is also lauded as the originator of social psychology, action research, as well asorganizational development. "Unfreezing" involves finding a method of making itpossible for people to let go of an old pattern that was counterproductive in someway.In this stage, the need for change is recognized, the process of creating awarenessfor change is begun and acceptance of the proposed change is developed "Movingto a new level" involves a process of change--in thoughts, feelings, behavior, or allthree, that is in some way more liberating or more productive. The need for changeis accepted and implemented in this stage. "Refreezing" is establishing the changeas a new habit, so that it now becomes the "standard operating procedure." Withoutsome process of refreezing, it is easy to backslide into the old ways.The newchange is made permanent here.Lewin also created a model called ―force field analysis‖ which offers directionfor diagnosing situations and managing change within organizations andcommunities. According to Lewin‘s theories, human behavior is caused by forces –beliefs, expectations, cultural norms, and the like – within the "life space" of anindividual or society. These forces can be positive, urging us toward a behavior, ornegative, propelling us away from a behavior. ―Driving Forces‖ - Driving forcesare those forces affecting a situation that are pushing in a particular direction; theytend to initiate a change and keep it going. In terms of improving productivity in awork group, pressure from a supervisor, incentive earnings, and competition maybe examples of driving forces. ―Restraining Forces‖ - Restraining forces are
7. forces acting to restrain or decrease the driving forces. Apathy, hostility, and poormaintenance of equipment may be examples of restraining forces against increasedproduction. ―Equilibrium‖ - This equilibrium, or present level of productivity,can be raised or lowered by changes in the relationship between the driving and therestraining forces. Equilibrium is reached when the sum of the driving forcesequals the sum of the restraining forces.Lippitt‟ s phases of change theory: Lippitt‟ s theory is based on bringing in anexternal change agent to put a plan in place to effect change. There are sevenstages in this theory. The first three stages correspond to Lewins unfreezing stage,the next two to his moving stage and the final two to his freezing change. In thistheory, there is a lot of focus on the change agent. The third stage assesses thechange agent‘s stamina, commitment to change and power to make change happen.The fifth stage describes what the change agent‘s role will be so that it isunderstood by all the parties involved and everyone will know what to expect fromhim. At the last stage, the change agent separates himself from the change project.By this time, the change has become permanent. The seven phases shift the changeprocess to include the role of a change agent through the evolution of the change.• Phase 1:Diagnose the problem• Phase 2:Assess the motivation and capacity for change• Phase 3:Assess the resources and motivation of the change agent(commitment thechange, power, and stamina)• Phase 4:Define progressive stages of change• Phase 5: Ensure the role and responsibility of the change agent is clear andunderstood (communicator, facilitator, and subject matter expert.
8. • Phase 6:Maintain the change through communication, feedback, and groupcoordination• Phase 7:Gradually remove the change agent from the relationship, as the changebecomes part of an organizational culture.Havelocks change model: Havelocks change theory has six stages and is amodification of the Lewins theory of change. The six stages are building arelationship, diagnosing the problem, gathering resources, choosing the solution,gaining acceptance and self renewal. In this theory, there is a lot of informationgathering in the initial stages of change during which staff nurses may realize theneed for change and be willing to accept any changes that are implemented. Thefirst three stages are described by Lewins unfreezing stage the next two by hismoving stage and the last by the freezing stage.John P Kotters eight steps to successful change John Kotters highly regardedbooks Leading Change (1995) and the follow-up The Heart Of Change (2002)describes a helpful model for understanding and managing change. Each stageacknowledges a key principle identified by Kotter relating to peoples response andapproach to change, in which people see, feel and then change: Kotters eight stepchange model can be summarized as:Increase urgency - inspire people to move, make objectives real and relevant.Build the guiding team - get the right people in place with the right emotionalcommitment, and the right mix of skills and levels.Get the vision right - get the team to establish a simple vision and strategyfocus on emotional and creative aspects necessary to drive service and efficiency.
9. Communicate for buy-in - Involve as many people as possible, communicatethe essentials, simply, and to appeal and respond to peoples needs. De-cluttercommunications - make technology work for you rather than against.Empower action - Remove obstacles, enable constructive feedback and lots ofsupport from leaders - reward and recognize progress and achievements.Create short-term wins - Set aims that are easy to achieve - in bite-size chunks.Manageable numbers of initiatives. Finish current stages before starting new ones.Dont let up - Foster and encourage determination and persistence - ongoingchange - encourage ongoing progress reporting - highlight achieved and futuremilestones.Make change stick - Reinforce the value of successful change via recruitment,promotion, and new change leaders. Weave change into culture.General considerations for planning change Secure and maintain commitment to change Define and communicate desired end state Identify critical success factors Establish targets and prioritize activities Develop a theme Understand why the change is desired/ required General considerations for planning change Secure and maintain commitment to change Define and communicate desired end state Identify critical success factors Establish targets and prioritize activities
10. Develop a theme Understand why the change is desired/ requiredNurse Leader (manager) as role model for Planned ChangeImplement a comprehensive and coordinated change management program:Discover, develop, detect. ‖ Identify ―change agents and engage people at all levels in the organization. Ensure the message comes from the top, and executives and line managers are―walking the talk.‖ Make change visible with new tools and/or environment. Ensure clear, concise, and compelling communication. Integrate change goals with day-to-day activities, e.g., recruiting, performancemanagement, and budgeting. Address short-term performance while setting high expectations about long-termperformance. Help management avoid attempts to short circuit the change managementprocess. Foster change in people‘s attitudes first, then focus on change in processes, thenchange in the formal structure. Manage both supporters and champions, as well opponents and possibledetractors.
11. Accept that all people go through the same steps – some faster, some slower –and it is not possible to skip steps. Build a safe environment that enables people to express feelings, acknowledgefears, and use support systems. Acknowledge and celebrate successes regularly and publicly!Mistakes by a leader manager Fail to provide visible support and reinforce th change with other managers. e Do not take the time to understand how current business processes would beaffected by change. Delayed decision-making, which leads to low morale and slow project progress. Are not directly or actively involved with change project. Fail to anticipate the impact on employees. Underestimate the time and resources needed Abdicate ownership of the project to another manager. Fail to communicate both the business reasons for the change and the expectedoutcome to employees and other managers Change the project direction mid-stream Do not set clear boundaries and objectives for the projectOrganizational ageing The organization has to undergo progress through certaindevelopmental stages within the organizational structure termed organizationalageing. The young organization is characterized by high energy, movement andconstant change and adaptation; while the aged organizations will have established‗turf boundaries functioning in an orderly and predictable fashion, and are focusedon rules and regulations. In any type of ageing, organizations must find a balance
12. between chaos and stagnation. Some areas that undergo restructuring during anorganizational ageing are; • leadership changes • organizational restructuring •outsourcing and offshoring • new technologies and tools • new competitors andmarkets INNOVATIONS IN NURSINGIntroductionChange is a natural social process of individuals, groups, organizations andsociety. The source of change originates inside and outside health careorganizations. Change today is constant, inevitable, pervasive and unpredictable,and varies in rate and intensity, which unavoidably influences individuals,technology and systems at all levels of the organization.Creativity and innovation Creativity is defined as ‗artistic or intellectualinventiveness.‘Innovation is defines as ‗introduction of something new. ‗These definitionssuggest that the terms are interchangeable. A person could say that creativity is themental work or action involved in bringing something new into existence, whileinnovation is the result of that effort.A constant flow of new ideas is needed to procure new products, services,processes, procedures and strategies for dealing with the change occurring in everysphere of endeavour:technology social system, government and everyday living. Innovation is the keyto survival and growth of health care and nursing. Change, innovation andcreativity are comparison terms but can also be differentiated. Changes occur whenthe system is disrupts; innovation uses changes to create new and differentapproaches to resolve an issue and develop new products or procedures.
13. (Huber 1996). Systemic innovations according to (Drucker 1992) requirewillingness to look on changes as an opportunity. Innovations do not createchange. Successful innovations are accomplished by exploiting the change notforcing it.Process of Innovation The process of the innovation may include several steps.They are:AssessmentIt is the first step of process and it requires a look at both the strength andproblems. An administrator must focus on what is specific content requirement theexpected outcome. Specific content requirement changes often in the health care,as new technologies and research bring new knowledge needs.Defining objectivesIt is the second step. The administrator should search for research or technique thatcould address the identical needs. Asking the peers for the suggestion is alsohelpful. This is the place where the creativity begins. It is important to look atmany different ways to address the learning objectives before selecting one.PlanningOnce a strategy has been selected the third step, planning is important. Understandwho the stakeholders are and what their investment is in the status quo or in changecan be helpful in planning the strategies to bring them on board. Many stakeholders do not like the changes and will resist the new approaches. Using thechange theory it can assist in demonstrating the needs and provide information thatcan make resistors more amenable to change. It‘s important to take time to developa support for the strategy. In more complex strategies it may be important to bringother administrators.
14. Gaining support for the innovationSome strategies require little or resources to implement where as others requiresignificant physical and financial resources. If resources are needed then gainingsupport for the accusation of those resources are essential. Grants can provide goodfunding sources but require time and effort to secure and may be for a limited time.Administrative support may be required but administrators may also be anexcellent resource to tap to discuss the potential funding or acquisitions of thephysical resource.Preparing faculty members for the innovationRehearsal time may be required or additional education may be required. Planningsufficient for those activities will increase everyone‘s comfort level with thisprocess. This is the time where everyone agrees how the strategy will be in run.Use of perception, validate and clarification can be a valuable tool.Implementing the evaluationIn this step it is hope that the things will be going well, but flexibility may berequired if problems arise. Sometimes unintended consequences, such as surfacingof emotional issues can occur. Administrator should be alert to the need for thefollow up or referral if problem arise.Evaluating the outcomeIt is the final step of the process. It may be possible to measure short termattainment goals. A strong evaluation process provides an opportunity to evaluatethe outcome of the change.
15. Sources of innovation Seven sources for innovative ideas have been identified by(Drucker 1992)Four sources are found internally within the institutions are:Unexpected outcomes: Situation presents themselves that require differentmethods to be adopted. Knowing what is happening in an institution allows anindividual to prepare for the impending changes.Incongruous circumstances: Disruptions occur that require change to be madediscrepancies exists between the reality as it is and reality as it is assumed to be.Innovations made on the process needs: Procedures and policies need to bealtered to respond to the new regulations, policies or law.Changes in structure: Organizational changes require changes in method of theoperations.Three sources are outside the institutions:Change in the demographics: Alteration in the community statistics such asage and income levels affect the organizational operations.New information or knowledge: New technological knowledge requireschange in practice.Change in perception, taste and meaning: Shifts in demographics,technologies and social needs create different ways of looking at the situation.Steps in Innovation adoptionKnowledge: Aware of new information and possible significance to practice.Persuasion: Positive attitudes about importance and utility of new knowledge.Decision: Trial use of new information to test relevance to practice.
16. Implementation: Change of care setting to facilitate use of the innovations.Confirmation: Gathering of evidence to confirm appropriateness of using theinnovations.Theories Planned change using linear approaches Theories for plannedchange Six phases of planned change Havelock (1973) is credited with thisplanned change model Key idea: Change can be planned, implemented andevaluated in six sequential stages. The model is advocated for development ofeffective change agents and use as a rational problem solving process. The sixstages are:-1. Building a relationship2. Diagnosing the problem3. Acquiring relevant resources4. Choosing the solution5. Gaining acceptance6. Stabilizing the innovation and generating self renewalApplication to practice: Useful for low level, low complexity change. Sevenphases of planned change Lippitt, Watson and westly (1958) are credited withthis planned change model Key idea: change can be planned, implemented andevaluated in seven sequential phases. Ongoing sensitivity to forces in the changeprocess is essential. The seven phases are:1. The client system become aware of the need for the change2. The relationship is developed between the client system and change3. The change problem is defined4. The change goal are set and options for achievements are explored
17. 5. The plan for the change is implemented6. The change is accepted and stabilized7. The change entities redefine their relationshipApplication to practice: Useful for low level, low complexity change. Innovation– decision process Rogers (1995) is credited with formulating this process. Keyidea: Change for an individual occurs over five phases when choosing to accept orreject an innovation/idea. Decision is to not accept the new idea may occur at anyfive stages. The change agent can promote acceptance by giving information aboutbenefits and disadvantages and encouragement. The five stages are:1. Knowledge2. Persuasion3. Decision4. Implementation and5. ConfirmationApplication to practice: Useful for individual change.Nonlinear change Chaos theory Organization can no longer rely on rules,policies, and hierarchies to get work accomplished in flexible ways. According tothe chaos theory perspectives because of rapidly changing nature of human andworld factors health organizations cannot control long term outcomes. Theassertion of chaos theory are that ‗organization are potentially chaotic‘(thietat andForgues, 1995). In other words, ‗order emerges through fluctuations and chaos‘.Organization will experience periods of stability interrupted with periods of intensetransformation. Response to change / Human side of change The human side of
18. the managing change refers to staff responses to change that either facilitate orinterfere with change process. Responses to all or part of the change process byindividuals and group may vary from full acceptance and willing participation toopen rejection. Responses may be categorized behaviourally or emotionally. Somenurses may manifest their dissatisfaction visibly; others may quietly accommodatethe change. Some individuals consistently reject any new thinking or way of doingthings. The initial response to change may be, but not always, reluctance andresistance. Resistance and reluctance are common when the change threaten thepersonal security. Eg: -Changes in the structure of an agency can result in changesof position for personnel. The change agent‘s recognition of the ideal and commonpatterns of the individuals behaviour responses to change can facilitate an effectivechange process (Rogers 1983). The responses and brief descriptions are as follows:Innovators thrive on change, which may be disruptive to the unit stability.Early adopters are respected by their peers and thus are sought out for adviceand information about innovations/changes.Early majority prefer doing what has been done in the past but eventually willaccept the new ideas.Late majority are openly negative and agree to change only after most othershave accepted the change.Laggards prefer keeping tradition and openly express their resistance to newideas.Rejecters oppose change actively.General characteristics of effective change agents Isa respected member of the organization (insider) or community (outsider). Possesses excellent communication skills.
19. Understands change process. Knows how group functions. Is trusted by others. Participates actively in change processes. Processes expert and legitimate power.Principles characterizing effective change implementation The recipients of change feel they own the change. Administrators and other key personnel support the proposed change. The recipients of change ant cipate benefit from the change. i The recipient of change participates in identifying the problem warranting achange. The change holds interest for the change recipients and other participants. Agreements exist within the work group about the benefit of the change. The change agents and recipients of change perceive a compatibility of values. Trust and empathy exist among the participants of the change process . Revision of the change goal and process is negotiable. Thechange process is designed to provide regular feedback to its participants.Challenges met by the change leaders Mc Daniels (1996) advocates that changeleaders in healthcare organizations meet the challenges of managing by applying12 recomendations:1. Dispense with controlling and planning.
20. 2. Operate on the margin between order and disorder.3. Develop new organizations with the help of everyone.4. Allow individual autonomy.5. Encourage information sharing among staffs.6. Promote staffs knowledge of others work.7. Stimulate open learning through discussion generating ‗creative tension‘.8. Considering the organization structure as dynamic.9. Help staffs discover their goals.10. Encourage cooperation not competition.11. Approach work from smarter view, not harder.12. Uncover values continuously to form organization wide visions.