Challenge of Initiating and Managing Change
in Professional Nursing
What Is It?
Perspective of the Change
to Lesson Index
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.
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
Wilson (1992) has described
change as an unattended truck going down the highway that is headed toward
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 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.
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 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
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.
the change agent as having four major roles: specialist, coordinator, fact
finder and information link, and consultant.
addition to being initiated by the nurse, is also initiated by the system,
by management, and by the patient/client/family.
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
I would like
for you to think about the overall skills of the change agent and share
your thoughts during the discussion this week.
Perspective of Change
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.
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.
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.
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?
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).
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.
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".
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
Read chapter 11 of your text.
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.
change essential to nursing practice and what outside forces affect
of cause change in professional nursing practice?
has been your experience as a change agent? Were you the specialist,
the fact finder and information link, the coordinator, or the
Discuss your use of change agent skills or your observation of these
skills being used by other successful change agents.
about a change that you have been involved in either actively or
passively and discuss your reaction to that change.
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.
Is resistance to change always bad? Are there instances when
resistance can not be beneficial?
do you see the role of the nurse manager is in the three stages of
Lewin's Change Theory? The assessment and interpersonal skills
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.
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:
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.