Change as a Concept in Contemporary Nursing Practice

Introduction

According to Swansburg & Swansburg (2002), change is “a focused, planned attempt to bring about improvements in a system, with the help of a change agent”. In nursing, change involves a sequence of events that are implemented in order to achieve set targets (Surgeon 2000). Major players such as the middle and executive managers in the nursing hierarchy require basic knowledge of the change theories to enhance their selection and overall implementation of the change (Barnard & Locsin, 2007). The preliminary sections of this essay will highlight a critical literature review of change and the commonly used change theories, and will explore how they can be utilized in implementing change in the nursing field with some examples of case studies and projects of change. It will also shed light on the impact of change on nursing practice and performance of nurses. The essay will also discuss policy issues and influences that impact on change within the nursing context.

Literature review

Theories on change management are based on two differing perspectives (Carnall 1990; Watzlawick 1990). While planned change theorists argue that change takes place in a series of linear of events, processual change theorists are of the view that change is a multifaceted process is too complex to treat as a simple series of linear events (Burnes 2004; Dawson 1996). In this regard, Buchanan and Storey’s (1997) criticized Lewin’s model arguing that it “imposes an order and a linear sequence to processes that are in reality messy and untidy, and which unfold in an iterative fashion with much backtracking and omission” (p. 27). Despite criticism, planned model still remain the most applicable theoretical framework for change management in most health care settings.

Kurt Lewin (1951) theory provides a 3-step linear model that includes the unfreezing, moving, and refreezing stage (Kassean & Jagoo 2005). The theory is dependent on achieving balance on the driving and resistant forces that dictate the direction taken by nurses during the process of change, driving forces must reign for real change to occur (Robbins 2003;Swansburg & Swansburg 2002). At the unfreezing stage, the problem is identified and any opposition to designing a change strategy is identified and eliminated or its intensity lessened. The moving stage involves identification of solution and the resources needed to implement it. At the refreezing stage, the change is assessed to see if it has been effective and its acceptance levels among the nursing staff.

Rogers’ (1970, 1983) theory borrows heavily from Lewin principles whereby its application is mainly on long-term projects (Hall 1981). The theory focuses on behaviour whereby negative reactions towards the change are overturned over time towards acceptance especially when they are convinced by the protagonists on the importance of the change (Swansburg & Swansburg 2002).

Based on Lewin’s stages, Havelock (1973) designed a theory that allows flexibility in dealing with the complexities experienced in life. The theory follows six steps that include the establishment of a working relationship, diagnosis, timely acquisition of required resources, selection of an important pathway, embracement of the established change and sustainability and withdrawal of the agents of change (Kritsonis 2005).

Spradley (1979) came up with an eight-stage theory based on the elements of the Lewin theory (Kassean and Jagoo, 2005). Change is reliant on the continuous monitoring in the project. The stages include the identification of the symptoms, diagnosis of the problem, identification and eventual selection of the ideal solution, planning and subsequent implementation and evaluation of the change, before stabilization sets in.

Reddin (1987) theory employs seven steps in its efforts to bring change. In this theory, nurses diagnose the problem, come up with the desired goals, emphasis on the group strength, and deduce maximum information before indulging in implementation and integration of rituals in the face of resistance (Shanley 2007). The participatory element carried by the nurses is useful in creating a linkage between theory and practice. The theory lays much emphasis on the need of consulting and involvement of all affected stakeholders to reduce instances of resistance to the change process. With regard to this, it achieves greater acceptance to the nursing workforce (Kritsonis 2005).

This paper is based on Lewin’s 3-step model. The author settled on this model because it is the simplest model to implement in health care setting. Despite criticism from supporters of processual change, available empirical evidence supports the applicability of Lewin’s theory to change management in contemporary nursing practice. However, there are no quantitative studies on the same known to the author hence providing a gap for future investigations.

Murphy, F. (2006) undertook a study in which she reviewed a case study concerning her role as a specialist nurse practitioner in developing a monthly blood test result information booklet in a renal haemodialysis unit. The most preferred theory for this change project was Lewin’s theory, where the specialist nurse was nominated to be the team leader and started marketing the change. During the first stage, the change agent held meetings with different groups of nurses and patients and made them aware of the need for the change. However, some agreed for the change and some others resisted the idea. Effective communication skills helped clarifying all queries and moved to the second stage during which the supporters of the change were encouraged by the positive feedback and the opponents were urged to consider the need for team work to improve care. At the third stage and after the change was implemented, meetings were held with responsible nurses for follow up and evaluation and the booklet was distributed to all patients. The change was successfully implemented using Lewin’s theory.

Wagstaff, R. (2006) described pitfalls of the implementation of a computer information system in a critical care area during a period of 18 months. Using qualitative approach, the author examined three main issues observed during the implementation stages; behaviour of the nursing staff managing the change, of the project manager, and of others in relation to the project manager. On her reflection on the change project, Rebecca acknowledges that there were two theories appropriate for use in this situation, which are Lewin’s (1951) and Bennis et al (1985) theory.

On the other hand, Johnson, S. et al (2009) conducted a case study of change management in aged care. The aim of the case study was to describe a qualitative initiative to minimize restraint in an Australian residential aged care facility. Outcomes of the study recommends that managers involved in change management initiatives should have a great understanding of change management theories and models to be able to transform quality improvement initiatives into practice enhancements.

In another study Kassean and Jagoo (2005) conducted a study on change management in the nursing handover from traditional to bedside handover. The authors used a combination of Lewin’s 3-step model and Spradley’s 8-step model. From their evaluation of the change process, the two found out that Lewin’s model provided a framework for successful implementation of change while Spradley’s model provided a framework for future monitoring of the progress. From their findings, Kassean and Jagoo (2005) concluded that managing change in a hospital set up is a difficult task that requires continuous monitoring hence Lewin’s model may not provide an appropriate framework when used solely.

Role of Change Theories in the Nursing Practice

Of all the theories discussed, Kurt Lewin’s theory of change is the most widely used change strategy, and the most acceptable in healthcare settings (Swansburg & Swansburg 2002). Each change theory combines different interrelated components that are implemented in succession to make the change process a success. The theories are very important towards implementing movement of nurses between health institutions, and can make this movement a stress free exercise when it is well managed based on a theory stages.

From the author’s experience, Lewin’s theory helped a lot when there was shortage of nurses in some health centers situated in remote areas. At the first stage, the author identified the problem (nurses shortage) and announced to nurses in the region of Al-Buraimi Governorate that there is shortage in health centre situated in remote areas. Nurses started talking about it and guessing what would be the solutions and some of nurse managers came up with some suggestions. During the second stage, he announced compensations for nurses volunteering to move from the city centre to remote areas, like providing them with free accommodation, extra days off, and senior nurses may be given administrative responsibilities if proofed to be competent to take charge duty of the health centre. And in the third stage, volunteers applied for the posting in remote areas. They have been thoroughly oriented with the work and then moved to respective health centres to settle down and solve the problem.

The most common factor in any change theory is the change agent, which may be a nurse manager who is introduced to a health institution for implementing change (Carney 2006). The whole process of change management depends on how the change agent introduces change and how he/she influences others to take it. The second factor consists of the driving and opposing factors as explained in Lewin’s theory (Robbins 2003). Both of these factors can also be the change agents, for instance, the driving factor could be the administration implementing the transfer while the opposing factor is the staff that do not require movement or resistive to the plan. The driving factors could also be increasing staff in some health institutions, meeting the goals of the institution, or training. Opposing factors include not prepared to adopt to move, having family commitments, transfer is not compensated, or the staff may be contented with stability (Jackson et al. 2002).

The final part of all change theories is the assessment and adoption of the change plan. In case of staff transfer, this amount to strategizing ways of making the new staff adopt to their new environment with minimum disruption. This may include orientations and organizing several induction meetings. The management at the new health institution could also look into other challenges that the new staff face, such as shortage in equipments or medicines or may be call duties and working hours, and find solutions for it (Wood 2000).

Policy issues that impact on change in the nursing context

The introduction of managerial roles in addition to the normal routine duties meant the nurses were overwhelmed with the workload (Lorraine 2005). The fact that majority of healthcare institutions are understaffed has compounded this problem (JONA 2002). The change of environment, if not well managed, also lowers motivation and morale of the nurses thereby affecting the overall delivery of competent and quality services (Surgeon 2000). Rotation of nurses based on time of day brings emotional and psychological problems particularly to nurses who have children (Lenburg 1991). Lack of flexibility in some institutions not only results in demoralized staff but also leads to poor quality in the delivery of services thereby impacting negatively on the reputation of the nurses and the healthcare organizations (Rosenbach & Taylor 2001).

By writing this paper the author gained an insight on the use of change theories in the nursing practice. It is clear that many change theories are used in many different situations depending on the type and size of change intended to be implemented. However, all theories are driven from Lewin’s theory as called the father of change theories.

Conclusion

Change is a very important component of the nursing practice. Even though the process of change from one health institution to another or even within an institution can be quite a challenge, the adoption of an appropriate change theory in nursing can make such a process smooth and can improve staff confidence and hence productivity at the workplace (Wood 2000). By writing this paper, the author observed that all theories were developing according to the current needs of life but all deriving from Lewin’s theory and developing more stages accordingly. From the author’s perspective, all theories can lead you to the attempted change but the type of theory to be used depends on the type of situation and personnel you are dealing with. All theories have acknowledged that change is a dynamic and on-going constant process in today’s health settings. However, the change agent should focus on increasing the motivating factors and reducing the opposing factors for the change to succeed (Thomas & Dunkerley 1999).

The main points of debate in this essay recommend that; nurses get trained in “change management” in the work place, and this may be achieved by including it in the basic training of nurses. Policies may be made on how often nurses should be rotated between healthcare institutions. From the authors experience of managing change, attractive compensations like free accommodation and offering extra off days for those staff working in remote areas could be useful strategies for nurses’ movement. Another strategy may be offering them administrative posts for those senior nurses who proof competence in managerial roles.

References

Barnard, A. & Locsin, R., 2007. Technology and nursing practice: practice, concepts and issues. New York: Palgrave Macmillan.

Buchanan, D. A. and Storey, J., 1997. ‘Role-taking and role-switching in organizational change: the four pluralities’. In McLoughlin, I. and Harris, M. (Eds), Innovation, Organizational Change and Technology. London: International Thompson.

Burnes, B., 2004. Kurt Lewin and the planned approach to change: A re-appraisal. Journal of Management Studies, Vol. 41, Iss. 6, pp. 0022-2380.

Carnall, C., 1990. Managing change in organizations. Hemel Hempstead: Prentice Hall International.

Carney, M., 2006. Understanding organizational culture: the key to successful middle manager strategic involvement in health care delivery? Journal of Nursing Management, Vol. 14, Iss. 1, pp. 23–33.

Dawson, P., 1996. Beyond conventional change models: A processual perspective. Asia Pacific Journal of Human Resources, Vol. 34, Iss. 2, pp. 57-70.

Hall, B., 1981. The change paradigm in nursing: Growth verses persistence, Advanced Nursing Science, Vol. 3, pp.1-6.

Havelock, R. G., 1973.The change agent’s guide to innovation in education. Englewood Cliffs, NJ: Educational Technology Publications.

Jackson, M. & Chiarello, L. & Gaynes, R. & Gerberding, J., 2002. Nurse staffing and health care associated infections: Proceedings from a working group meeting. Journal of Nursing Administration, 32 (6). June, 314-322.

Johnson, S. et al., 2009. Moving beyond resistance to restraint minimization: A case study of change management in aged care. Worldviews on Evidence-Based Nursing Journal, Vol. 6, Iss. 4, pp. 210-218.

Kassean, H. K., and Jagoo, Z. B., 2005. Managing change in the nursing handover from traditional to bedside handover – a case study from Mauritius. BMC Nursing, 49(1).

Kritsonis, A., 2005. Comparison of change theories, International Journal of Scholarly Academic Intellectual Diversity, Vol. 8, No. 1, pp. 1-8.

Lenburg, C.B., 1991. Assessing the goals of nursing education: Issues and approaches to evaluation of outcomes. Assessing education outcomes, eds Garbin, M., New York: NLN Press.

Lorraine, M., 2005. Transformational leadership: a cascading chain reaction. Journal of Nursing Management, Volume 13, Issue 2, pages 128–136.

Murphy, F., 2006. Using change in nursing practice: A case study approach. Nursing Management Journal, Vol. 13, Iss. 2, pp. 1-5.

Reddin, W. J., 1987. How to make management style more effective. Maidenhead: McGraw Hill.

Robbins, S., 2003. Organizational behavior, 10th ed. NJ: Prentice Hall, Upper Saddle River.

Rosenbach, W., & Taylor, R., 2001. Contemporary issues in leadership, 5th ed. Boulder: Westview Press.

Shanley, C., 2007. Management of change for nurses: lessons from the discipline of organizational studies. Journal of Nursing Management, Volume 15, Issue 5, pages 538–546.

Surgeon, K., 2000. Managing in a professional bureaucracy. International Journal of Health Care Quality Assurance, Vol. 3, Iss. 2, pp. 1978-80.

Swansburg, R., & Swansburg, R., 2002. Introduction to management and leadership for nurse managers, 3^rd ed. Sudbury: Jones and Bartlett Publishers.

Thomas, R. & Dunkerley, D., 1999. Careering downwards? Middle managers’ experiences in the downsized organization. British Journal of Management, Vol. 10, pp. 157–169.

Wagstaff, R., 2006. Using change in nursing practice: A Case Study Approach. Nursing Management Journal, Vol. 13, Iss. 2, pp. 1-5.

Watzlawick, P., 1990. Munchhausen’s pigtail, NY: W.W. Norton.

Wood, P., 2000. Clinical governance: The Role of Nursing Leadership in a Time of Change, p.12.