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Class/Lesson 4

The Challenge of Initiating and Managing Change
in Professional Nursing

Change: What Is It?
Why Change?
Reasons for Change
Change Agent
Your Perspective of the Change
Change Theorist
Politics of Change
Learning Activities

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The reading assignment for this class is Chapter 11 in your text. The focus of the class is on the process of "change" and how the nurse can be an effective change agent. Information in this chapter is essential in preparation for completing the change paper assignment that is due during week eight (8). You need to refer to the assignment for the change paper in the syllabus. Begin thinking about a change that has been implemented in your clinical practice setting. Specifically, I would like for you to look at the process used to implement the change, the change agent(s), the theory used to implement the change (if you can identify one) and the success of lack of success in implementing the change.

Change:  What Is It?

Nunnery (page 176 of your text) offers a definition of change. Change is a normal part of daily life. It is really something that we can depend on each day. We experience change in our private life, (change our hair color, change our mind, change our address, change our name, changes in political alliances, etc.)  and we experience change in professional practice. 

Change can be either planned, which involves conscious effort toward some goal in a deliberate and collaborative process. Change can be "by drift", meaning the change is accidental, spontaneous, or haphazard and caused by outside forces. 

Wilson (1992) has described change as an unattended truck going down the highway that is headed toward you.


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You are standing in the highway and you have to make a change or some type of decision and your options are to react by moving out of the way, to do nothing and stand in the path of the truck, or to spring into action by running and jumping on the truck and steer it in the direction you want it to go.

Why Change?

Why is change essential to nursing practice? I would like for you to think about this question and discuss it in this week's discussion time.

I would also like for you to discuss outside forces that affect or cause change in professional nursing practice and your role as the nurse change agent.

Reasons for Change

What are some reasons for change in nursing practice? First and foremost I believe that change in professional practice needs to be PROACTIVE rather than retroactive. Change should be implemented only for a good reason and never for change sake. Change should be made to for the purpose of solving a problem, for the purpose of making the delivery solve problems, to make work procedures more efficient and to reduce unnecessary workload (Zerwekh and Claborn, 1997).

Change Agent

Whenever change is taking place there is always a change agent. Who can be a change agent? Well, the change agent is the one who works to bring about the change. The change agent can be an individual or can be a group of people.  Groups in themselves are often effective change agents. The group is more willing than most individuals to assume risks that are associated with change.

Professional nurses are change agents, the movers and shakers for people, for health, and for health care and reform. Nurses have a role in identifying the need for change and for planning change for individuals, families, community groups and society. So this process can be on a small scale involving only one person, or on a much larger scale and even occur at a national level and involve large scale population groups.

Think about the change agent as having four major roles: specialist, coordinator, fact finder and information link, and consultant.  

Change, in addition to being initiated by the nurse, is also initiated by the system, by management, and by the patient/client/family.

Marquis and Huston (1996) describes three strategies that the change agent uses when implementing change. These strategies are known as the power-coercive strategy, the empirical-rational strategy and the normative-reeducative strategy.  The power-coercive strategy is based on the change agent utilizing power by legitimate authority, economic sanctions, or political clout. This might be through control of the budget, the enactment of a law, or the change in the policy and procedure of an institution. Power-coercive strategies are especially useful when there is little chance of the participants in reaching an agreement on the change proposed. This is used in situations when change needs to be initiated immediately and is critical for the well being of the organization. Empirical-rational strategies involves the change agent assuming that people are rational beings and follow self-interest if that self-interest is made evident. The power in this strategy is knowledge. The need for the people for the knowledge and the assumption that the change agent has the knowledge/information to share. The normative-reeducative strategy has as its assumption that individuals act in accordance with social norms and values.

I would like for you to think about the overall skills of the change agent and share your thoughts during the discussion this week.

Your Perspective of Change

Your perspective of the change will be influenced by whether your are taking a passive role in the change or are taking an active role in the change. Zerwekh and Claborn (1997) discuss the WIIFM principle related to change, in other words What's In It For Me principle. Is this not a common thought when people are faced with change. How is the change going to affect ME? What type of reactions do you or other people experience when feeling threatened by change? Wilson (1992) indicates that there are five (5) steps that a person will go through in order to conquer the threat of the change.


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It is a normal response to be resistant to the change (the first step), to have uncertainty with how the change will affect the individual (step two), assimilation/absorption of the change (step three), transference and integration of the change (steps four and five).

How do you respond to change. Your response and my response will vary with what is being changed. We can be in neutrality and not perceive the change as a threat or we might be in an unstable system and view the change as a threat and react in anger, fear, etc.

Resistance to change, the first step to conquering the threat of change. Why do we resist change and why should we expect that this might be a natural reaction of others to change? Well, resistance to change is based on past experiences, present needs, culture, values, our role as it relates to the change, our coping abilities. The mature, healthy individual seeks opportunities for further growth through change. Taking this online course is an example of a change. Past experience with online courses, experience either positive or negative with use of the computer, need to complete this course and move on to the next course in the RN to BSN program, etc. are all experiences that will influence ones approach to this course.

Think about these questions. How can the change agent reduce the resistance associated with change?  Is resistance to change always bad? When can resistance not be beneficial?

Change Theorist

There are many theories and theorist of change and your text discusses many (pages 176-181). Lewin's theory is probably the most widely used change theory and involves restraining forces and driving forces, and proceeds through three distinct stages (unfreezing, moving, and refreezing).

Other theorist include Lippitt, Havelock, and Rogers (Sullivan & Decker, 1997).  Each of these theorist have a change theory that carries their name and each theory has a variety of steps to implement change. Lippitt's theory involves seven steps: diagnosis of the problem, assessment of motivation, assessment of the change agent's motivation to change and available resources, selection of progressive change objects, maintaining change, termination of helping relationships established in change process. Havelock's theory consists of six steps: relationship building, problem diagnosis, resource acquisition, selection of a solution for the problem, generating and gaining acceptance for the solution, and stabilization and self-renewal after change implemented. Roger's theory is a five step process: knowledge, persuasion, decision, implementation, and confirmation (sounds like the nursing process doesn't it?)?

I would like for you to think about the role of the nurse in each of these stages, the interpersonal skills and assessment skills used in each stage. Think about how the change process can be affected if these skills are not put to good use.  The persons ability to assess is so important. One important example is the ability to identify the real problem and the solution selected to change a situation can and will be affected if the correct problem is not identified. 

Politics of Change

Nurses frequently use information, expertise and possibly positional power to persuade others. Think about the definition of changed offered by Nunnery (page 176) and the end result of change is altering behaviors of one or more individuals.  Do nurses need to be able to use political strategies to implement change?  If so, how do you think this can effectively be accomplished? How important is it to analyze the organizational chart and know the formal lines of authority and to identify the informal lines of authority (that are not on the organizational chart)?  How important is it to identify the key people who will be affected by the change and pay attention to those immediately above and below the point of change?  Why is it important to find out as much as possible about the key people, to learn their "tickle points", what interest them, what excites them and what turns them off? Nurses need to know the personal agenda of the key players and the organizational agenda. Nurses need to know who aligns with whom on important decisions. Nurses also need to begin to build a coalition of support prior to initiating the change process. This involves identifying key people who are likely to support the change and the individuals who can be persuaded easily (either for or against the change). The astute nurse will speak informally and flush out possible objectives to ideas and the potential opponents of the change.

To many nurses being involved in this process is not for them, in fact they just want to do their job and not get involved in anything "political". Frequently you might hear a nurse say the do not want to play the political game. Other nurses view change as challenging and wish to be "involved" and they like the action that accompany the possibility of implementing change. As you can see it takes an astute, savvy nurse to "play the game".

Learning Activities:

I have asked several questions or areas that you need to think about throughout this lesson and would like for you to consider them as part of this week's discussion. For your convenience I have listed these questions and points to think about below. Also, feel free to raise questions of your own and each of you should feel free to respond to questions or ideas posed by your classmates.

1. Read chapter 11 of your text.

2. Log on the discussion board and address the following questions, ideas, issues in the appropriate threaded discussion section. You need to address at least 5 of the 8 threads in order to receive credit for active participation in class this week. Your response can be in the form of responding to other individual's comments in these threads, making this a true discussion.
2.a  Why is change essential to nursing practice and what outside forces affect of cause change in professional nursing practice?
2.b  What has been your experience as a change agent? Were you the specialist, the fact finder and information link, the coordinator, or the consultant?
2.c  Discuss your use of change agent skills or your observation of these skills being used by other successful change agents.
2.d  Think about a change that you have been involved in either actively or passively and discuss your reaction to that change.
2.e  What have been successful strategies you have used as a change agent or observed other change agents use to reduce resistance associated with change? Think not only of nursing, but other areas of your life where change has been observed.
2.f   Is resistance to change always bad?  Are there instances when resistance can not be beneficial?
2.g  What do you see the role of the nurse manager is in the three stages of Lewin's Change Theory? The assessment and interpersonal skills needed?
2.h  Discuss some of the political strategies you or other nurses have used to implement change.

I look forward to reading what your thoughts are on these questions and areas of thought.

Note: Look at the Change Paper requirements in the syllabus and complete this assignment by March 13, 2000. This assignment is to be completed and e-mailed to the instructor.

Note: Look at the Change Paper requirements in the syllabus and complete this assignment by March 13, 2000. This assignment is to be completed and e-mailed to the instructor. I would suggest completing the assignment as a MS Word document and sending it as an attachment to the e-mail.



Marquis, B. L. and Huston, C. J. (1996).  Leadership roles and management functions in nursing:  Theory and application.   Philadelphia:  Lippincott.

Sullivan, E. J. and Decker, P. J.  (1997).  Effective leadership and management in nursing.  Menlo Park, CA.  Addison Wesley Longman.

Zerwekh, J. and Claborn, J.C., (1997).  Nursing today:   Transition and trends, 2nd ed.  Philadelphia:  W. B. Saunders.




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