BioMed CentralPage 1 of 9(page number not for citation p.docx

BioMed Central
Page 1 of 9
(page number not for citation purposes)
Implementation Science
Open AccessDebate
A theory of organizational readiness for change
Bryan J Weiner
Address: Department of Health Policy and Management,
Gillings School of Global Public Health, University of North
Carolina Chapel Hill,
Chapel Hill, North Carolina, USA
Email: Bryan J Weiner - [email protected]
Abstract
Background: Change management experts have emphasized the
importance of establishing
organizational readiness for change and recommended various
strategies for creating it. Although
the advice seems reasonable, the scientific basis for it is
limited. Unlike individual readiness for
change, organizational readiness for change has not been
subject to extensive theoretical
development or empirical study. In this article, I conceptually
define organizational readiness for
change and develop a theory of its determinants and outcomes. I
focus on the organizational level
of analysis because many promising approaches to improving
healthcare delivery entail collective

behavior change in the form of systems redesign--that is,
multiple, simultaneous changes in staffing,
work flow, decision making, communication, and reward
systems.
Discussion: Organizational readiness for change is a multi-
level, multi-faceted construct. As an
organization-level construct, readiness for change refers to
organizational members' shared resolve
to implement a change (change commitment) and shared belief
in their collective capability to do
so (change efficacy). Organizational readiness for change varies
as a function of how much
organizational members value the change and how favorably
they appraise three key determinants
of implementation capability: task demands, resource
availability, and situational factors. When
organizational readiness for change is high, organizational
members are more likely to initiate
change, exert greater effort, exhibit greater persistence, and
display more cooperative behavior.
The result is more effective implementation.
Summary: The theory described in this article treats
organizational readiness as a shared
psychological state in which organizational members feel
committed to implementing an
organizational change and confident in their collective abilities
to do so. This way of thinking about
organizational readiness is best suited for examining
organizational changes where collective
behavior change is necessary in order to effectively implement
the change and, in some instances,
for the change to produce anticipated benefits. Testing the
theory would require further
measurement development and careful sampling decisions. The

theory offers a means of reconciling
the structural and psychological views of organizational
readiness found in the literature. Further,
the theory suggests the possibility that the strategies that
change management experts recommend
are equifinal. That is, there is no 'one best way' to increase
organizational readiness for change.
Published: 19 October 2009
Implementation Science 2009, 4:67 doi:10.1186/1748-5908-4-67
Received: 20 March 2009
Accepted: 19 October 2009
This article is available from:
http://www.implementationscience.com/content/4/1/67
© 2009 Weiner; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the
Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&d
b=PubMed&dopt=Abstract&list_uids=19840381
http://creativecommons.org/licenses/by/2.0
http://www.biomedcentral.com/
http://www.biomedcentral.com/info/about/charter/
Implementation Science 2009, 4:67

of 9
Background
Organizational readiness for change is considered a criti-
cal precursor to the successful implementation of complex
changes in healthcare settings [1-9]. Indeed, some suggest
that failure to establish sufficient readiness accounts for
one-half of all unsuccessful, large-scale organizational
change efforts [6]. Drawing on Lewin's [10] three-stage
model of change, change management experts have pre-
scribed various strategies to create readiness by 'unfreez-
ing' existing mindsets and creating motivation for change.
These strategies include highlighting the discrepancy
between current and desired performance levels, foment-
ing dissatisfaction with the status quo, creating an appeal-
ing vision of a future state of affairs, and fostering
confidence that this future state can be achieved [2,4,11-
16].
While this advice seems reasonable and useful, the scien-
tific basis for these recommendations is limited. Unlike
individual readiness for change, organizational readiness
for change has not been subject to extensive empirical
study [17]. Unfortunately, simply calling for more
research will not do. As two recently published reviews
indicate, most publicly available instruments for measur-
ing organizational readiness for change exhibit limited
evidence of reliability or validity [17,18]. At a more basic
level, these reviews reveal conceptual ambiguity about the
meaning of organizational readiness for change and little
theoretically grounded discussion of the determinants or
outcomes of organizational readiness. In the absence of
theoretical clarification and exploration of these issues,
efforts to advance measurement, produce cumulative
knowledge, and inform practice will likely remain stalled.

In this article, I conceptually define organizational readi-
ness for change and develop a theory of its determinants
and outcomes. Although readiness is a multi-level con-
struct, I focus on the supra-individual levels of analysis
because many promising approaches to improving
healthcare delivery entail collective behavior change in
the form of systems redesign--that is, multiple, simultane-
ous changes in staffing, work flow, decision making, com-
munication, and reward systems. In exploring the
meaning of organizational readiness and offering a theory
of its determinants and outcomes, my intent is to promote
further scholarly discussion and stimulate empirical
inquiry of an important, yet under-studied topic in imple-
mentation science.
Discussion
What is organizational readiness for change?
Organizational readiness for change is a multi-level con-
struct. Readiness can be more or less present at the indi-
vidual, group, unit, department, or organizational level.
Readiness can be theorized, assessed, and studied at any
of these levels of analysis. However, organizational readi-
ness for change is not a homologous multi-level construct
[19]. That is, the construct's meaning, measurement, and
relationships with other variables differ across levels of
analysis [17,20]. Below, I focus on organizational readi-
ness for change as a supra-individual state of affairs and
theorize about its organizational determinants and organ-
izational outcomes.
Organizational readiness for change is not only a multi-
level construct, but a multi-faceted one. Specifically,
organizational readiness refers to organizational mem-
bers' change commitment and change efficacy to imple-

ment organizational change [17,20]. This definition
followed the ordinary language use of the term 'readiness,'
which connotes a state of being both psychologically and
behaviorally prepared to take action (i.e., willing and
able). Similar to Bandura's [21] notion of goal commit-
ment, change commitment to change refers to organiza-
tional members' shared resolve to pursue the courses of
action involved in change implementation. I emphasize
shared resolve because implementing complex organiza-
tional changes involves collective action by many people,
each of whom contributes something to the implementa-
tion effort. Because implementation is often a 'team
sport,' problems arise when some feel committed to
implementation but others do not. Herscovitch and
Meyer [22] observe that organizational members can
commit to implementing an organizational change
because they want to (they value the change), because
they have to (they have little choice), or because they
ought to (they feel obliged). Commitment based on 'want
to' motives reflects the highest level of commitment to
implement organizational change.
Like Bandura's [21] notion of collective efficacy, change
efficacy refers to organizational members' shared beliefs
in their collective capabilities to organize and execute the
courses of action involved in change implementation.
Here again, I emphasize shared beliefs and collective
capabilities because implementation entails collective (or
conjoint) action among interdependent individuals and
work units. Coordinating action across many individuals
and groups and promoting organizational learning are
good examples of collective (or conjoint) capabilities. As
Bandura and others note, efficacy judgments refer to
action capabilities; efficacy judgments are neither out-
come expectancies [23-25] nor assessments of knowledge,
skills, or resources [23]. Change efficacy is higher when

people share a sense of confidence that collectively they
can implement a complex organizational change.
Several points about this conceptual definition of organi-
zational readiness for change merit discussion. First,
organizational readiness for change is conceived here in
Page 3 of 9
psychological terms. Others describe organizational read-
iness for change in more structural terms, emphasizing
the organization's financial, material, human, and infor-
mational resources [26-34].
In the theory presented here, organizational structures
and resource endowments shape readiness perceptions. In
other words, organizational members take into consider-
ation the organization's structural assets and deficits in
formulating their change efficacy judgments. Second,
organizational readiness for change is situational; it is not
a general state of affairs. Some organizational features do
seem to create a more receptive context for innovation
and change [35-37]. However, receptive context does not
translate directly into readiness. The content of change
matters as much as the context of change. A healthcare
organization could, for example, exhibit a culture that val-
ues risk-taking and experimentation a positive working
environment (e.g., good managerial-clinical relation-
ships), and a history of successful change implementa-
tion. Yet, despite this receptive context, this organization

could still exhibit a high readiness to implement elec-
tronic medical records, but a low readiness to implement
an open-access scheduling system. Commitment is, in
part, change specific; so too are efficacy judgments. It is
possible that receptive context is a necessary but not suffi-
cient condition for readiness. For example, good manage-
rial-clinical relationships might be necessary for
promoting any change even if it does not guarantee that
clinicians will commit to implementing a specific change.
The theory proposed here embraces this possibility by
regarding receptive organizational context features as pos-
sible determinants of readiness rather than readiness
itself. Third, the two facets of organizational readiness for
change--change commitment and change efficacy--are
conceptually interrelated and, I expect, empirically corre-
lated. As Bandura [21] notes, low levels of confidence in
one's capabilities to execute a course of action can impair
one's motivation to engage in that course of action. Like-
wise, as Maddux [25] notes, fear and other negative moti-
vational states can lead one to underestimate or downplay
one's judgments of capability. These cognitive and moti-
vational aspects of readiness are expected to covary, but
not to covary perfectly. At one extreme, organizational
members could be very confident that they could imple-
ment an organizational change successfully, yet show lit-
tle or no motivation to do so. The opposite extreme is also
possible, as are all points in between. Organizational
readiness is likely to be highest when organizational
members not only want to implement an organizational
change and but also feel confident that they can do so.
What circumstances are likely to generate a shared sense of
readiness? Consistent leadership messages and actions,
information sharing through social interaction, and
shared experience--including experience with past change

efforts--could promote commonality in organizational
members' readiness perceptions [19]. Broader organiza-
tional processes like attraction, selection, socialization,
and attrition might also play a role [38-40]. Conversely,
organizational members are unlikely to hold common
perceptions of readiness when leaders communicate
inconsistent messages or act in inconsistent ways, when
intra-organizational groups or units have limited oppor-
tunity to interact and share information, or when organi-
zational members do not have a common basis of
experience. Intra-organizational variability in readiness
perceptions indicates lower organizational readiness for
change and could signal problems in implementation
efforts that demand coordinated action among interde-
pendent actors.
What conditions promote organizational readiness for
change?
If generating a shared sense of readiness sounds difficult,
that is because it probably is. This might explain why
many organizations fail to generate sufficient organiza-
tional readiness and, consequently, experience problems
or outright failure when implementing complex organiza-
tional change. Although organizational readiness for
change is difficult to generate, motivation theory and
social cognitive theory suggest several conditions or cir-
cumstances that might promote it (see Figure 1).
Change valence
Drawing on motivation theory [41-43], I propose that
change commitment is largely a function of change
valence. Simply put, do organizational members value the
specific impending change? For example, do they think
that it is needed, important, beneficial, or worthwhile?
The more organizational members value the change, the
more they will want to implement the change, or, put dif-

ferently, the more resolve they will feel to engage in the
courses of action involved in change implementation.
Change valence is a parsimonious construct that brings
some theoretical coherence to the numerous and dispa-
rate drivers of readiness that change management experts
and scholars have discussed [11,13,22,28,44-46]. Organi-
zational members might value a planned organizational
change because they believe some sort of change is
urgently needed. They might value it because they believe
the change is effective and will solve an important organ-
izational problem. They might value it because they value
the benefits that they anticipate the organizational change
will produce for the organization, patients, employees, or
them personally. They might value it because it resonates
with their core values. They might value it because manag-
ers support it, opinion leaders support it, or peers support
it. Given the many reasons why organizational members
might value an organizational change, it seems unlikely
Page 4 of 9
that any of these specific reasons will exhibit consistent,
cross-situational relationships with organizational readi-
ness for change. In fact, it might not be necessary that all
organizational members value an organizational change
for the same reasons. Change valence resulting from dis-
parate reasons might be just as potent a determinant of
change commitment as change valence resulting from
commonly shared reasons. For organizational readiness,
the key question is: regardless of their individual reasons,

do organizational members collectively value the change
enough to commit to its implementation?
Change efficacy
Drawing on social cognitive theory, and specifically the
work of Gist and Mitchell [47], I propose that change effi-
cacy is a function of organizational members' cognitive
appraisal of three determinants of implementation capa-
bility: task demands, resource availability, and situational
factors. As Gist and Michell [[47]:184] observe, efficacy is
a 'comprehensive summary or judgment of perceived
capability to perform a task.' In formulating change-effi-
cacy judgments, organizational members acquire, share,
assimilate, and integrate information bearing on three
questions: do we know what it will take to implement this
change effectively; do we have the resources to implement
this change effectively; and can we implement this change
effectively given the situation we currently face? Imple-
mentation capability depends in part on knowing what
courses of action are necessary, what kinds of resources are
needed, how much time is needed, and how activities
should be sequenced. In addition to gauging knowledge
of task demands, organizational members also cognitively
appraise the match between task demands and available
resources. That is, they assess whether the organization
has the human, financial, material, and informational
resources necessary to implement the change well. Finally,
they consider situational factors such as, for example,
whether sufficient time exists to implement the change
well or whether the internal political environment sup-
ports implementation. When organizational members
share a common, favorable assessment of task demands,
resource availability, and situational factors, they share a
sense of confidence that collectively they can implement a
complex organizational change. In other words, change

efficacy is high.
Contextual factors
Change management experts and scholars have discussed
other, broader contextual conditions that affect organiza-
tional readiness for change. For example, some contend
that an organizational culture that embraces innovation,
risk-taking, and learning supports organizational readi-
ness for change [48-51]. Others stress the importance of
flexible organizational policies and procedures and posi-
tive organizational climate (e.g., good working relation-
ships) in promoting organizational readiness [52-54].
Still others suggest that positive past experience with
change can foster organizational readiness [2]. I contend
that these broader, contextual conditions affect organiza-
tional readiness through the more proximal conditions
described above. Organizational culture, for example,
could amplify or dampen the change valence associated
with a specific organizational change, depending on
whether the change effort fits or conflicts with cultural val-
ues. Likewise, organizational policies and procedures
could positively or negatively affect organizational mem-
bers' appraisals of task demands, resource availability,
and situational factors. Finally, past experience with
change could positive or negatively affect organizational
members' change valence (e.g., whether they think the
change really will deliver touted benefits) and change effi-
cacy judgments (e.g., whether they think the organization
Determinants and Outcomes of Organizational Readiness for
ChangeFigure 1
Determinants and Outcomes of Organizational Readiness for
Change. Included in separate document, per instruc-
tions to authors concerning figures.
Or ganizational

Readiness for Change
Change commitment
Change efficacy
Infor mational Assessment
Task demands
Resource perceptions
Situational factors
Change-Related Effor t
Initiation
Persistence
Cooperative behavior
Change
Valence
Possible Contextual Factor s*
Organizational culture
Policies and procedures
Past experience
Organizational resources
Organizational structure
* Briefly mentioned in text, but not focus of the theory
Implementation

Effectiveness
Page 5 of 9
can effectively execute and coordinate change-related
activities).
What outcomes result from organizational readiness for
change?
Outcomes are perhaps the least theorized and least stud-
ied aspect of organizational readiness for change. Change
experts assert that greater readiness leads to more success-
ful change implementation. But how, or why, is this so?
Social cognitive theory suggests that when organizational
readiness for change is high, organizational members are
more likely to initiate change (e.g., institute new policies,
procedures, or practices), exert greater effort in support of
change, and exhibit greater persistence in the face of
obstacles or setbacks during implementation [21,47].
Motivation theory not only supports these hypotheses,
but suggests another [22,41-43]. When organizational
readiness is high, organizational members will exhibit
more pro-social, change-related behavior--that is, actions
supporting the change effort that exceed job requirements
or role expectations. Research by Herscovitch and Meyer
[22] supports this contention. They found that organiza-
tional members whose commitment to change was based
on (i.e., determined by) 'want to' motives rather than
'need to' motives or 'ought to' motives exhibited not only

more cooperative behavior (e.g., volunteering for prob-
lem-solving teams), but also championing behavior (e.g.,
promoting the value of the change to others).
What is the end result of all this change-related effort?
Drawing on implementation theory, the most proximal
outcome is likely to be effective implementation. Follow-
ing Klein and Sorra [55], implementation effectiveness
refers to the consistency and quality of organizational
members' initial or early use of a new idea, program, proc-
ess, practice, or technology. To illustrate, when organiza-
tional readiness for change is high, community health
centers providers and staff will more skillfully and persist-
ently take action to put a diabetes registry in practice and
demonstrate more consistent, high-quality use of the reg-
istry. By contrast, when organizational readiness for
change is low or nonexistent, community health center
providers and staff will resist initiating change, put less
effort into implementation, persevere less in the face of
implementation challenges, and exhibit compliant regis-
try use, at best. In the absence of further intervention, reg-
istry use is likely to be intermittent, scattered, and uneven.
Organizational readiness for change does not guarantee
that the implementation of a complex organizational
change will succeed in terms of improving quality, safety,
efficiency or some other anticipated outcome. Implemen-
tation effectiveness is a necessary, but not sufficient condi-
tion for achieving positive outcomes [55]. If the complex
organizational change is poorly designed, or if it lacks effi-
cacy, no amount of consistent, high-quality use will gen-
erate anticipated benefits. Moreover, it is important to
recognize that organizational members can misjudge
organizational readiness by, for example, overestimating
(or even underestimating) their collective capabilities to

implement the change. As Bandura [21,23] notes, efficacy
judgments based on rich, accurate information, preferably
based on direct experience, are more predictive than those
based on incomplete or erroneous information.
Some thoughts on testing this theory
Because this theory of organizational readiness for change
is pitched at the organizational level of analysis, a test of
the theory's predictions would require a multi-organiza-
tion research design in which a set of organizations imple-
ments a common, or at least comparable, complex
organizational change. A large healthcare system imple-
menting Six Sigma or lean manufacturing on a system-
wide basis would provide a useful opportunity to test the
theory. So too would an association of community health
centers agreeing to implement a common multi-compo-
nent diabetes management program, or a group of affili-
ated specialty practices deciding to implement a common
electronic medical record.
Could the theory be tested at the clinic, department, or
divisional level? The idea of testing the theory at an intra-
organizational level of analysis holds some appeal given
sample size and statistical power considerations. If a rea-
sonable case can be made that the clinics, departments, or
divisions are distinct units of implementation (e.g., they
have some autonomy in change implementation), then
the idea of testing the theory at an intra-organizational
level of analysis seems defensible. However, careful con-
sideration should be given to the question of whether the
construct's meaning, measurement, and functional rela-
tions change by moving to the analysis down to intra-
organizational level.
It is important to note that organizational readiness for
change is conceptualized here as a 'shared team property'-

-that is, a psychological state that organizational members
hold in common [19]. The extent to which this shared
psychological state exists in any given situation is an
empirical issue requiring the examination of within-group
agreement statistics. If sufficient within-group agreement
exists (i.e., organizational members agree in their readi-
ness perceptions), then analysis of organizational readi-
ness as a shared team property can proceed. If insufficient
within-group agreement exists (i.e., organizational mem-
bers disagree in their readiness perceptions), organiza-
tional readiness as a shared team property does not exist.
Instead, the analyst must either focus on a lower level of
analysis (e.g., team readiness) or conceptualize organiza-
tional readiness as a configural property and theorize
Page 6 of 9
about the determinants and outcomes of intra-organiza-
tional variability in readiness perceptions [19].
Finally, as noted earlier, most publicly available instru-
ments for measuring organizational readiness for change
exhibit limited evidence of reliability and validity. As two
recently published reviews indicate, most of the instru-
ments employed in peer-reviewed research were not
developed systematically using theory, nor were they sub-
jected to extensive psychometric testing [17,18]. There are
a few instruments have undergone thorough psychomet-
ric assessment. However, none of these instruments is
suitable for measuring organizational readiness for

change as defined above, either because they focus on
individual readiness rather than organizational readiness,
or because they treat readiness as a general state of affairs
rather than something change-specific, or because they
include items that the theory presented above considers
determinants of readiness rather than readiness itself (e.g.,
items pertaining to change valence). Although it is
beyond the scope of this article to discuss measurement
issues in detail, an instrument that would best fit the con-
struct of readiness as described above would have the fol-
lowing characteristics:
1. Some means of focusing respondents' attention on a
specific impending organizational change, perhaps by
including a brief description of the change in the survey
instrument and by mentioning the change by name in the
instructions for specific item sets.
2. Group-referenced rather than self-referenced items
(e.g., items focusing on collective commitment and capa-
bilities rather than personal commitment and capabili-
ties).
3. Items that only capture change commitment or change
efficacy, not related constructs, like the antecedent condi-
tions discussed above (Nunnally [56] refers to such items
as direct measures).
4. Efficacy items that are tailored to the specific organiza-
tional change, yet not so tailored that that the instrument
could be used in other circumstances without substantial
modification.
Satisfying this last point would be challenging, but it does
not seem impossible. Health behavior scientists have suc-
cessfully developed self-efficacy instruments for smoking,

physical activity, and other health behaviors that are reli-
able and valid within their domain of application [57-63].
Although item content is tailored, the instruments are
based on theory and have enough features in common
that scholars can accumulate scientific knowledge across
health problems. With respect to organizational readiness
for change, it might be possible to identify a set of fre-
quently occurring courses of action that must be skillfully
organized and executed to achieve effective implementa-
tion of complex organizational changes. Possible candi-
dates include: developing an effective strategy or plan for
implementing the change; getting people involved and
invested in implementing the change; coordinating tasks
so that implementation goes smoothly; anticipating or
preventing problems that might arise during implementa-
tion; and managing the politics of implementing the
change. A pool of items could perhaps be developed that
researchers could use in order to construct organizational
readiness for change instruments that fit specific change
contexts, yet share at least some content with other tai-
lored instruments.
Summary
In this article, I sought to conceptually define organiza-
tional readiness for change and develop a theory of its
determinants and outcomes. In contrast to much of the
literature on the topic, the conceptual definition offered
here treats organizational readiness as a shared team
property--that is, a shared psychological state in which
organizational members feel committed to implementing
an organizational change and confident in their collective
abilities to do so. This way of thinking about organiza-
tional readiness is best suited for organizational changes
where collective, coordinated behavior change is neces-
sary in order to effectively implement the change and, in

some instances, for the change to produce anticipated
benefits. Some of the most promising organizational
changes in healthcare delivery require collective, coordi-
nated behavior change by many organizational members.
Electronic health records, chronic care models, open
access scheduling, quality improvement programs, and
patient safety systems are but a few examples. There are,
however, many evidence-based practices that providers
could adopt, implement, and use on their own with rela-
tively modest training or support (e.g., smoking cessation
counseling, foot exams for diabetic patients). Often such
practices can generate benefits for individual providers, or
their patients, regardless of whether other providers also
adopt, implement, or use them. Individual-level theories
of behavior change--such as the theory of planned behav-
ior or the trans-theoretical model of change--apply more
readily to such cases than organization-level theories do
because the adoption, implementation, use, and out-
comes of such evidence-based practices do not depend on
collective, coordinated behavior change. The greater the
degree of interdependence in change processes and out-
comes, the greater the utility of supra-individual theories
of readiness, such as the one presented here.
The article makes three contributions to theory and
research. First, the article's discussion of the meaning of
Page 7 of 9
organizational readiness addresses a fundamental concep-

tual ambiguity that runs through the literature on the
topic: is readiness a structural construct or a psychological
one? The theory that I describe seeks to reconcile the struc-
tural view and psychological view by specifying a relation-
ship between them. In this theory, resources and other
structural attributes of organizations do not enter directly
into the definition of readiness. Instead, they represent an
important class of performance determinants that organi-
zational members consider in formulating change efficacy
judgments. This view is consistent with Bandura's [21]
contention that efficacy judgments focus on generative
capabilities--that is, the capability to mobilize resources
and orchestrate courses of action to produce a skillful per-
formance. Thus, organizations with the same resources,
endowments, and organizational structures can differ in
the effectiveness with which they implement the same
organizational change depending on how they utilize,
combine, and sequence organizational resources and rou-
tines. It seems preferable to regard organizational struc-
tures and resource endowments as capacity to implement
change rather than readiness to do so. This distinction
between capacity and readiness could move theory and
research forward by reducing some of the conceptual
ambiguity in the meaning and use of the term 'readiness.'
Second, the article's discussion of determinants illumi-
nates the theoretical basis for the various strategies that
change management experts recommend for creating
organizational readiness. For practitioners, it might not
seem necessary to explain in theoretical terms how or why
a strategy works. For researchers, however, theoretical
explication of the pathways through which these strategies
affect readiness is important for advancing scientific
knowledge. The theory that I propose suggests that strate-
gies such as highlighting the discrepancy between current
and desired performance levels, fomenting dissatisfaction

with the status quo, creating an appealing vision of a
future state of affairs increase organizational readiness for
change by increasing change valence--that is, by increas-
ing the degree to which organizational members perceive
the change as needed, important, or worthwhile. In addi-
tion to advancing scientific knowledge, identifying and
testing the pathways through which actions (strategies)
have effects can have practical implications as well. Such
efforts can prompt the discovery of new strategies or alter-
native pathways, or they can show the equifinality of
already known strategies. For example, in the theory that
I describe, the keys to increasing readiness are raising
change valence and promoting a positive assessment of
task demands, resource availability, and situational fac-
tors. It seems unlikely that there is one best way to achieve
these goals; at the same time, it seems unlikely that all
ways are always equally effective. Creating a sense of
urgency might be useful for increasing change valence in
some situations (i.e., when complacency is high), but not
others (i.e., when uncertainty is high). Likewise, end-user
involvement in change design and implementation plan-
ning can be a powerful way for not only increasing change
valence (e.g., helping people to see why this change is
needed, important, and worthwhile), but also for helping
organizational members realistically appraise the match
of task demands, available resources, and situational fac-
tors. When, for whatever reason, end-user involvement is
not an appropriate or feasible strategy, vicarious learning
strategies (e.g., site visits) could be useful for supplying
organizational members with accurate information about
task demands, resource requirements, and situational fac-
tors affecting implementation. If readiness-enhancing
strategies are indeed equifinal--and this is an empirical
question--then organizational leaders, innovation cham-
pions, and other change agents could take with a grain of

salt the 'one best way' advice so often found in prescrip-
tive change management writing, and focus instead of
developing and using strategies that are tailored to local
needs, opportunities, and constraints.
Third, the article's discussion of outcomes develops a the-
oretical link between two disparate bodies of research:
organizational readiness for change and implementation
theory and research. As noted earlier, change experts have
asserted that greater organizational readiness leads to
more successful implementation without specifying what
'successful implementation' means or explaining how or
why this might be so. This article uses implementation
theory to conceptually define the notion of implementa-
tion effectiveness and distinguish implementation effec-
tiveness from innovation effectiveness. Moreover, the
article draws on social cognitive theory and motivation
theory to explain how greater organizational readiness
could result in more effective change implementation.
Implementation theory could also benefit from a stronger
theoretical link. Although it is beyond the scope of this
article to discuss in detail, I suspect that the construct of
implementation climate--which Klein and Sorra [55]
define as organizational members' shared perception that
innovation use is expected, supported, and rewarded--has
much in common with organizational readiness for
change, the principal difference being that one construct
applies in the 'pre-implementation' period while the
other applies once implementation has begun. This article
merely begins the dialogue between these two bodies of
research which hitherto have developed independently of
one another. Whether or not the theory developed here
ultimately finds empirical support, I hope that its discus-
sion promotes scholarly debate and stimulates empirical
inquiry into an important, yet under-studied topic in
implementation science.

Page 8 of 9
Competing interests
The author declares that he has no competing interests.
Acknowledgements
This work was supported by funding from the National Cancer
Institute (1
R01 CA124402). The author would like to thank Megan Lewis
and the two
reviewers for their thoughtful comments on and suggestions.
References
1. Amatayakul M: EHR? Assess readiness first. Healthc Financ
Man-
age 2005, 59:112-113.
2. Armenakis AA, Harris SG, Mossholder KW: Creating
readiness
for organizational change. Human Relations 1993, 46:681-703.
3. Cassidy J: System analyzes readiness for integrated delivery.
Health Prog 1994, 75:18-20.
4. Hardison C: Readiness, action, and resolve for change: do
health care leaders have what it takes? Qual Manag Health Care
1998, 6:44-51.

5. Kirch DG, Grigsby RK, Zolko WW, Moskowitz J, Hefner DS,
Souba
WW, Carubia JM, Baron SD: Reinventing the academic health
center. Acad Med 2005, 80:980-989.
6. Kotter JP: Leading change Boston: Harvard Business Press;
1996.
7. Kuhar PA, Lewicki LJ, Modic MB, Schaab D, Rump C,
Bixler S: The
Cleveland Clinic's magnet experience. Orthop Nurs 2004,
23:385-390.
8. O'Connor EJ, Fiol CM: Creating readiness and involvement.
Physician Exec 2006, 32:72-74.
9. Sweeney YT, Whitaker C: Successful change: renaissance
with-
out revolution. Semin Nurse Manag 1994, 2:196-202.
10. Lewin K: Field theory in social science: Selected theoretical
papers 1st edi-
tion. New York,: Harper; 1951.
11. Armenakis AA, Harris SG: Crafting a change message to
create
transformational readiness. Journal of Organizational Change
Man-
agement 2002, 15:169-183.
12. Backer TE: Assessing and enhancing readiness for change:
implications for technology transfer. NIDA Res Monogr 1995,
155:21-41.
13. Backer TE: Managing the human side of change in VA's
trans-

formation. Hospital & Health Services Administration 1997,
42:433-459.
14. Levesque DA, Prochaska JM, Prochaska JO: Stages of
change and
integrated service delivery. Consulting Psychology Journal:
Practice
and Research 1999, 51:226-241.
15. Levesque DA, Prochaska JM, Prochaska JO, Dewart SR,
Hamby LS,
Weeks WB: Organizational stages and processes of change
for continuous quality improvement in health care. Consulting
Psychology Journal: Practice and Research 2001, 53:139-153.
16. Narine L, Persaud D: Gaining and maintaining commitment
to
large-scale change in healthcare organizations. Health Serv
Manage Res 2003, 16:179-187.
17. Weiner BJ, Amick H, Lee SY: Conceptualization and
measure-
ment of organizational readiness for change: a review of the
literature in health services research and other fields. Med
Care Res Rev 2008, 65:379-436.
18. Holt DT, Armenakis AA, Harris SG, Feild HS: Toward a
Compre-
hensive Definition of Readiness for Change: A Review of
Research and Instrumentation. In Research in Organizational
Change and Development Greenwich, CT: JAI Press; 2006:289-
336.
19. Klein KJ, Kozlowski SWJ: From Micro to Meso: Critical
Steps in
Conceptualizing and Conducting Multilevel Research. 2000,

3:211-236.
20. Weiner BJ, Lewis MA, Linnan LA: Using organization
theory to
understand the determinants of effective implementation of
worksite health promotion programs. Health Educ Res 2009,
24:292-305.
21. Bandura A: Self-efficacy: the exercise of control New York:
W.H. Free-
man; 1997.
22. Herscovitch L, Meyer JP: Commitment to organizational
change: Extension of a three-component model. Journal of
Applied Psychology 2002, 87:474-487.
23. Bandura A: Social foundations of thought and action: a
social cognitive the-
ory Englewood Cliffs, N.J.: Prentice-Hall; 1986.
24. Bandura A: Exercise of human agency through collective
effi-
cacy. Current Directions in Psychological Science 2000, 9:75-
78.
25. Maddux JE: Self-efficacy theory: an introduction. In Self-
efficacy,
adaptation, and adjustment: theory, research, and application
Edited by:
Maddux JE. New York: Plenum Press; 1995:3-27.
26. Bloom JR, Devers K, Wallace NT, Wilson N: Implementing
capi-
tation of Medicaid mental health services in Colorado: Is
"readiness" a necessary condition? Journal of Behavioral
Health

Services & Research 2000, 27:437-445.
27. Stablein D, Welebob E, Johnson E, Metzger J, Burgess R,
Classen DC:
Understanding hospital readiness for computerized physi-
cian order entry. Joint Commission Journal on Quality and
Safety 2003,
29:336-344.
28. Lehman WEK, Greener JM, Simpson DD: Assessing
organiza-
tional readiness for change. Journal of Substance Abuse
Treatment
2002, 22:197-209.
29. Demiris G, Patrick T, Khatri N: Assessing home care
agencies'
readiness for telehealth. Annual Symposium Proceedings AMIA
Sym-
posium 2003:825.
30. Demiris G, Courtney KL, Meyer W: Current status and per-
ceived needs of information technology in Critical Access
Hospitals: a survey study. Informatics in Primary Care 2007,
15:45-51.
31. Medley TW, Nickel JT: Predictors of home care readiness
for
managed care: a multivariate analysis. Home Health Care Serv
Q
1999, 18:27-42.
32. Oliver DRP, Demiris G: An assessment of the readiness of
hos-
pice organizations to accept technological innovation. J
Telemed Telecare 2004, 10:170-174.

33. Snyder-Halpern R: Measuring organizational readiness for
nursing research programs. West J Nurs Res 1998, 20:223-237.
34. Snyder-Halpern R: Indicators of organizational readiness for
clinical information technology/systems innovation: a Delphi
study. Int J Med Inform 2001, 63:179-204.
35. Dopson S, FitzGerald L, Ferlie E, Gabbay J, Locock L: No
magic tar-
gets! Changing clinical practice to become more evidence
based. Health Care Manage Rev 2002, 27:35-47.
36. Newton J, Graham J, McLoughlin K, Moore A: Receptivity
to
Change in a General Medical Practice. British Journal of
Manage-
ment 2003, 14:143-153.
37. Pettigrew AM, Ferlie E, McKee L: Shaping strategic
change: making
change in large organizations: the case of the National Health
Service Lon-
don; Newbury Park, Calif.: Sage Publications; 1992.
38. Klein KJ, Dansereau F, Hall RJ: Levels Issues in Theory
Develop-
ment, Data-Collection, and Analysis. Academy of Management
Review 1994, 19:195-229.
39. Schneider B, Goldstein HW, Smith DB: The ASA
framework: An
update. Personnel Psychology 1995, 48:747-773.
40. Sathe V: Culture and related corporate realities: text, cases,
and readings

on organizational entry, establishment, and change Homewood,
Ill.: R.D.
Irwin; 1985.
41. Fishbein M, Ajzen I: Belief, attitude, intention, and
behavior: an introduc-
tion to theory and research Reading, Mass.: Addison-Wesley
Pub. Co;
1975.
42. Vroom VH: Work and motivation New York,: Wiley; 1964.
43. Meyer JP, Herscovitch L: Commitment in the workplace:
toward a general model. Human Resource Management Review
2001, 11:299-326.
44. Cole MS, Harris SG, Bernerth JB: Exploring the
implications of
vision, appropriateness, and execution of organizational
change. Leadership & Organization Development Journal 2006,
27:352-567.
45. Madsen SR, Miller D, John CR: Readiness for
organizational
change: Do organizational commitment and social relation-
ships in the workplace make a difference? Human Resource
Development Quarterly 2005, 16:213-233.
46. Holt DT, Armenakis AA, Feild HS, Harris SG: Readiness
for organ-
izational change: The systematic development of a scale. J
Appl Behav Sci 2007, 43:232-255.
47. Gist ME, Mitchell TR: Self-Efficacy - a Theoretical-
Analysis of Its
Determinants and Malleability. Academy of Management

Review
1992, 17:183-211.
48. Jones RA, Jimmieson NL, Griffiths A: The Impact of
Organiza-
tional Culture and Reshaping Capabilities on Change Imple-
mentation Success: The Mediating Role of Readiness for
Change. Journal of Management Studies 2005, 42:361-386.

Publish with BioMed Central and every
scientist can read your work free of charge
"BioMed Central will be the most significant development for
disseminating the results of biomedical researc h in our
lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community

peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central
yours — you keep the copyright
Submit your manuscript here:
http://www.biomedcentral.com/info/publishing_adv.asp
BioMedcentral
Page 9 of 9
49. Adelman HS, Taylor L: Toward a scale-up model for
replicating
new approaches to schooling. Journal of Educational and
Psycholog-
ical Consultation 1997, 8:197-230.
50. Ingersoll G, Kirsch J, Merk S, Lightfoot J: Relationship of
organiza-
tional culture and readiness for change to employee com-
mitment to the organization. Journal of Nursing Administration
2000, 30:11-20.
51. Chonko LB, Jones E, Roberts JA, Dubinsky AJ: The role of
environ-
mental turbulence, readiness for change, and salesperson
learning in the success of sales for change. Journal of Personal
Selling & Sales Management 2002, 22:227-245.
52. Eby LT, Adams DM, Russell JEA, Gaby SH: Perceptions of

organi-
zational readiness for change: Factors related to employees'
reactions to the implementation of team-based selling.
Human Relations 2000, 53(3):419-442.
53. Turner D, Crawford M: Change Power: Capabilities that
Drive Corporate
Renewal Warriewood, Australia: Business & Professional
Publishing;
1998.
54. Kanter RM: The change masters: innovation and
entrepreneurship in the
American corporation 1st Touchstone edition. New York: Simon
and
Schuster; 1984.
55. Klein KJ, Sorra JS: The Challenge of Implementation.
Academy
of Management Review 1996, 21:1055-1080.
56. Nunnally JC: Psychometric theory 2nd edition. New York:
McGraw-Hill;
1978.
57. Dishman RK, Motl RW, Saunders R, Felton G, Ward DS,
Dowda M,
Pate RR: Self-efficacy partially mediates the effect of a school-
based physical-activity intervention among adolescent girls.
Preventive Medicine 2004, 38:628-636.
58. Dishman RK, Motl RW, Saunders RP, Dowda M, Felton G,
Ward DS,
Pate RR: Factorial Invariance and Latent Mean Structure of
Questionnaires Measuring Social-Cognitive Determinants of
Physical Activity among Black and White Adolescent Girls.

Preventive Medicine 2002, 34:100-108.
59. Finkelstein J, Lapshin O, Cha E: Feasibility of promoting
smoking
cessation among methadone users using multimedia compu-
ter-assisted education. J Med Internet Res 2008, 10:e33.
60. Etter J-F, Bergman MM, Humair J-P, Perneger TV:
Development
and validation of a scale measuring self-efficacy of current
and former smokers. Addiction 2000, 95:901-913.
61. Robinson-Smith G, Johnston MV, Allen J: Self-care self-
efficacy,
quality of life, and depression after stroke. Archives of
Physical
Medicine and Rehabilitation 2000, 81:460-464.
62. Elise LL, Steven VO: A measure of self-care self-efficacy.
1996,
19:421-429.
63. Leung DYP, Chan SSC, Lau CP, Wong V, Lam TH: An
evaluation of
the psychometric properties of the Smoking Self-Efficacy
Questionnaire (SEQ-12) among Chinese cardiac patients
who smoke. Nicotine & Tobacco Research 2008, 10:1311-1318.

http://www.biomedcentral.com/info/publishing_adv.asp
BioMed Central publishes under the Creative Commons
Attribution License (CCAL). Under the CCAL, authors
retain copyright to the article but users are allowed to
download, reprint, distribute and /or copy articles in
BioMed Central journals, as long as the original work is
properly cited.

377
Journal of Occupational and Organizational Psychology (2002).
75, 377-392
© 2 0 0 2 The British Psychological Society
www.bps.org.uk
Readiness for organizational change:
A longitudinal study of workplace, psychological
and behavioural correlates
Charles E. Cunningham'*, Christel A. Woodward^,
Harry S. Shannon^, John Macintosh', Bonnie Lendrum',
David Rosenbloom' and Judy Brown^
'Hamilton Health Sciences and McMaster University, Hamilton,
Ontario, Canada
^McMaster University, Hamilton, Ontario, Canada
To examine factors influencing readiness for healthcare
organizational change, 654
randomly selected hospital staff completed questionnaires
measuring the logistical
and occupational risks of change, ability to cope with change
and to solve job-
related problems, social support, measures of Karasek's (1979)
active vs. passive job
construct (job demand x decision latitude) and readiness for
organizational change.
Workers in active jobs (Karasek, 1979) v/hich afforded higher
decision latitude and

control over challenging tasks reported a higher readiness for
organizational change
scores. Workers with an active approach to job problem-solving
with higher job
change self-efficacy scores reported a higher readiness for
change. In hierarchical
regression analyses, active jobs, an active job problem-solving
style and job-change
self-efficacy contributed independently to the prediction of
readiness for organiz-
ational change. Time I readiness for organizational change
scores and an active
approach to job problem-solving were the best predictors of
participation in
redesign activities during a year-long re-engineering
programme.
Healthcare organizations are undergoing unprecedented changes
(Shortell, Gillies,
Anderson, Erickson, & Mitchell, 1996). (Competition, funding
reductions, efforts to
improve cost-efficiency, mergers and the re-engineering of work
processes are placing
enormous demands on healthcare organizations and their
employees (Woodward
et al., 1999). Research on individual differences in readiness for
organizational
change, workplace processes that facilitate change and factors
that influence the
impact of organizational change on the health and emotional
well-being of employees
Is important to the success of efforts to improve the health
service delivery system.
Readiness for change research suggests that a demonstrable
need for change, a sense

of one s ability to successfully accomplish change (self-
efficacy) and an opportunity to
participate in the change process contribute to readiness for
(Armenakis, Harris, & Mossholder, 1993). Readiness for change
models have
been applied widely in the organizational and behavioural
sciences. Prochaska and
^Requests for reprints should be addressed to Charles E.
Cunningham, Department of Psychiatry and Behavioural
Neurosdences. Faculty of Health Sciences. McMaster
University, 1200 Main Street, Homiltor], Ontario, L8N 3Z5.
Canada
(e-mail: [email protected]).
378 Charles E. Cunningham et al.
colleagues, for example, found that readiness for individual
change proceeded through
stages (Prochaska et al., 1994; Prochaska, Redding, & Evers,
1997) beginning at the
precontemplative stage, where the need for change is not
acknowledged. At the
contemplative stage, individuals consider but do not initiate
change. As a preparatory
stage is reached, planning for change occurs (Prochaska etal.,
1994, 1997). Individuals
engaged in the process of behavioural change are at the action
stage, whereas those
attempting to sustain changes are at the maintenance stage.
Movement through
these stages is governed by decisional balance, the anticipated
risks of change vs. the

potential benefits of change.
This study applied an individual readiness for change model to
a longitudinal study
of organizational re-engineering in healthcare settings. We
developed a brief measure
of individual readiness for organizational change based on
Prochaska et a/.'s (1994)
questionnaires and tested several assumptions of individual and
organizational
readiness for change models.
Benefits vs. risks of organizational change
Readiness for change begins with an individual's perception of
the benefits of change
(Prochaska et al., 1994), the risks of failing to change
(Armenakis et al., 1993; Beer,
1980; B. A. Spector, 1989), or the demands of externally
imposed changes (Pettigrew,
1987). We hypothesized, therefore, that workers' perceptions of
opportunities for
improvement in staff competence, service quality, quality
improvement programme or
organizational staff relationships would contribute to readiness
for change scores.
Readiness for change research suggests that staff perceptions
regarding the risks of
re-engineering should also influence readiness for
organizational change (Prochaska
et al., 1994). Employees in healthcare organizations facing re-
engineering are con-
fronted with at least three types of risks. First, because
organizational re-engineering
poses a threat of job change or loss, we postulated that
perceptions of occupational

insecurity would lower readiness for organizational change
scores and limit partici-
pation in re-engineering activities. Second, the logistical burden
of re-engineering
represents a risk that may shift decisional balance and reduce
ational change (Prochaska et al., 1997). In a healthcare work
force composed largely of
women, the domestic responsibilities assumed by many
employees might increase the
logistical demands of organizational re-engineering (Hall, 1989,
1992). Shift work
might contribute to an already difficult logistical burden. We
predicted, therefore, that
child care, household tasks, shift work and a perception of
conflict between domestic
and occupational responsibilities would reduce readiness for
and limit participation in re-engineering. Third, because
represents a considerable source of stress (Eerrie, Shipley,
Marmot, Stansfeld, & Smith,
1995; Woodard et al., 1999), re-engineering may pose special
risks lor employees
experiencing psychological distress. We hypothesized that
emotional exhaustion and
depression would reduce readiness for organizational change
and participation in
redesign activities.
Individual contributors to readiness for organizational change
Self-efficacy, the perceived ability to manage change
successfully, exerts a mediating
effect on readiness for individual (Prochaska et al., 1997) and
(Armenakis et al., 1993; Pond, Armenakis, & Green, 1984).

Workers with confi-
dence in their ability to cope with change should be more likely
to contribute to
Readiness for organizational change 379
organizational redesign. In contrast, workers may resist cbanges
that they believe
exceed their coping capabilities (Armenakis et al., 1993;
Bandum, 1982). We pre-
dicted, therefore, tbat staff who were cotifidetit in their ability
to cope with job change
and who adopted ati active approach to job problem-solvitig
would bave a higher
readiness for cbatige scores and participate in a greater number
of organizational
Workplace contributors to readiness for organizational change
Finally, we a.ssumed that individual readiness for cbange would
be influenced by
broader organizational factors. Jobs wbich empower (Spreitzer,
1995) employees with
the skills, attitudes and opportunities to manage change should
increase work-related
self-efficacy (Conger & Kanungo, 1988) and readiness for
(Armenakis et al., 1993; Neuman, 1989). Karasek (1979)
described active jobs as
psycbologically demanding positions affording bigh decision
latitude. Jobs with low
demands and loŵ decision latitude were defined as passive
(Karasek, 1979)- Active
jobs increase learning opportunities and contribute to desirable

stress, whicb increases
motivation and tbe development of new bebaviour patterns
(Tbeorell & Karasek,
1996). Active jobs provide opportunities for enactive mastery
and incremental prep-
anition for larger-scale organizational cbange (Armenakis et al.,
1993). Workers in
active jobs should be more confident in their ability to manage
cbange (Spreitzer,
1995) and better prepared to participate in organizational
redesign (Armenakis et al..,
1993; Beer & Walton, 1987; Neuman, 1989). Passive jobs,
wliicb limit opportunities for
decision-making and control, may compound tbe anticipated
occupational risks of
organizational re-engineering, lower self-efficacy and limit
readiness for change. A third
factor, .social support (Johnson, 1991; Karasek, Triantis, & C
ĥaudhry, 1982; LaRocco,
House, & French, 1980; Stansfeld, North, White, & Marmot,
1995) appears to interact
witb active jobs to predict workplace adjustment. We predicted,
therefore, that
higher scores on both Karasek and Tbeorell's (1990) active vs.
passive job dimension
and social support would be associated witb readiness for
organizatiotial cbange and
stibsequent participation in a year-long hospital re-engineering
programtne.
Method
Participants
A sample ot 880 staff, =21% of the employees at a large
Canadian teaching hospital, was
randomly selected from tbe organization s human resources

files. Participants were
drawn from a wide range of job descriptions (e.g. nurses,
pbysiotherapists, housekeep-
ing) at two former general hospital sites wbich eacb possessed a
ntimber of units (a
cbildren s bospital, a cbildren's outpatient developmental and
mental bealth centre,
a rehabilitation hospital and a chrotiic care setting).
Procedures
Baseline surveys were sent to staff selected for tbe study after
the intent to re-engineer
was amioimced, but several months before redesign planning
began. Staff were
itiformed tbat the purpose of the stirvey was to understand bow
workplace cbanges
affect both employees and services. Staff returned
questionnaires to a university
research unit witb assurance tbat data would remain
confidential, and tbe hospital
admitiistnition would not have access to individual scores.
Following baseline sitrveys,
an extensive programme of organizational re-engineering began.
Design teams worked
for a year to achieve cost reductions and service improvements
by introducing pro-
gramme management, designing evidenced-based clinical
pathways, redistributing
tasks (multiskilling) and reducing staff. Staff were informed by
regular newsletters and
town hall discussions and encouraged to pose questions, make

suggestions or offer
feedback anonymously. Staff were given opportunities to
participate in a wide range of
redesign activities and provided with transitional workshops and
supports (e.g. resume
preparation, interview training, computer skills and career
planning). At Time 2, one
year following the completion of the first survey, the same
cohort of employees was
sent a second survey.
Measures
Measures of the risks ofchatige
Family demographics. Participants completed questions
regarding marital status, number
of chiitlren, time devoted to child care, care of extended family
members and family
income.
job insecurity. A 6-item 5-point (strongly disagree to strongly
agree} scale (alpha=.65)
measured job insecurity (Greenhalgh & Rosenhlatt. 1984).
job ir)terference. A 3-item 3-point (not at all to a great deal)
scale (alpha=.64) from
the Whitehall studies measured the adverse effects of one's job
on family life (North
etal., 1993).
tAeasures of self-efficacy
jotxhange seif-efficacy. Confidence in one's ability to cope with
job change, the transfer-
ability of joh skills, and joh prospects were measured with a
new 5-item 5-point

(strongly disagree to strongly agree) seale (alpha= .71).
Active approach to job problem-soiving. This 5-item 5-point
(never to almost all the time)
scale, which measured an active approach to the solution of
work-related
prohlems (alpha=.75), was adapted from Israel, Schurman, and
House (1986).
Aleasures of joh characteristics
job demands. A 6-point 5-item (strongly disagree to strongly
agree) variation of
the original 4-point scale (Karasek, 1985) measured
psychological and physical job
demands (alpha = .69).
Decision latitude. A 9-item 5-point (strongly disagree to
strongly agree) variation of the
original 4-point scale (Karasek, 1985) composed of skill
discretion (the breadth of skills
workers could use) and decision-making authority measured
decision latitude
(alphas.60).
Active vs. passive job. Karasek's (1979) active joh construct
was computed hy multiplying
decision latitude by job-demand scores.
Social support. A 10-item 5-point (strongly disagree to strongly
agree) scale
(alpha=.86) composed of three supervisor support and seven
colleague support

questions was adapted from Karasek's Job Content
Questionnaire (four new and six
adapted questions).
Organizationlstaff relations. This 5-item 5-point (poor to
excellent) scale (alpha=.79) was
adapted from the Hospital Corporation of America's staff
judgments of hospitals
questionnaire (Hays, 1994). For example, staff rated 'The way
this hospital treats its
employees'.
Service quality
Quality of patient core. A l6-item 5-point (poor to excellent or
don't know) scale
(alphas .93) was adapted from the Hospital Corporation of
America's quality of patient
care measures (Hays, 1994). For example, staff rated the
'current quality of care
provided'.
Staff competence. This 9-item 5-point (poor to excellent or
don't know) scale
(alpha=.94) included items from the Hospital Corporation of
America's measures
(Hays, 1994). For example, staff rated the extent courtesy and
respect are shown
patients by staff.
Attention to quality improvemer^t This measure was a 5-item,
5-point (poor to excellent to
don't know) scale based on the Hospital Corporation of
America's questionnaire
(Hays, 1994) plus additional items examining staff perceptions

of the hospital's com-
mitment to quality improvement (alpha=.88). For example, staff
rated the emphasis
placed on evidence to guide improvement of quality in eare and
services'.
Psychological measures
Readiness for organizational change. A 6-item 5-point (strongly
disagree to strongly agree)
readiness for change scale (alpha=.63) was modelled after the
measures
developed by Prochaska and colleagues (1994), with questions
reflecting the
precontemplative, contemplative, preparatory, action and
maintenance stages of the
model (Prochaska et al., 1994). Scoring for items at the
precontemplative stage (e.g.
programme does not need changing) were reversed to yield a
continuous scale, with
higher scores reflecting increased readiness.
Planned health and lifestyle changes. Staff checked lifestyle-
change options from a list of 15
Ontario Health Survey items (Ontario Ministry of Health, 1992).
Emotional exhaustion. Staff completed the 7-item 6-point (never
to every day) Emotional
Exhaustion seale (alpha= .91) from the Maslaeh Burnout
Inventory (Maslach & Jackson,
1981).
Depression. Symptoms of depression ^vere measured with a 10-
item 4-point (rarely or
none of tbe time to mostly all of tbe time) scale (alpha=.78)
version of the Centre for
the Epidemiological Study of Depression scale (CESD)

(Radloff, 1977; Reis & Herz,
1986).
Contributions to re-engineering
Participation in re-engineering. At Time 2, one year after the
start of redesign, staff
recorded which of seven possible re-engineering activities (e.g.
submitting design
ideas, volunteering for design teams, joining design teams,
participating in redesign
2.9
3.5
3.5
3.5
1.0
1.0
I.I
1.2
382 Charles £ Cunningham et al.
Table I . Mean and standard deviations for readiness for
organizational change questions"
Stage of change
Content of question Mean SD

Precontemplative stage
The programme or area in which I work functions well and does
not have any
aspects which need changing
There's nothing that I really need to change about the way I do
my job to be
more efficient
Contemplative stage
I've been thinking that I migbt want to help change something
about the
programme or area in which I work
Preparatory stage
I plan to be involved in changing the programme or area in
which I work
A c t i o n ^ tage
I am working hard to help improve aspects of the programme or
area in which I
work 3.7 I.I
Maint^ance stage
W e are trying to make sure we keep changes/improvements my
programme/area
has made 3.5 .9
"Scale range I (strongly disagree) t o 5 {strongly agree).
work groups, etc.) they participated in during the year following
Time 1 assessments.
At Time 2, staff rated their contribution to the re-engineering
process on a 5-point scale
(not at all to very much).

Results
This analysis begins by examining the workplace, psychological
and domestic
correlates of baseline readiness for org:mizational change.
Hierarchical regression
equations (Tabachnik & Fidel, 1996) were computed to model
the contribution ol the
anticipated risks of change, job change sef-efficacy, an active
approach to job-related
problem-solving and Karasek's (1979) model of an active job to
ational change. A final regre.ssion equation examined the
predictors of participation in
a year-long programme of organizational re-engineering.
Responses to the six items on
the readiness for organizational change measure are presented
in Table 1.
Response rate
Of the 65^ (74'X)) staff returning surveys, most were women
(87%) mth community
college (44%) or university degrees (28%). Most participants
were nonsupervisory
(87%), nonunion (87%) staff, employed on hourly contracts
(77%) with shift work
requirements (44%). A majority of participants were married or
living with partners
(76%) and had children in the home (71%). Although
participants were employed an
average of 35 h per week, a considerable amount of additional
time was devoted to
child care (29 h) and household activities (14.7 h). Of the 834
employees eligible for
participation at Time 2, 528 (63%) completed surveys.

Risks and benefits of organizational change
Correlational analysis showed that domestic factors which
might influence the logisti-
cal burden of change, or limit participation in the redesign
process, were not linked to
readiness for organizational change scores. With the exception
of children under age 6
in the home, whicb was related to lower participation (r=-.l6**)
but not readiness
(r=-.O7), gender (r=.O2, r=.O5), time devoted to child care (r=-
.O3, r=-.O7),
responsibility as the main family earner (r= - .08, r= - .04),
household chores (r= - .08,
r=-.O5), and marital status (r=.03. r=.O3) were not related to
readiness for change or
participation in redesign activities, respectively. Table 2 shows
that staff with a higher
readiness for organizational change scores reported slightly
more job interference with
family life and higher emotional exhaustion scores. Shift work,
which might limit
participation in redesign activities, was associated with a
slightly lower readiness for
organizational change scores (r=-.15**) and less participation in
redesign activities
(r=-.25**). Job insecurity (Table 2) was not linked to readiness
for organizational
change or participation in redesign activities.
The correlation analysis showed that readiness for
organizational change scores

were not linked to potential benefits of change. Staff
perceptions of the quality of
patient care (r=-.O4, r=-.O4), statT competence ir=-.O6, r=-
,09), quality improve-
ment programmes (r=.OO, r=-.O7), or staff-organizational
relations (r=.O8, r=.O4)
were not linked to readiness for organizational change or
participation in redesign
activities, respectively.
Individual correlates of readiness for organizational change
As predicted, Table 2 shows that workers with an active
approach to job related
problem-solving and higher job-change self-eftlcacy at Time 1
reported a higher readi-
ness for change scores, participated in a greater number of
redesign activities during
the following year, and reported making a greater contribution
to organizational
change.
Workplace contributors to readiness for organizational change
Table 2 shows that staff in active jobs (e.g. high decision
latitude x high job demands)
reported a higher readiness for organizational change scores,
participated in a greater
number of redesign activities, and felt they made a greater
contribution to organiz-
ational change than those in passive jobs. Although social
support was only weakly
related to readiness for organizational change and was not
related to participation in
redesign activities, it was associated with lower emotional
exhaustion scores.
As a measure of discriminant validity, we detemiined whether

ational change was specific to the workplace or reflective of a
more generalized
readiness for personal change. Readiness for change was not
linked to plans to engage
in health-related personal lifestyle changes (r=.()6).
As shown in Table 2, staff with a higher readiness for
organizational change scores at
Time 1 participated in a greater number of redesign activities
during a year-long
re-engineering programme and reported making a greater
contribution to organiz-
ational change at Time 2.
Predicting readiness for organizational change
A hierarchical regression equation (Tabachnik & Fidell, 1996)
tested the predictions of
individual (Prochaska et al., 1994, 1997) and organizational
readiness for change
models (Armenakis et al., 1993). Prochaska s model suggests
that readiness reflects a
balance between the risks and benefits of change. After
controlling for hospital site on
step 1, step 2 entered occupational and logistical risks of
change: shift work, job
384 Charles E. Cunningham et ai
o
U
re

- r — —
I I
t I
o o —
* 4.
ro O (N
— _ O
o o 00 LTl
00
• o
r-..
1= u H ---
a. U
5 "
O Q < i/i
o
Readiness for organizational charige 385
Table 3. Sequential regression equation predicting readiness for
organizational change scores
(N=62S)

Measure
Step 1: Control variable
Site
Step 2: Occupational risks
Shift work
Job interferes with family
Job insecurities
Step 3: Psychological risks
Emotional exhaustion
Depression
Step 4: Self-efficacy
Job change self-efficacy
Active job problem-solving approach
Step 5: Karsek's active job
Active vs. passive job
M u l t r
.12
11
.31
.48
.54
Mult r̂
.02

.07
.10
.23
.29
2 change
.02
.06
.02
.13
.07
Beta''
.06
- . 1 1
.11
.12
.03
- . 1 0
.14
.26

.29
t
1.83
- 3 . 1 5 * *
2.36*
2.81**
.60
- 2 . 5 1 * *
3.20***
7.03***
7 55***
"Standardized beta from final step of the regression equation.
interference with family and job insecurity'. On step 3, ^ve
entered psychological
variables that might increase the risk of change: emotional
exhaustion and depression.
Because readiness for organizational change is mediated by
self-efficacy, the percep-
tion that one can manage change (Aremenakis et al., 1993;
Prochaska et al., 1994),
measures of job change self-efficacy and an active approach to
job problem-solving
were entered on step 4. Finally, because an active job should
prepare workers for
organizational change (Armenakis et al., 1993; Spreitzer, 1995;
Theorell & Karasek,
1996), we entered Karasek's active vs. passive job construct
(decision latitudexjob

demands) on step 5.
Table 3 shows the multiple r, multiple R^, R^ change,
standardized regression
coefficients, f-values and probability levels following entry of
each variable. Overall,
this model accounted for 29% of the variance in readiness for
scores. Standardized beta scores for the final step showed that
an active job and an
active approach to job problem-solving were tbe best predictors
of readiness for
organizational change scores. Entering the components of
Karasek's active vs. passive
job construct, decision latitude and job demands before active
vs. passive job in
a second hierarchical regression equation did not contribute
significantly to the
prediction of readiness for organizational change.
Predicting participation in organizational change
We postulated that, in combination with anticipated risks, self-
efficacy and active jobs,
baseline readiness for change scores would predict participation
in a year-long process
of organizational redesign. The hierarchical regression equation
summarized in Table 4
shows that this model accounted for 27% of the variance in re-
engineering partici-
pation. Standardized beta scores for the final step suggest that
Time I readiness for
change scores and an active approach to job problem-solving
were the best predictors
of participation in redesign activities. Shift work and higher
depression scores were

Table 4. Hierarchical regression equation; Time I variables
predicting Time 2 participation in
redesign activities (N=450)
Measure
Step 1: Control variable
Site
Step 2: Occupational risks
Shift v^ork
Job insecurity
Depression
Active job problem-solving approach
Step 5: Karsek's active job
Active vs. passive job
Step 6: Readiness for change
Time 1 readiness for organizational change
M u l t r
.10

.31
.35
.47
.48
.52
Mult r̂
.01
.10
.12
.22
.23
.27
J change
.01
.09
.03
.10
.01

.04
Beta"
.06
- . 2 0
.11
.05
.08
- . 1 1
- . 0 1
.23
.03
.24
t
1.32
_ 4^9*^M<
2.02̂ *̂
.90
1.24
- 2.29*
- . 1 3

4 . 9 5 * * *
.61
4.88***
"Standardized beta from final step of the regression equation.
associated with lower participation in redesign activities.
Entering the compotients of
Karaseks active vs. passive job construct, decision latitude and
job demands before
active vs. passive job in a second hierarchical regression
equation did not contribute
significantly to the prediction of participation in redesign
activities.
lo determine whether participation was a function of the
opportunities afforded by
supervisory status, we computed the same sequential regression
equation in a
subsaniple of 274 nonsupervisor>' health professit)nals (Table
5). This model, again,
accounted for 27% of the variance in participation in redesign
activities. Significant
beta scores for the final step suggest that a higher readiness for
change scores, an
active approach to job problem-solving and site were the best
predictors of partici-
pation in redesign activities. Shift work was, again, associated
with less involvement in
Discussion
Organizational contributors to readiness for organizational

change
Readiness for change was best predicted by combining
organizational (Armenakis
etal., 1993) and individual models (Prochaska etal., 1994,
1997). Work variables were
the best predictors of readiness for organizational change.
Employees in active pos-
itions witb more control over challenging jobs reported a higher
ational change sct)res dmi were mt)re likely to participate in
organizational redesign.
This is consistent with research suggesting that active jobs
foster personal empower-
ment, improve performance, increase initiative and contribute to
organizational
innovation (Conger & Kasungo, 1988; Spreitzer, 1995; fheorell
& Karasek, 1996).
Table 5. Sequential regression equation of baseline measures
predicting participation in organiz-
ational re-engineering during the next year
Measure
Step I: Occupatfonal risks
Job insecurity
Step 2: Logistical risks
Shift v/ork

W o r k stress
Depression
Job problem-solving
Step 5: Active job
Step 6: Readiness for change
M u l t r
.030
.292
.353
.469
.491
.522
Multr*
.001
.085
.124
.220
.241

.272
Beta"
.060
- . 1 8 4
.096
- . 0 3 8
.052
- . 1 1 2
- . 0 1 6
.205
.307
.215
t
I.I
- 4 . 2 1
1.80
- . 7 5
.83
- 2 . 2 9
- . 2 9
4.33
7.8
4.35

P
.272
.012
.073
.453
.408
.022
<.OOI
<.OOI
<.OOI
<.OOI
"Standardized beta from final step of the regression equacion.
The dynamic demand-control hypothesis suggests that active
jobs contribute to a
sense of mastery (Theorell & Karasek, 1996). In the present
study, positive correlations
among active jobs, an active approach to job problem-solving
and bigber job cbange
self-efficacy are consistent with these predictions. Theorell and
Karasek (1996) also
suggested that the sense of mastery created by active jobs
inhibits the perception of
stress or engenders positive stress (Theorell & Karasek, 1996).
Active jobs, however,
were associated with greater interference with family and higher
emotional exhaustion

scores. This observation questions the assumption that active
jobs contribute to a state
of positive stress.
Previous studies have linked workplace social support to
employee adjustment
Oohnson, 1991; Karasek et al., 1982; LaRocco et al., 1980;
Stansfeld et al, 1995). In
this study, job-related interpersonal relationships made a very
limited contribution to
the prediction of readiness for organizational change scores. A
socially supportive
workplace, however, was correlated with lower emotional
exhaustion scores. These
findings suggest that supportive colleagues may play a more
important role in
employee efforts to cope with the stress of organizational
change (Woodward et al.,
1999).
Decisional balance: Risks and benefits of change
Readiness for change models suggest that evidence of a need for
change, a discrepancy
between present conditions and a targeted organizational
objective, are important to
the creation of readiness for organizational change (Armenakis
et al., 1993; Beer, 1980;
B. A. Spector, 1989). As in many healthcare redesign initiatives
(Ho, C:han, & Kidwell,
1999), the need to change was imposed by funding reductions.
In this study,
staff judgments of the quality of the care and services provided
by the organization
were not linked to readiness for change scores. When imposed
change represents
occupational, logistical and psychological risks to employees,

and is not linked to a
388 Charles £, Cunningham et al.
perceived need for quality improvements, the success of these
changes may be
compromised (Armenakis et al., 1993; Ho et al., 1999; B. A,
Spector, 1989),
Decisional balance models suggest that individuals prepare for
action when the
perceived benefits of change outweigli the anticipated risks of
change (Prochaska
et al., 1994). Our results provide limited support for this model.
Thus, shift work,
which poses logistical risks to employees considering
participation in organizational
redesign, was linked to a lower readiness for organization;il
change scores and less
participation in re-engineering activities.
Most of the employees studied bere were women. The child care
and household
responsibilities which employed women assume may prolong
job-related physiological
arousal, intensify work overload and role conflict, and increase
vulnerability to
workplace stress (Burke, 1993; Eckcnrode & Gore, 1990; Hall,
1989, 1992; Keita &
Jones, 1990). In this study, the perception th;it work interferes
with family life was
strongly linked to emotional exliaustion and depression scores.
Staff reporting a higher
readiness lor change scores and participating iii a greater

number or redesign activities
reported a slightly greater interference with their family and
somewhat higher
emotional exhaustion scores. Nonetheless, children in the home
under age 6 was
the only domestic responsibility measure linked to lower
participation in redesign
activities.
Organizational redesign is a stressful experience for many staif
(Woodw:ird et al.,
1999). Nonetheless, psychological factors, which might increase
the personal risks of
rapid organizational change, did not reduce readiness for
change. As noted above,
workers with a higher readiness for change scores reported
slightly higher emotional
exhaustion scores. This is consistent with studies finding that
organizational stressors
may prompt innovation and a coping response (Bunce & West,
1994). Finally, contrary
to the predictions of decisional balance models, a key work-
related measure of risk, job
insecurity, was not related to readiness for organizational
change or participation in
Individual correlates of readiness for organizational change
Self efficacy, the perceived ability to cope with change, is
thought to be an important
contributor to readiness (Armenakis et al., 1993; Pond et al.,
1984; Prochaska et al.,
1994), In this study, workers with an active approach to work
problems, who were
more confident in their ability to cope with job change, reported
a higher readiness for

organizational change scores at Time 1, participated in a greater
number of redesign
activities during the following year, and felt that they made a
greater contribution to
organizational change at Time 2, These data are consistent with
studies on personal
hardiness suggesting that a similar constellation of
psychological characteristics is
associated with favourable responses to stressful events
(Kobasa, Maddi, Fucetti, &
Zola, 1985; Kobasa &Pucetti, 1983; Westman, 1990).
Measuring readiness far organizational change
In tliis study, statf with higher readiness scores participated in
more re-engineering
activities and felt that they made a greater contribution to the
organization s redesign
efforts. The data support the predictive validity of this measure.
The independent
contribution of readiness for change scores to the predication of
participation provides
iurther support for this measure's predictive validity.
The finding that readiness for organizational change scores
were not related to the
planning of personal health behaviour changes supports the
discriminant validity of
this measure. Readiness for organizational change scores did
not reflect a general
propensity to personal change.
Limitations

Although a single corporate sampling frame may have limited
the generalizability
of these findings, participants were selected from different
occupational groupings,
inpatient and outpatient settings, and geographical locations.
Participants worked in
programmes serving children and adults with a wide range of
acute and chronic health
problems at sites with different funding bases, histories and
ctiltures.
In addition, estimates of decision latitude, social support and
individual readiness for
organizational change were based on employee reports.
Although subject to informant
biases, perceptions of workplace eharaeteristics have been
linked to more objective
analyses (P. Spector, Dwyer, & Jex, 1988). Moreover,
physiological responses are
mediated by the interaction of perceptions of workplace
characteristics (e.g. job
control) and more objective measures (Fox, Dwyer, & Ganster,
1993; Stansfeld et al.,
1995).
Implications
This study has several implications for healthcare organizations
facing change. First,
active jobs that afford control over challenging tasks,
conditions which optimize health
and emotional well-being (Blegen, 1993; Greenberger, Strasser,
Cummings, & Dunham,
1989; Karasek & Theorell, 1990; Landsbergis, 1988; Tetrick &
LaRoeco, 1987; Tbeorell

& Karasek, 1996), prepare workers to initiate or contribute to
Second, encouraging an active approach to job problem-solving,
building the
strategies needed to manage change suceessfully and enhancing
job ehange self-
effieacy (Armenakis et «/., 1993) should contribute
independently to the preparatory
benefits of an active job.
Third, workers in demanding jobs reported a higher emotional
exhaustion. Longi-
tudinal studies suggest that organizational re-engineering
increases emotional exliaus-
tion (Woodward et al., 1999), wbich may adversely effect work
performance (Wright
& Bonett, 1997) and lower patient satisfaction (Leiter, Harvie,
& Frizzell, 1998). If the
strain of rapid organizational change is not modulated, the
contribtitions of employees,
and the ultimate impact of redesign on patient care, may be
compromised. Building
supportive relationships with co-workers and supervisors and
limiting confiiet
between work and home life might modulate the stress of
Stage models suggest that workers at the precontemplative or
contemplative stages
would respond to different interventions to those at the
preparatory or action stages
(Prochaska et al., 1994, 1997). Studies linking organizational
functioning to work-
group readiness for ehange suggest that employees in the same
work group would be

at similar stages (Fox, Ellison, & Keith, 1988). The types of
brief measures used here
may help identify workgroup readiness levels and design
preparatory interventions
addressing the needs of employees at different stages of the
change process.
Stage models suggest a dynamic process of individual and
(Prochaska et al., 1994, 1997) in which a shift in the perceived
risks and benefits of
change may prompt return to an earlier phase. This study
suggests that active involve-
ment in organizational ehange, reducing barriers to participation
(e.g. shift work).
building problem-solving strategies and enhancing workers"
perceptions of their
ability to cope witb change (change sclf-efficacy) should botb
enhance commitment to
redesign and reduce the stress of organizational change.
Acknowledgements
This research was supported by Haniiltoti (Icalth Sciences and
the Social Sciences and
Humanities Research Foundation during the collection of this
data. Preparation of this
manuscript was supported by a Senior Research Fellowship to
the first author from the Ontario
Mental Health Foundation and the John C. Laidlaw Chair in
Patient Centred Health Care.

Deborah Fitzpatrick provided helpful comments during the
preparation of the manuscript.
References
Armenakis. A, A,, Harris, S, G.. & Mossholder, K. W, (1993).
Creating readiness for organizational
change. Human Relations, 46, 681-703.
Ilandura, A, A, (i982), Selt-efficacy mechanism in human
agency, American Ps}>chologist, 37,
122-147,
Beer, M. (t980). Organization change and dei'elopment: A
systems vieu: Santa Monica, CA:
Goodyear,
lleer, M,, & Walton, A. E, (1987). Organization change and
development. Annual Review of
Psychology, 38, 339-367.
Blegen. M. A. (1993), Nurses' job satisfaction: A meta-analysis
of related variables. Nursing
Research. 42, 36-41,
Bunce, I),, & West, M, (1994), c:hanging work environments:
Intiovative coping responses to
occupational stress. Work and Stress, 8, 319-331.
Burke, R. J. (1993). Organizational-level interventions to
reduee occupational stre.ssors. Work
and Stress, 7, 77-87.
Conger, J. A., & Kaniingo, R. N. (1988), The empowerment
process: integrating theory and
pntctice. Academy of Management Review, 13, 471-482,

Eckenrode, .)., & Gore, S, (1990). Stress and coping at the
boundary' of work, aiid family. In
J. Eekenrode & S. Gore (Eds,), Stress between ivork and family
(pp. l-l6). New York:
Plenum Press.
Ferrie.J. E., Shipley, M. J., Marmot, M. G., Stansfeld, S., &
Smith, G. D. (1995), Health effects of
anticipation of job change and non-employment: Longitudinal
data from the Wbitehall II
study, British MedicalJtnirnal. 311, 1264-1269.
Fox, M, I.,, Dwyer, I). J,. & Clanster, D. C, (1993), Effects of
stressful job demands and control
on physiological and attitudinal outcomes in a hospital setting.
Academy of Management
Review, 30, 289-318.
Fox, D. G., Ellison, R, L, & Keith, K, L. (1988). Human
resource management: An index and its
relationship to readiness for change. Public Personnel
Management, 17, 297-302,
Cireenberger, D, B., Strasser, S., Cummings, L. S., & Dunham,
R. (1989), The impact ol personal
control on pertbrmance and satisfaction. Organizational
Behavior and Human Decision
Processes, 43, 29-51.
Greenhalgh, L., & Rosenblau, Z. (19H4). Job insecuritj: Toward
conceptual clarity. Academy of
Management Review. 9. 438-448,
Hall. E. M, (1989), Gender, work control, and stress: A
theoretical discussion and an empirical

test. International Journal of Health Services. 19, 72S-74S,
Hall, E. M. (1992), Double exposure: The combined impact of
tbe bome and work environments
on mental strain and physical illness. International Journal of
Health Services, 22, 239-260.
Hays. R, D, (1994), Short from measures of physician and
employee judgements about hospital
quality./omr Commission Journal of Quality Improvement, 20,
i^(^-ll.
Ho, S, J., Chan, L,, & Kidwell, R, E, Jr. (1999). The
improvement of business process reengineer-
ing in American and Canadian hospitals. Health Care
Management Review, 24, 19-31.
Israel, B. A.. Schurman, S, J,, & House, J. A, (1986). Stress and
wellness project survey. Ann
Arbor, MI: University of Michigan, School of Public Health,
Johnson. J, V. (1991), Collective control: strategies for survival
in the workplace, InJ, V. Johnson
& G, Johansson (Eds,), The psychosociat work environment:
Work organization, democra-
tization, and health: Essays in memory of Berbil Gardell (pp,
121-132). Amityville, NY:
Baywood.
Karasek, R. A, (1979), Job demands, job decision latitude, and
mental strain: Implications for job
redesign. Administration Science Quarterly, 224, 285-307,

Karasek, R. A. (1985)- Job Content Instrument Questionnaire
(Mimeograph). Lowell, MA:
University of Massachusetts.
Karasek, R, A,, & Theorell, T. (1990), Healthy work—Stress,
productivity, and the
reconstruction of working life. New York: Basic Books,
Karasek, R, A,, Triantis, K. P,, & Chaudhry, S. S, (1982),
Coworker and supervisor support
as moderators of associations between task characteristics and
mental strain. Journal of
Occupational Behavior, J, 181-200,
Keita, G, P., & Jones, J, M, (1990). Reducing adverse reaction
to stress in the workplace,
American Psychologist, 45, 1137-1141.
Kobasa, S, C, Maddi, S, R.. Pucetti, M., & Zola. M, (1985).
Effectiveness of hardiness, exercise,
and social support as resources against illness. Journal of
Psychosomatic Research, 29,
525-533,
Kobasa. S. C, & Pucetti, M, C, (1983). Personality and social
resources in stress resistance.
Journal ojPersonality and Social Psychology, 45, 839-850.
LaRocco, J, M., House, J. S., & French, J, R, P, (1980). Social
support, occupational stress, and
hcdXth. Journal of Health and Social Behavior, 21, 202-216,
Leiter, M, P., Harvie, P,, & Erizzell, C, (1998). The
correspondence of patient satisfaction and
nurse humout. Social Science in Medicine, 47, 1611-1617,

BioMed CentralPage 1 of 9(page number not for citation p.docx

BioMed CentralPage 1 of 9(page number not for citation p.docx

Recommended

Recommended

More Related Content

Similar to BioMed CentralPage 1 of 9(page number not for citation p.docx

Similar to BioMed CentralPage 1 of 9(page number not for citation p.docx (20)

More from jasoninnes20

More from jasoninnes20 (20)

Recently uploaded

Recently uploaded (20)

BioMed CentralPage 1 of 9(page number not for citation p.docx