Nursing Care of the Patient With Endocrine Disease Køren K. Gi,ttùngs Unfolding Case Study #36 T,, Jenny Jenrry is a56-year-old female who is scheduled for a routine primary care provider's (PCP) visit to follow-up on her hypertension. She reports no signi-ficant complaints other than her vision being blurry; she states, "I need to go to the eye doctor to have my eyes checked." At the conclusion of her visit, the PCP orders a basic meta- bolic panel (BMP) and complete blood count (CBC) to be drawn. Jenny receives a phone call 2 days later from her PCP's office to schedule an appointment for later that day. Jenny is told that her blood sugar is elevated. At her appointment, Jenny and the nurse begin by reviewing Jenny's risk factors for diabetes. Exercise 6-lz Select øl.l tltøt øþþly Identify risk factors commonly associated with diabetes mellitus: E Obesiry fl ege less than 45 years E Caucasianrace I Family history D History of gestational diabetes E History of delivering babies over 9 pounds eResource 6-l: To review risk factors associated with diabetes, consult Epocrates Online: [Pathway: -+ hnpt//online.epocrates.com -> select the "diseases" tab -+ enter "Diabetes" into the search field -+ review content related to "risks"] Jsnny reports that her mother and grandmother were diabetics. She is also over 45 years old and overweight at 5 feet 2 inches anld 2OO pounds. Jenny still finds it hard to believe that she could be diabetic since she is feeling okay; she asks the nurse to explain to her how diabetes occurs. Anstpers to tbis cbapter begin on page 231 215 216 CHAPTTR 6: ENDOCRINE DISEASE Exercise 6-22 Multiple-cltoí.ce question The nurse educating Jenny on type 2 diabetes determines that she understands tþs information when she states: A. "I am not producing any insulin because of a problem with my immune system." B. "I will need to take insulin for the rest of my life.,' c. "I'm not making enough insulin or my body isn't as sensitive to it.,, D. "I won't need to make any dietary changes if I take my medicine." Exercise 6-32 Møtcbing Match the type of diabetes in Column A with its typical characteristics in Column B Answers in Column A can be used more than once. ColumnA Column B A. Type L diabetes Onset is usually under 30 years old B. Type 2 dial¡etes patient is often thin at time of diagnosis Treated with diet, exercise, and oral agents Patient is often obese at time of diagnosis Antibodies are present in the body Patients require insulin for life G) ;ffi::i,"",'J ^ä¿'"äîîî#."å:*t'#i;:lË:iffi,îå:ä. _enter "Type 2 Diabetes" into the search field -+ in the "overview,'section, select "pathophysiology" and review content] By the time it is Jenny's turn to see her PCP, she has a beginning understanding about diabetes. Her PCP sits with her and begins by reviewing hãr hboratory re- sults. Her fasting plasma glucose from her last visit was 236 mg/dL.The pCp lists some typical signs and symptoms of diabetes, and he asks J.

1. Nursing Care of the Patient
With Endocrine Disease
Køren K. Gi,ttùngs
Unfolding Case Study #36 T,, Jenny
Jenrry is a56-year-old female who is scheduled for a routine
primary care provider's
(PCP) visit to follow-up on her hypertension. She reports no
signi-ficant complaints
other than her vision being blurry; she states, "I need to go to
the eye doctor to
have my eyes checked." At the conclusion of her visit, the PCP
orders a basic meta-
bolic panel (BMP) and complete blood count (CBC) to be
drawn. Jenny receives a
phone call 2 days later from her PCP's office to schedule an
appointment for later
that day. Jenny is told that her blood sugar is elevated. At her
appointment, Jenny
and the nurse begin by reviewing Jenny's risk factors for
diabetes.
Exercise 6-lz Select øl.l tltøt øþþly
Identify risk factors commonly associated with diabetes
mellitus:
E Obesiry
fl ege less than 45 years
E Caucasianrace
I Family history

2. D History of gestational diabetes
E History of delivering babies over 9 pounds
eResource 6-l: To review risk factors associated with diabetes,
consult
Epocrates Online: [Pathway: -+ hnpt//online.epocrates.com ->
select the
"diseases" tab -+ enter "Diabetes" into the search field -+
review content
related to "risks"]
Jsnny reports that her mother and grandmother were diabetics.
She is also over
45 years old and overweight at 5 feet 2 inches anld 2OO
pounds. Jenny still finds it
hard to believe that she could be diabetic since she is feeling
okay; she asks the
nurse to explain to her how diabetes occurs.
Anstpers to tbis cbapter begin on page 231
215
216 CHAPTTR 6: ENDOCRINE DISEASE
Exercise 6-22 Multiple-cltoí.ce question
The nurse educating Jenny on type 2 diabetes determines that
she understands tþs
information when she states:
A. "I am not producing any insulin because of a problem with
my immune
system."
B. "I will need to take insulin for the rest of my life.,'

3. c. "I'm not making enough insulin or my body isn't as sensitive
to it.,,
D. "I won't need to make any dietary changes if I take my
medicine."
Exercise 6-32 Møtcbing
Match the type of diabetes in Column A with its typical
characteristics in Column B
Answers in Column A can be used more than once.
ColumnA Column B
A. Type L diabetes Onset is usually under 30 years old
B. Type 2 dial¡etes patient is often thin at time of diagnosis
Treated with diet, exercise, and oral agents
Patient is often obese at time of diagnosis
Antibodies are present in the body
Patients require insulin for life
G) ;ffi::i,"",'J ^ä¿'"äîîî#."å:*t'#i;:lË:iffi,îå:ä. _enter "Type 2
Diabetes" into the search field -+ in the "overview,'section,
select "pathophysiology" and review content]
By the time it is Jenny's turn to see her PCP, she has a
beginning understanding
about diabetes. Her PCP sits with her and begins by reviewing
hãr hboratory re-
sults. Her fasting plasma glucose from her last visit was 236
mg/dL.The pCp lists
some typical signs and symptoms of diabetes, and he asks Jenny
if she is experi-
encing any of them.

4. Exercise 6-4: Select ølt tbat øþpty
Identify coÍunon clinical manifestations associated with
diabetes mellitus
E rolyuria
E Decreased appetite
Q Decreased fluid intake
E Vision changes
fl natigue
eResource 6-3: For more information regarrding clinical
manifestations
associated with diabetes mellitus, refer to the Merck Manual:
fpathwayt
www.merckmanuals.com + select "Merck Manual of Diagnosis
and
o
Answers to tbis cbapter begin on page 2J1
CFIAPTER 6: ENDOCRINE DISEASE Questions 217
o
Therapy" --> enter "Diabetes" into the search field + select
"Diabetes
Mellitus (DM)" -à select "Symptoms and Signs" and review
content]
Jenny reports that her vision has been blurry, but she thought
that she needed
new glasses. She also recognizes that she has been drinking and
urinating more
than usual. Based on her symptoms and elevated fasting plasma
glucose, the phy-

5. sician suspects Jenny has type 2 diabetes.
eResource 6-4: To learn more about the diagnostic work-up for
Jenny,
refer to Medscape on your mobile device: [Pathway: Medscape
*) enter
"Type 2 Diat¡etes" into the search fleld + select "Type 2
Diabetes
Mellitus" -+ select "'$7'orkup" and review content]
To further confirm the diagnosis, he orders a random fingerstick
blood sugar and
Hemoglobin A1C (HgbAlC).
Exercise 6-52 Sbort ønsu)er
Briefly explain how a HgbAlC is used to evaluate blood glucose
compared to a ran-
dom blood glucose level.
o eResource 6-5zTo learn more about HgbAlC, refer to
Medscape on yourmobile device: [Pathway: Medscape -+ enter
"A].C" into the search field -+
select "Hemoglobin A1C testing"and review content]
Jenny's blood results are ready within a short period of time.
Her fingerstick blood
sugar is 286 and her HgbAlC is 9%. Her physician orders
metformin 500 mg
orally twice a day, andJenny is scheduled to meet with a
diabetes educator in2 days.
Exercise 6-6: Fill-in
Identify three ways in which metformin acts to maintain normal
blood glucose levels:
1

6. 2
3
o eResource 6-6:To review patient teaching regarding
metformin withJenny, refer to Epocrates on your mobile device:
[Pathway: Epocrates ->
enter "metformin" into the search field + select "metformin" -)
scroll
down to review "common reactions" and other relevant content]
Jenny meets with the diabetes educator as scheduled. During her
appointment,
they discuss many topics including nutrition and exercise. The
educator begins by
talking about meal planning and caloric needs.
Anstaers to tbis cba.pter begin on page 231
218 CHAPTER 6: ENDOCRINE DISEASE guestions
rxefcrse o- / 2 .Íttt-Nt .
For obese patients who are diabetic, the key to treatment is:
Exercise 6-8: Fùll-in
Identify the food groups that are part of the Exchange List
system and give one ex-
ample of a specific food within each group:
Exercise 6-9: True orfølse
Identify whether the following statements about nutrition in the
diabetic patient are
true or false:

7. 1. Soluble fiber lowers blood glucose levels by slowing the rate
of
glucose absorption from these foods.
2. Alcohol used in combination with chlorpropamide
(Diabinese)
may cause facial flushing, warmth,.rrauseal and vomiting.
3. Nutritive sweeteners have no effect on blood glucose levels.
Exercise 6-l0t Multìple-cltoíce question
The nurse educating Jenny on exercise determines that she
needs further instruction
when she states:
A. "Exercise will lower my blood glucose level.,,
B. "I should try to exercise at the same time each day.,,
C. "Walking is generally a safe form of exercise.,'
D. "I should exercise more when my glucose levels are more
than
25O mgldL;'
o eResource 6-72 To learn more about nutritional management
of patientswith diabetes, refer to Medscape on your mobile
device: [pathway:
Medscape -+ enter "nutrition" into the search field -+ select
"Nutritional
Management of Patients with Diabetes" and review content]
Jenny is given a blood glucose monitor with instructions for
self-monitoring of her
glucose levels. Once Jenny's blood glucose level is stabilized,
she is instructed to
test at least fwo to three times per week.

8. 1.
2.
3.
4.
5.
6.
7.
8.
Ansuters to tbis cbapter begin on pøge 2J1
CHAPTER 6: ENDOCRINE DISEASE Questions 219
Exercise 6-ll: Select øll tltøt øpply
Identify other ci¡cumstances in which more frequent testing is
recommended:
D Missing a mealtime
Ü Symptoms of hypoglycemia
I Changes in medications
E During periods of increased stress
E Times of illness
The diabetes educator explains to Jenny how metformin works
to control her
blood glucose level. Jenny expresses concern that she may have

9. to use insulin if
the metformin is ineffective, but the nurse explains that there
are many other oral
agents availat:le that can be tried before moving to insulin.
Exercise 6-l2t Mø.tcbing
Match the medication in Column A with its drug classification
and action in Column B.
ColumnA
A. chlorpropamide
(Diabinese)
B. glipizide
(Glucotrol)
C. metformin
(Glucophage)
D. acarbose
(Precose)
E. nateglinide
(Starlix)
Column B
Alpha-glucosidase inhibitor; delays intestinal
absorption of complex carbs
First-generation sulfonylurea; stimulates beta
cells of the pancreas to secrete insulin
Nonsulfonylurea insulin secretagogue;
stimulates th.e pancreas to secrete insulin
Second-generation sulfonylurea; stimulates beta
cells of the pancreas to secrete insulin

10. Biguanide; inhibits production of glucose by
the liver
o eResource 6-8: To learn more about these medications,
consultMedscape on your mobile device: [Pathway: Medscape -)
enter "Type Z
Diabetes" -+ select "Medication" and review content]
As Jenny's appointment draws to an end, the diabetes educator
teaches her about
hypoglycemia and long-term complications.
Exercise 6-15: Multiple-cltoice question
The nurse educating Jenny on hypoglycemia determines that she
understands the in-
formation when she states:
A. "I won't get hypoglycemic when I am only taking
metformin.,'
B. "If I feel my blood sugar dropping, I will eat some chocolate
candy)'
C. "My family should be educated on how to help me if I
become hypogþemic."
D. "Hypoglycemia most often occurs t hour after meals."
Anstaers to this cbapter begin on þage 231
220 CÉ{APTER 6: ENDOCRINE DISEASE Qøes¿loøs
Exercise' 6-14: Fnll-nn
Identify the macrovascular and microvascular complications
that can occur witlì
diabetes:

11. Macrovascular Microvascular
L
eResoufce 6-9zTo learn more about microvascular and
macrovascular
complications, refer to Medscape on your mobile device:
[Pathway:
Medscape -+ enter "Type 2 Diabetes" -> select "Treatment and
Management" -) select'Approach and Considerations" and scroll
down
to review contentl
Exercise 6-15: Select øll tÍtøt øpply
Identifiz foot care techniques recommended for diabetic patients
B Assess feet daily
E Lotion the feet, especially between the toes
fl Use hot water for soaking the feet
D trim toenails straight across
E Never walk barefoot
o eResource 6-LO: To supplement patient teaching regarding
diabetes,refer to:
I MedlinePlus's interactive tutorial, Dia.betes-Introduction:
http://goo.gl/nJn7B
I National Institutes of Health's (NIH's) pamphlet, Your Guid.e
to
Diabetes: Type 1 and Type 2:http://goo.g/bgBNl
eResource 6-L1: To learn about the American College of
Physicians
recommended vaccinations forJenny to help keep her healthy,
download
the ACP Immunization Advisor (ACP-IA) "app" onto your

12. mobile device
(http://goo.gllNzQlB). [Pathway on your mobile device: ACP-
IA ->
select "frrud" -+ enter "age" aîd "Condition" (Note: There are
no special
considerations for Jenny) -+ select "Show Vaccines"]
Unfolding Case Study #37'% Lorrie
Lorrie is a 60-year-old female who was recently diagnosed with
hypothyroidism.
Her granddaughter, Alissa, who is in college studying to be a
registered nurse, is
very interested in learning more about hypothyroidism so that
she can help to
educate her grandmother about her disease process. Alissa
begins by reviewing
basic anatomy and physiology of the thyroid gland.
1
2
3
2
o
o
Ansuters to this cbapter begin on page 2Jl
CI-L{PTER 6: ENDOCRINE DISEASE Qøestlo'?s 221

13. Exercise 6-16z Select øll tltøt aþþly
ldentrfy the hormones released by the thyroid gland:
B ftryroxitte (T4)
Q Thyroid-stimulating hormone (TSH)
E Triiodothyronine (T3)
E calcitonin
E ,tntidiuretic hormone (ADH)
Exercise 6-17: Fíl'l-i.n
Essential for the synthesis of thyroid hormones,
through diet.
Exercise 6-7.82 Sbort a'nsu)er
Briefly explain how the release of thyroid hormone is regulated
in the body.
is obtained
o eResource 6-L2:To learn more, Alissa refers to Medscape on
hermobile device: [Pathway: Medscape -+ entef
"hypothyroidism" -+ select
"Ovefview" -) review content listed under "Background,"
"Epidemiology,"
and " PathophysiologY"J
Alissa is aware that many endocrine disorders have general
signs and symptoms,
which may be initially ignored or thought of as being a part of

14. the normal aging
process. Áirr" asks her grandmother what types of signs and
symptoms she was
experiencing.
Exercise 6-t9z P¡l'Lín
Identify three common signs and symptoms that may indicate an
endocrine disorder:
1.
)
3.
eResource 6-t3:To learn more about coÍunon signs and
symptoms
associated with an endocrine disordeq refer to the Merck
Manual:
I Hypothyroidism: [Pathway: www.mefckmanuals.com -) select
"Merck
Manual of Diagnosis andTherapy" -+ entef "hypothyroidism"
into the
search field + select "hypothyroidism" -+ select "symptoms and
Signs"
and review content]
I Endocrine Disorders: [Pathway: www.merckmanuals'com -t
select
"Merck Manual of Diagnosis and Therapy" -) enter "Endocrine
Disorders" into the search field -+ select "Endocrine Disorders"
and
review content]

15. Answers to tbis cÍra'Pter begin on page 231'
222 CIIAPTER 6: ENDOCRINE DISEASE
Lorrie tells her granddaughter that she had been feeling very
tired and hadenergy for cleaning the house or family activities.
Because she didn't initiallyanything was really wrong, Lorrie
did not seek medical attention, but waitedher regularþ scheduled
púmary carcprovider's (PCp) appointment 3 monthsto mention
her fatigue. Her pCp ordered some laboratory tests to be done
onday and scheduled her for a follow_up appointment in 1
week.
Exercise 6-2O: Select ølt tbøt øppty
Identify clinical manifestations associated with hypothyroidism:
fl weight loss
E Fatigue
E lrritability
D Hair loss
D Increased pulse
fl Feeling cold in awarmenvironment
oË,i::ä::'i"',ÍJ;,';î:å,ä?T3:ï:"i:,;å:1f, ,ffi,î1ïï:',1îî::"n
field -+ select "crinicar presentation" and r*i.* åontentl
Exercise 6-2Iz LIøtcttí.ng
Match the laboratory test in column A with its description and
normal value in
Column B.
ColumnA
A. TSH

16. B. T3
C. T4
D. Free T4
Column B
_7Û%o is protein-bound; normal is 5 to L.). mcg/dL
-
Direct measurement of unbound thyroxine;
normal is 0.8 ro 2.7 ng/dL
-
Best screening test for thyroid function; normal is
0.4 to 4.2 nIU/L
_ More accurate indicator of hyperthyroidism;
normal is 70 to 204 ng/dL
o;::,:ö::,9"ïJ;,Y:ååË3:ï:i:ffi :,";,;ffi,T*,,in,o,he
search field -+ select "work-up" -> select
,,íiboritory studies,,and review
contentJ
At her follow-up appointment, Lorrie received her diagnosis of
hypothyroidismand was started on levothyroxine (synthroid)
0.075 *g"or"tiy daily.Later,Alissa
reviews the medication with her grandmother so that sãe clearly
understands theneed to continue taking it as direited.
Anszaers to tbß cbapter begin onpage 2J1

17. CHAPTER 6: ENDOCRINE DISEASE Questions 223
Exercise 6-22: True orla.lse
Identify whether the following statements about thyroid
hormone replacement ther-
apy are true or false:
1. TSH levels are used for monitoring the effectiveness of
thyroid
hormone replacement and in making dosage adjustments of the
medications.
2. Signs of overdose are manifested as hyperthyroidism
(tachycar-
dia, weight loss, nervousness, and/or chest pain).
3. Thyroid hormone replacement is only needed until symptoms
subside; the medication can then be discontinued.
eResource 6-16z To learn more about this medication, Alissa
consults
Epocrates on her mobile dêvice: [Pathway: Epocrates -+ enter
"synthroid"
into the search field + review contentl
@
Since Lorrie has only recently been diagnosed with
hypothyroidism and started on
levothyroxine (Synthroid), she continues to have some- clinical
manifestations that
she did not previously know were related to the hypothyroidism.
Lorrie continues

18. to tire easily, feel cold despite'warmer environmental
temperatures, and struggle
with constipation. Alissa has found some nursing interventions
through her study
of hypothyroidism tl:rat may be useful to her grandmother.
Exercise 6-23: Multiple-cltoi.ce questíon
V/hen educating her grandmother on controlling her fatigue,
Alissa determines that
she understands the information when she states:
A, "I should push to get all of my housework done in one block
of time."
B. "f don't want to ask for help; I need to keep pushing myself."
C. "I need to get used to feeling tired since I will feel like this
the rest of my life."
D. "I need to space my activities so I can rest in befween."
Exercise 6-242 Multþle-cboice qaesti.on
Øhen educating Lorrie on how to maintain a normal body
temperatt)re, her grand-
daughter determines that she needs further instruction when she
states:
A. "I can just layer my clothing to provide more warmth."
B. "I can use heating pads or an electric blanket when I go to
bed."
C. "I should stay aw^y from cold, ûafty areas."
D. "I won't feel cold all the time once my medicine starts
working."
Exercise 6-25: Select øll tbøt øþþly
Identify interventions designed to improve constipation:
D use laxatives regulady
D Increase fluid intake if no restrictions

19. E Increase activity as tolerated
E Use enemas on a biweekly schedule
fl Increase fiber content in diet
Anstuers to tbis cba.pter begin on þage 231
224 C}IAPTEP. 6: ENDOCRINE DISEASE
o Ilypothyroid.ism: lvba.t Euery parient Needs toeResource 6-
172 Fot more patient education informafion, referKnout:
Alissa has compreted her study of hypothyroidism and educated
heron her disease process, but she decides to review a rittle
information
roidism since she knows that this can occur as a result of
ingestion
thyroid hormone.
Exercise 6-26: Select øil tba.t øþþty
Identift clinical manifestations associated with hyperthyroidism:
on
of
fl Nervousness
fl Heat intolerance
E Progressive weight gain
Ü Poor appetite and decreased intake
D Tachycardia
Exercise 6-27. F¿lt-irt
Identify three atypical signs and symproms of hyperthyroidism
rhat the elderþ
may present:

20. Gl eResource 6-rg: Arissa uses Medscape on her mobile device
tov supplement her_understanding of hyperthyroidism:
[pathway: Medscape-) enter "hyperthyroidism" into the sãarch
field -+ rãview contentl
Exercise 6-28: True orføtse
Identifir whether the following statements about laboratory
results used to diagnose
hyperthyroidism are true or false:
1. TSH levels are decreased with untreated hyperthyroidism.
2. Free T4 levels are decreased with untreated hyperthyroidism.
1.
)
:).
Unfolding Case Study #jg % finda
Linda is a 59-year-old femare with a medical history of
hypertension, asthm a, andchronic bronchitis. sle ha_s a
pasthistory of smoking orré ,o one and aharfpacksof cigarettes
per day for 35 years. Linda quit smokin! when her asthma
worsened;she has been smoke-free for 3 years now. As part of
her treatment regimen, Lindahas been takingprednisone 2o mg
oru:|ry dairy forthe past ii ,rrorrtrrr. at her mostrecent primary
care provider's (PCP) appointment, ;"iida expresses concern at
the
Ansuters to tbis cbaþter begin on þage 231..
Management Services

21. Spring 2015
Sustaining change in
manufacturing companies
By Bob Lillis and Marek Szwejczewski
W
hy do changes stick in some organisations, while
in others they peter out and decay? A fter all, for
most companies, it is a strategic imperative to
sustain change and its associated performance improvement.
Sustainability means th a t the new working practices and the
improved performance persist fo r an appropriate period of
time. The change has become the norm. It is 'how we do things
around here' and is not a one-off or a temporary improvement
but is on-going. Unfortunately, the failure rate o f change
initiatives is high - 70-90% are believed to fail.
While studies have focused on the factors th at minimise
initiative failure and help ensure the successful implementation
o f the change, far less is understood about how to sustain
the initiative once the initial implementation period is over.
For example, research into change initiatives specifically in
manufacturing organisations, have tended to cohere around
either how to implement total quality management (TQM)
successfully or the success factors affecting the process o f lean
production implementation. However, the most comprehensive
study into how to sustain any organisation's change initiative
once it has been successfully implemented, was th a t carried
out by Buchanan et al (2005). Their thorough review of what
is known and w ritten about sustaining organisational change
identified a set o f 11 common factors. The outline definitions
of
these factors are shown in Table 1.

22. For example, the influence o f Leadership is commonly
accepted as im portant in successfully sustaining change. This
factor would include facets such as, has the senior leadership
team established a clear and consistent vision? Is the Leadership
also leading the change once the implementation phase is
over? Considering the factors in Table 1 and outline definitions
at face value, w hat is missing is any understanding o f the
Management Services
Spring 2015 41
FACTOR DEFINITION
Leadership Setting the vision, goals and leading the change
Individual Employees' individual commitment
Managerial Managerial style, approach, and behaviours
Financial Balance of costs and benefits
Substantial Perceived centrality, scale, fit with organisation
Organisational Policies, procedures, system, and structures
Cultural Shared belief, norms, and values
Political Stakeholder and coalition power and influence
Processual Implementation methods used
Contextual External conditions and threats
Temporal J Timing and pace of change activities
Table 1: Buchanan et al (2005) factors w ith definitions.
Respondents'
Job T itle
N um ber
o f Years

23. in Role
N um ber o f
Employees
A ffe c te d by
th e Change
Program m e
D u ra tio n o f
th e Change
Programm e
(in years
and all
o n -goin g)
M a n u fa c tu rin g
Sector___ _________
Operations site
director
human resources
director
3.5
5
800 3.5 Food processing
Deputy vice
president
5 100 1.5 Engineering
European
operations director

24. 3 18,000 1.5 Metals
Production manager 15 80 1.5 Petrochemical
Regional operations
manager
4 100 2.5
Chemicals
(detergents)
Production manager
Managing director
2
10
50 3
Chemicals
(Coatings)
General Manager 3.5 300 3.5 Semiconductors
Head of integration
compliance
4.5 200 3.5 Telecommunications
Service director 6 400 3.5 Machinery
Global environment
manager
4 55,000 4.5
Chemicals (paint/
coatings)
Operations director 4 170 4.5 Cement
Plant controller 4.5 200 4.5 Car accessories

25. Managing director 6 50 6.5 | Plastics
Table 2: Respondents' identification and interview sample.
relevance of all 11 factors in different contexts and the
respective influence th a t each individual factor may have
on encouraging sustainability. For instance, does employees'
individual commitment to sustaining the change outweigh the
managerial style, approach and its behaviours? Is Leadership
more im portant than the Financial factor to sustaining change?
In other words, do some factors have more impact than others
on successfully sustaining change? In this article, we report
preliminary findings from stage one o f a tw o stage research
project which sought to answer these questions.
Research study
We divided the study into tw o separate but interconnected
empirical stages. The first consisted o f in-depth interviews
w ith executives from 13 manufacturing companies which
had sustained a change initiative in their business. During
this stage, we investigated the relevance o f the 11 factors.
Several propositions were developed, some o f which are
reported here. Stage tw o seeks to test these propositions in
three manufacturing companies, one o f which is Maserati in
Italy. We w ill be reporting the results o f the second stage in a
subsequent issue.
The interviewees in stage one came from a sample of
individuals who had attended one o f our courses at Cranfield
School of Management. In seeking an interview w ith a
particular manufacturing manager or manufacturing director,
we knew in advance th at the potential respondent's business
had undergone a change initiative, although the length o f the
change period was unknown to us at the tim e o f the interview
request. Table 2 provides a list o f interviewee job titles, how
long the job holder had spent in th at role, the number of

26. employees in the company affected by the change initiative
and the manufacturing sector o f the business.
The duration o f the change initiative varied from a minimum
o f 1.5 years to 6.5 years and all were still ongoing. We fe lt
these periods o f time would be o f an appropriate duration to
justify a change initiative being called 'sustained'.
Stage one findings
E xtent o f
fa c to r's
influence
SUB
Strongly
influential
throughout
Strongly
influential at the
start becoming
less influential
as change was
sustained
Not influential
at the start
becoming
more strongly
influential as
the change was
sustained
Did not appear
to influence
or arise as
significant

27. 13 1 4 10 1
7 3
7 6 7
6 3 6
12 13
Findings suggest th at most o f the factors had a role to play in
sustaining change, but th eir influence varied depending on the
stage o f the change programme. Four types o f influences were
gleaned which are shown in Table 3. These were:
i) The factor was strongly present at the start o f the change and
throughout the change period.
ii) The factor was strongly present at the start o f the change
but its influence waned as the change continued.
iii) The factor was not strongly present at the start o f the
change but became more influential as the change
continued.
iv) The factor was not seemingly influential at any point in the
change or appears not to have arisen.
The research results o f stage one indicated th a t 10 o f the 11
factors identified by Buchanan et al (2005) had an impact on
the sustainability o f change initiatives. The analysis o f the
interview data indicated th a t the Temporal factor (the tim ing
Table 3: Frequency o f influence o f the 11 factors across the 13
companies.

28. M anagement Services
Spring 2015
and pace o f the change initiative) did not appear to contribute
to sustainability in our sample and is therefore not included in
Table 3.
The interviews suggested th a t factors differed in when they
had most influence. Based on the analyses, several propositions
were developed. The fo ur propositions we consider to be of
most interest were:
P1 Leadership [setting the vision, purpose, goals, and
challenges]
remains strongly influential throughout the duration o f a
sustained change programme
P2 Political [stakeholder, coalition power and influence] is at
its most influential in the early stages o f a sustained change
programme
P3 Managerial [managerial style, approach, behaviours] is at
its most influential in the later stages o f a sustained change
programme
P4 Individual [employee's individual commitment] is at its
most influential in the later stages o f a sustained change
programme
Our data analyses in stage one also provided some interesting
interactions between the various factors. So fo r example, at
company 2 in the engineering sector, whose change period
at the tim e o f interview had been 1.5 years and affecting

29. 100 employees (Table 2), the factors Substantial, Financial,
Leadership, Political, Processual and Contextual were strongly
present at the start o f the change programme and had
remained so throughout its duration. Four o f the factors
namely.
Individual, Managerial, Organisational and Cultural were not
strongly present at the commencement o f the change but
became more influential as the change continued.
In addition, we were also interested in whether the company
had replaced its Managing Director or Chief Executive Officer
at the commencement o f the change programme. We believed
th a t this could have been an im portant factor in sustaining
the change. It transpired th a t 7 o f the 13 companies were so
affected and on the basis o f these statistics, we consider the
impact o f replacing a company's MD or CEO on sustaining a
change programme is inconclusive and requires further research.
Conclusions
Sustaining change is not a simple procedure. Our research
findings suggest th at managers need to put emphasis on
different factors at different stages o f the change. It has long
been recognised th a t Leadership is im portant at the start o f
the
implementation process. Our research supports this view but in
addition points to just how critical it is later in the life o f the
initiative. The leadership cannot afford to reduce its efforts
once
the change initiative has been successfully launched. If it takes
a
back-seat and hands over to the management team, such action
w ill invariably lead to sustainability failure.
The influence in sustaining change o f the political aspect is
often forgotten. It is assumed th at having good Leadership is
more important. However, concern w ith the political aspects

30. o f the change initiative is vital if it is to be sustained. In the
interviews, most o f the senior managers pointed to the fact
that
they had obtained obvious and visible support fo r the initiative
from various stakeholders at the start o f the implementation.
The research also suggests th a t getting the commitment of
the Individuals in the organisation at the start o f the change
process may not be as im portant as some claim. However, to
succeed, the Leadership needs to get the commitment from
most
o f the Individuals once the implementation is complete in order
to sustain the change. A successful initiative launched can be
achieved w ith o u t the vast m ajority being committed.
However,
once the implementation phase is over, if the vast majority
o f Individuals are not committed then the initiative is likely
to peter out and fail. The Managerial factor is also im portant
in sustaining the change initiative but only at the later stage
o f the process. Managers have an im portant role in helping
the leadership team to ensure th a t the new ways o f working
introduced by the change initiative are adhered too.
The research is still ongoing in stage two, w ith one case study
completed and a further tw o currently being conducted.
Therefore,
it is too early in the study to categorically state the respective
influences of the various 11 factors on sustaining change in
manufacturing companies. We hope the research, by indicating
which factor to focus on during the various stages o f the
change
programme, will ultimately prove helpful to those
manufacturers
keen on making change initiatives in their organisation stick.

31. References
Buchanan, D, Fitzgerald, L, Ketley, D., Gollop, R, Jones, J L,
Sharon Saint, L, Neath, A and Whitby, E (2005). 'No going
back:
A review o f the literature on sustaining organizational change',
International Journal o f Management Reviews, Vol 7, No 3, pp
189-205.
A bout the Authors
Dr Bob Lillis is senior lecturer in service operations
management
at Cranfield School of Management, Cranfield University
Dr Marek Szwejczewski is professor o f operations strategy
at Cranfield School o f Management and Director o f the UK's
Best Factory Award Scheme. To find out more about sustaining
organisational change, email [email protected]
mailto:[email protected]
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