Change Process Its Theories and Models In Nursing

The Change Process Its Theories and Models In Nursing. Theories and models of change in nursing provide frameworks for understanding, planning, and implementing changes in healthcare. These theories help nurses understand the complexity of implementing new practices, technologies, and policies, thereby improving patient care and outcomes.

What Is Change Process Its Theories and Models In Nursing

The theory of change is a perspective that seeks to manage changes in healthcare in all its forms so that the quality of patient care remains constant and unchanged. These changes come from a variety of sources, including organizational practices, patient care models, care policies, and regulatory compliance.

Change and conflict are ever present in health care today, thanks to constantly evolving technology, new regulations, changing public expectations, increasing environmental concerns, and heavy demand on scarce resources. In turn, nurses must be knowledgeable about the change process and understand that conflict can result when the process is ineffective. In the dynamic environment of health care, change is inevitable and unpredictable, and it affects staff, patients, and the organization overall.

Historian and critical feminist Joan Wallach Scott states, “Those who expect moments of change to be comfortable and free of conflict have not learned their history” (Quote Garden, 2016). Change in the work environment can create uncertainty and elicit emotional responses from employees (Bowers, 2011). Most people do not like change, and when experiencing change, not all people respond in the same way.

Nurses at all levels must develop a basic understanding of change theories and models to fulfill the social mandate for nursing practice outlined in the American Nurses Association (ANA, 2010) Nursing’s Social Policy Statement, which states that nurses must be open to changes and willing to apply new evidence in practice as it emerges. In addition, nurses must embrace change to ensure that safe and quality nursing care is provided. Change can be difficult and is often met with resistance, which can result in conflict.

Nurse leaders and managers are instrumental in facilitating successful change at both the unit and organizational levels. Successfully leading and managing the change process are vital leadership skills (Stefancyk, Hancock, & Meadows, 2013). Nurse leaders and managers are called to “take a leadership role and become early adopters in leading change, removing barriers, challenging the status quo, and creating innovative solutions to address nursing workforce issues that contribute to the health of America” (ANA, 2016, p. 16).

Although change is a very common cause of conflict, wise nurse leaders and managers recognize that conflict is always present in the workplace (Porter-O’Grady & Malloch, 2013). Further, conflict is dynamic and does not disappear; rather, it can only be managed. Nurse leaders and managers have a responsibility to acquire the knowledge, skills, and attitudes to manage and lead change, engage staff in consensus building, and conflict management (ANA, 2016).

Change Theories

Change is a dynamic process that results in altering or making something different. Change can be planned or unplanned. Planned change is purposeful, calculated, and collaborative, and it includes the deliberate application of change theories (Mitchell, 2013; Roussel, 2013). Change that is purposeful and planned is usually well received by staff. In contrast, unplanned change occurs when the need for change is sudden and necessary to manage a crisis.

Unplanned change can cause anxiety and stress among staff members. Successful nurse leaders and managers manage unplanned change “through effective communication, adaptability, coordination, and the ability to remain grounded” (Erickson, 2014, p. 125). Highly effective nurse leaders and managers develop high-functioning, empowered teams whose members know what is expected, remain calm during crisis, and do what is right for the patients (Erickson, 2014).

Closely related to and frequently an integral part of change is innovation, the process of creating something new after thoughtful analysis of a phenomenon or situation. Implementing change can be very challenging and yet is necessary for progress. Often, the change process fails because those executing the change neglect to take a structured approach. Planned change is best carried out using a theoretical frame work or model (Mitchell, 2013; Shirey, 2013).

The situation at hand and the type of change being implemented help determine the appropriate theory or framework to apply, lead, and manage the process, and this approach can result in a sustainable change (Shirey, 2013). Because not all theories fit all nursing situations, nurse leaders and managers must be familiar with various change theories to be able to select a framework wisely. The most common change theories and models used fall into two categories:

1) traditional theories and models

2) emerging theories.

Traditional Change Theories and Models

Traditional change theories and models are linear and suggest that change occurs in a sequential manner. For the change to be successful, the organization or unit must progress through each stage. These theories require ongoing work to ensure that goals are met and change is sustained.

Lewin’s Force-Field Model (1951)

Lewin’s Force-Field theory is one of the most widely used theories. Lewin believed that change results from two field or environmental forces:

1) driving forces (helping forces) that attempt to facilitate the change and move it forward

2) restraining forces (hindering forces) that attempt to impede change and maintain the status quo.

Successful change requires the driving forces to be greater than the restraining forces. This three-step change model involves unfreezing the status quo, moving toward the new way, and refreezing or stabilizing the change for sustainability (Lewin, 1951; Mensik, 2014; Shirey, 2013):

1. The unfreezing stage is the point at which it is determined that change is needed, and driving and restraining forces are identified. The change agent must create a sense of urgency to change, strengthen the driving forces, and weaken the restraining forces for successful change. During this stage, nurse leaders and managers can help prepare staff members for the change by helping them recognize the need for change, building trust, and actively engaging staff in the change process. Motivation to change occurs in this stage.
2. The moving stage begins the initiation of the desired change. Information is gathered, the change is planned, and movement toward changing begins in this stage. During the moving stage, the new innovation is examined, accepted, and tried. This stage requires unfreezing and moving toward a new way of thinking and behaving. Nurse leaders and managers can facilitate movement by coaching those affected by the change to overcome fears and engage them in problem solving and working toward the desired outcome.
3. The refreezing stage involves stabilizing the change and achieving equilibrium. The innovation is incorporated into the routine. The change becomes the new norm. In this stage, nurse leaders and managers should reinforce the change through formal and informal processes including policies, procedures, standards of care, and other common tools used throughout the organization. This stage is crucial to sustaining change over time

Throughout the process, the nurse leader and manager must employ strategies to increase driving forces and/or decrease restraining forces for the change to be successful. Many other theories are based on Lewin’s theory.

Lippitt’s Phases of Change Model (1958)

Lippitt, Watson, and Wesley (1958) expanded Lewin’s original theory by identifying additional stages of the change process. The Phases of Change Model uses language similar to the nursing process and focuses more on the people involved in the change process than on the change process itself. This model stresses the importance of communication and rapport with those involved in the process. The model follows these seven steps (Lippitt, Watson, & Wesley, 1958; Mensik, 2014; Mitchell, 2013):

1. Diagnosing the problem involves identifying the need for the change and recruiting others to assist with data collection. Effective communication is critical in the first phase to avoid miscommunication through the grapevine. Nurse leaders and managers can spearhead drafting a plan for change at this time.
2. Assessing the motivation and capacity for change is actually assessing the unit or organization for readiness to change. Nurse leaders and managers must communicate with those affected by the change, respond to concerns, provide rationale for the change, and identify possible resistance to the change.
3. Assessing the change agent’s motivation and resources must be done for successful change to occur. The change agent must be willing to commit to the change and see the process through to the end. This phase requires nurse leaders and managers to identify their role in the change process. They must be realistic about the time commitment necessary and recruit assistance.
4. Selecting progressive change objectives involves clearly defining the change, establishing realistic goals, and developing a plan for change. Nurse leaders and managers actively assess their team and delegate appropriate responsibilities during this phase of the process.
5. Choosing an appropriate role for the change agent and implementing the plan for change comprise one of the final steps. It is important that nurse leaders and managers remain flexible during this stage. 6. Maintaining the change after it has started and as it is being incorporated into the unit or organization culture is critical. Nurse leaders and managers monitor the stability of the change as it becomes part of the system. Communication and feedback are critical during this phase to avoid regressing to the previous state.
6. Terminating the helping relationship once the process has stabilized occurs when the change agent withdraws from the process and the change is evaluated. Nurse leaders and managers continue monitoring and evaluating the change for sustainability.

The role of the change agent is extremely important in Lippitt’s model. Nurse leaders and managers most often function in the change agent role and are responsible to drive “the innovation into everyday practice” (Mensik, 2014, p. 64).

Rogers’ Innovation-Decision Process (1995)

Rogers (1995) broadened Lewin’s theory and developed a five-stage innovation decision process, which consists of a series of actions and choices over time that an individual or decision-making unit must follow. Further, recognizing the common behavioral responses to change that individuals may experience can facilitate change. The five stages are as follows (Rogers, 1995; Shirey, 2006):

1. Knowledge occurs when an individual or decision-making unit is exposed to an innovation and gains understanding of how it functions. Nurse leaders and man agers create the need for the innovation and increase motivation among staff members to learn more about the innovation.
2. Persuasion occurs when an individual or decision-making unit forms a favorable or unfavorable attitude toward the innovation. The perceived attributes of the innovation are key in this stage. Nurse leaders and managers can engage staff members to share positive experiences with the innovation with their peers to promote favorable attitudes.
3. Decision occurs when an individual or decision-making unit engages in activities to adopt or reject the innovation. To facilitate adoption, nurse leaders and managers may want to pilot the innovation on a specific unit. Staff members can then experience the desirable qualities of the innovation.
4. Implementation occurs when an individual or decision-making unit begins using an innovation. Nurse leaders and managers must ensure that adequate technical support and proper infrastructure are available during implementation to avoid stalling the innovation.
5. Confirmation occurs when an individual or decision-making unit seeks reinforcement of a decision made or reverses a previous decision to adopt or reject innovation (Rogers, 1995, p. 162). Overall, staff members desire to avoid conflict and work to keep the innovation going. Nurse leaders and managers may provide encouragement and validate that the decision was the correct one (Shirey, 2006). Long-term support may be needed to stabilize the change and help those involved develop self-reliance during this phase.

Rogers suggests that, for change to be successful, everyone involved with the change and/or affected by the change must be committed to the change. In addition, nurse leaders and managers must deal with behavioral responses to change and attempt to figure out how to channel negative responses into support for the change or innovation (Rogers, 1995). Nurse leaders and managers are involved in creating a shared vision for the innovation and provide the leadership needed to sustain the change (Mensik, 2014).

Kotter’s Eight-Stage Process of Creating Major Change (1996)

Kotter (1996) suggested that successful change involves a multistep process that overcomes all sources of resistance and must be directed by high-quality leadership. He describes eight stages of the change process that can help nurse leaders and managers manage change cognitively as well as emotionally (Kotter, 1996):

1. Establishing a sense of urgency involves examining the competition or need for change to improve quality and/or safety. During this stage, nurse leaders and managers must discuss major opportunities and potential crises identified and present convincing evidence for the need to change.
2. Creating the guiding coalition means putting together a group with the necessary power to lead the change and getting everyone to work together. Identifying key staff members and empowering them to participate in the change process is important for nurse leaders and managers during this stage.
3. Developing a vision and strategy means creating a vision to direct the change effort. Nurse leaders and managers spend time during this stage making the vision clear and understandable for everyone.
4. Communicating the change vision to everyone involved in or affected by the change is important, as is having the leader or manager model the behavior expected of employees. The goal for nurse leaders and managers is to persuade as many staff members as possible to embrace the vision.
5. Empowering broad-based action involves changing systems or structures that undermine the vision, getting rid of obstacles, and encouraging risk taking and nontraditional ideas. Nurse leaders and managers must actively confront opponents. In addition, they can provide information and assist staff members to embrace the vision.
6. Generating short-term wins consists of planning for and creating improvements in performance, or “wins,” and visibly recognizing and rewarding those responsible for the “wins.” The focus is on lessening the impact of the cynics, pessimists, and skeptics by rewarding and motivating staff members embracing the change (Salmela, Eriksson, & Fagerström, 2013).
7. Consolidating gains and producing more change include using increased credibility to change systems and processes that do not fit the vision. This stage also involves hiring, promoting, and developing those who can implement the vision, as well as reinvigorating the process with new projects and themes.
8. Anchoring new approaches in the culture is creating better performance through productivity orientation and through better and more effective leadership and management. In this stage, the connection between behavior and organizational success is emphasized, as well as ensuring leadership development and succession (Kotter, 1996, p. 21). Nurse leaders and managers focus on sustaining the change or innovation.

Nurse leaders and managers are seen in Kotter’s model as important during the various phases of the process because of their keen communication skills, ability to anchor the vision of the change, and skill in persuading staff members to embrace the change (Salmela et al., 2013).

Emerging Change Theories

Traditional theories are useful in providing structure and direction for change. However, the linear models do not recognize the dynamic context in which change occurs and the unanticipated human actions and responses. Newer theories are emerging that are more complex than the traditional theories. Systems theory pro vides the foundation for emerging theories of change. Using a systems approach to change and innovation results in a comprehensive view and realization that systems are complex.

Human beings, families, organizations, cities, and nations are all systems with interrelationships among members, and a close look at those interrelationships reveals infinite complexity. Emerging theories are cyclical rather than linear and require organizations to react with speed and flexibility. The newer theories provide another perspective from which to view change and innovation based on complexity science. Complexity science recognizes that the world is in continual motion and that a change in one area can result in numerous changes in other areas.

Change and innovation from the perspective of complexity science are highly interrelated, dynamic, and unpredictable (Porter-O’Grady & Malloch, 2013). Understanding complex systems when leading and managing change results in a collective commitment to the change created.

Two theories based on complexity science and systems theory, chaos theory and learning organization theory , are actually used to understand organizational behavior. Chaos theory and learning organizations theory are also used to understand change and innovation. Nurse leaders and managers who understand these theories in relation to change and innovation can assist staff through the change process successfully.

Chaos Theory

Many relate chaos to complete randomness. In fact, the word chaos is derived from the Greek language and means “formless matter.” However, even when a system may appear chaotic and disorderly, there is actually an underlying com plex order. Chaos theory is nonlinear and unpredictable, and it explains why a small change in one area can have a large affect across an organization.

This is also known as the “butterfly effect,” or the notion that the flapping of a butterfly’s wings in one part of the world can have a major impact, such as a hurricane or tsunami, on the other side of the world (Crowell, 2011; Mensik, 2014; Porter-O’Grady & Malloch, 2010). Nurse leaders and managers must be aware of the complexity of health care, the unit, and the organization. Further, they must understand that, because of multiple factors, decisions made can result in changes that were unintended.

Learning Organization Theory

Learning organization theory was first described by Senge (1990), who suggested that to excel, future organizations will need to “discover how to tap people’s commitment and capacity to learn at all levels in an organization” (p. 4).

He called on leaders to move away from traditional authoritarian “controlling organizations” to learning organizations. In a learning organization, all staff members are involved in problem-solving and implementing change and innovation, and this involvement enables the organization to respond quickly to chaos. Senge (1990) defined a learning organization as an “organization where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning how to learn together” (p. 3).

Senge identified systems thinking, personal mastery, mental models, building shared vision, and team learning as five disciplines that organizations need to adopt and practice to become learning organizations. Members of a learning organization are continually practicing the five disciplines and are continually learning. The more learning that occurs, the more aware the members become of what they can still learn. In health care, adopting the five disciplines has the potential to result in high-quality and safe patient care.

Nurse leaders and managers who help staff members see the larger system build an understanding of complex problems. This understanding enables staff members to develop long-term changes and work together to impact the whole system, rather than pursuing symptomatic fixes to parts of the whole (Senge, Hamilton, & Kania, 2015). In turn, change and innovation can be sustained over time.

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