How many times have you watched a change

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1 J O U R N A L F O R N U R S E S I N S T A F F D E V E L O P M E N T Volume 24, Number 4, Copyright A 2008 Wolters Kluwer Health Lippincott Williams & Wilkins Change Management Magic or Mayhem? Keverne L. Lehman, MSN, RN-BC The Nursing Professional Development Educator role includes that of change agent. Much of the literature addresses reaction to change rather than purposeful guidance of the process. This article describes the development of a planned change template. Distilled from change literature, experience in change management, and wisdom from the nuclear power industry, it can assist in avoiding some of the common pitfalls that thwart the success of change initiatives.... How many times have you watched a change unfold and commented, If only this had been better planned? Change will continue to be a major focus of nursing s future, according to Nowicki (1996). Indeed, as nurses struggle with all of the stresses and problems of progress, mergers, financial pressures, electronic documentation, emphases on customer service, and patient safety, change is necessary to succeed. To rest or to assume a posture of inertia, if even temporarily, invites failure for us and those under our watchful care. One of the pressing issues for health care is a nonstop rapid cycle environment. In a staff development position, the role of the educator as a change agent includes facilitating the initiation, adoption of, and adaptation to change (American Nurses Association, 2000, p. 9). Articles, perspectives, advice, and theories are numerous. Translation of those concepts into daily work is less clear. Where the rubber meets the road, how exactly does the nursing educator implement change management to be certain that the change is necessary, sound, well planned, and anchored? This article describes one nursing staff development department s efforts to... Keverne L. Lehman, MSN, RN-BC, is Director, Nursing Practice, Education, and Research, Spectrum Health, Grand Rapids, Michigan. delineate specific tools to use in consultation and intervention in change projects in a large acute care environment. Drawing from change literature, an example from the nuclear power industry, and numerous experiential incidents, a change process guideline and template are described. REVIEW OF LITERATURE Familiar words in sorting thorough literature on change are resistance, fear, unfreezing, diffusion, denial, chaos, andintegration. Many writings refer to managing the reaction to change. Others address change within the individual. However, to provide consultation and leadership as a change agent, it is also necessary to consider power, communication, relationships, and system-based thinking (Menix, 2001). Commonly referenced contributors to planned change include Lewin, Rogers, Lippitt, and Havelock. The following discussion relates aspects of the models to acquired knowledge on change management and the templates developed. Lewin Tiffany, Cheatham, Doornbos, Loudermelt & Momadi in the 1994 survey of change management in nursing periodical literature, report that 21% of theory citations 176 July/August 2008

2 allude to Lewin s work. Often referred to as the force field analysis model, Lewin maintained that change is the result of opposing forces in a field or environment (Bozak, 2003). Driving forces encourage the change to occur; restraining forces attempt to maintain the status quo. Lewin described the steps in change as unfreezing from the current state, moving, and freezing (or refreezing ) at the new level. Drawing from Lewin s perspective, it is essential in any change initiative to fully understand and describe the current situation, need, or problem. According to Schein (2004), unfreezing involves creation of a dissatisfaction or frustration generated by data that disconfirms our expectations and hopes. Perhaps feedback from patients and their families is distressing or audit results indicate a picture of practice in conflict with professional standards and nursing values. New evidence-based practice information may illuminate a different path. These data or this information could still be ignored, unless it is connected to something valued. Staff require a clear, concise description of the why of the change. If the why is not conveyed up front, it will be the first question to be asked, or even worse, other hypotheses for the change will be generated that do not reflect the true situation. Lewin s model also counsels us to fully understand the current state surrounding the issue and investigate the forces compelling the change as well as those that may act to curtail it. The period of actual change is the ending of the old and the beginning of the new. Feelings are especially paramount, and many articles address the stages and their manifestations and suggest intervention strategies. From the project management s perspective, fundamentals of the change period include maneuvering all elements of the change into place, supporting the change with training and problem solving resources, and communication, communication, communication. Refreezing involves alteration of the system or organization to encourage the permanency of the change. How many changes have you seen introduced only to fade away, lose steam, or require reeducation? It is essential to implant an element of refreezing in any change project. Consider related policies or practices that require alteration to support the new practice. Design a mechanism for follow-up, outcome measurement, auditing, and accountability. Some authors portray this as the handoff. Lewin s theory is incomplete, however, in that change is assumed to be introduced and directed by a person or group in authority and that the evaluation of the event occurs only as it relates to replanning strategies (Tiffany et al., 1994). There is also no emphasis on specific stakeholder identification or involvement. Rogers The next most commonly used change theorist in nursing publications, according to Tiffany et al. (1994), is Everett Rogers. His diffusion of innovation theory describes the process through which an individual passes from having knowledge of an innovation, to forming an attitude toward the innovation, to making a decision to adopt or reject the new idea, and finally to confirming that decision. The change agent actively facilitates and regulates the diffusion process by recognizing and capitalizing on group strengths and by identifying and managing factors that impede the process. Rogers theory is more a change-watching theory than a change-planning theory (Tiffany et al., 1994). Lippitt A modification of Lewin s theory, Lippitt identifies seven phases of planned change: (1) diagnosing the problem in a complete form, (2) assessing system motivation and resources, (3) identifying the change agent and assessing the change agent s motivation and resources, (4) identifying progressive objectives, often including a pilot test, (5) choosing the appropriate role for the change agent and delineating the chain of command, (6) diffusing and maintaining the change, and (7) terminating the helping relationship of the change agent (Geraci, 1997). Beneficial contributions to a working change template from Lippitt s model include involving those affected by the change, paying attention to planning objectives and time frames, considering a pilot event, establishing mechanisms for feedback, and anchoring the change through formal systems such as policies. Havelock Havelock s six phases of planned change also build from Lewin s unfreezing/change/refreezing model. Relationship building is an important part of the initial phase of change (Lane, 1992). Formal and informal leaders are identified, trust is built, and a planning committee is formed. Next, accurate and complete diagnosis of the problem and acquisition of necessary resources are addressed. This step includes the possibility of a library search, which introduces the gathering of evidence-based practice as a source of information about the situation. Phase 4 centers on choosing the solution. Havelock also suggests a pilot implementation, which provides helpful information contributing to success of further execution of the change. Phase 5 concentrates on the people part of the change: communication, staff response, education, support systems during implementation, and recognition. Finally, stabilization of the system, empowerment of staff, communication of results, revisions, and lessons are undertaken. JOURNAL FOR NURSES IN STAFF DEVELOPMENT 177

3 Bhola Bhola s theory of planned change emphasizes three primary considerations: systems thinking, dialectical approach, and constructivism. Regarding systems thinking, Bhola stresses the understanding of the relationships among parts of the whole. Dialectical processes involve placing opposing ideas together with dialogue (Schwartz & Tiffany, 1994) in which the result is different and of more significance than what currently exists. Another valued perspective of Bhola s planned change theory is the constructivist viewpoint, in which the planner and adopters are equal partners in change, are co-learners in the process, and are both changed by the interaction. This participative and collaborative power structure of the model fits well with nursing s worldview. Change is seen not as something given by P (planner) to A (adopter), but as mutually invented (Bhola, 1994, p. 62). Bhola further develops the planned change model to delineate relationships among the participants and attends to the environment in which the change occurs. His CLER framework speaks to the configurations (C) or relationships between the planners and adopters (individuals, groups, institutions, or cultures) and the linkages (L) or communication between them. It analyzes the environment (E) or systems important to the change effort and also the resources (R) available to assist the planners to foster change and the adopters to assimilate the change. These resources are evaluated in six areas: cognitive, influence, material, personnel, institutional, and time. According to Bhola (1994), change models dealing with living systems cannot promise the model-user simplicity, clear causality, certainty and prediction...nor a set of formulas or exact steps to be taken...can be no more than a template for organizing available knowledge and material resources in relation to a particular social or educational change. (p. 59) WISDOM FROM INDUSTRY: NUCLEAR POWER Struggling to adjust to the increasingly and rapidly changing acute healthcare environment and to translate change requisitions into plans that were both successful and inclusive of bedside staff expertise, our staff development department discovered a systematic change management tool utilized by a local nuclear power plant. Within that institution, management is expected to participate in instruction on change management. Completion of a toolkit is required with any proposed change. This process was also employed for personnel changes. Comparing the nature of the industries, both health care and nuclear power have complex processes, are heavily regulated, and are entrusted with the safety of the public they serve. Even small errors can have drastic consequences. Change management becomes not only desired, but essential. Menix (2001) advocates for prescribed tools in a change process, including activity plans, strategic plans, and planning worksheets. The nuclear facility had formalized many of these processes into a toolkit. Steps in the power plant s blueprint deemed valuable for consideration included a statement on alignment with the organization s strategic goals. A stakeholder identification list was also specified. Taking this one step further, the template provided in this article lists common stakeholders for consideration. The advantage of this specificity lies in consideration of affected entities that the change planner may not have originally envisioned. An enlightening element of the nuclear power plant s plan was plotting the change on a risk/ complexity matrix. It is worthwhile to consider any change in light of the complexities involved, which can be anything from the number of roles, units, or departments affected, the extent of resources required by the change, or the intricacy of the steps of the change itself. Risk can be defined as threat to patients, staff, or potential for failure. In determining risk/ complexity, we have informally classified the changes into categories such as Level 1, something a flyer would take care of to Level 3, director involvement and mandatory education. This classification also suggests appropriate support levels during the period of the change itself. Contingency plans were another added step suggested by the nuclear facility s plan. It is important to consider the possible sources of failure, what the consequences of that failure would mean to patients and the project, and what backup plans may be implemented in case an unwelcome event occurs or the plan does not play out as expected. In the increasingly familiar world of electronic documentation, this is summarized in one word: downtime. The last major contribution from our industry partners is the attention to quality critique and incorporation into organizational learning. Hardwiring an evaluation of the process also signals the handoff of the change process to system personnel or processes. REAL-LIFE APPLICATIONS When thinking of change, consider policies, processes, procedures, products, and personnel. All are worthy of proper management. The Change Process Form included in this article can serve as a template to address essential considerations in planning and implementing a change. Contemplate the implementation of new IV 178 July/August 2008

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8 pumps in which all the stakeholders are not identified and included in the planing of the change process. The failure to identify specific tubing pressure needs of contrast injectors in the radiology department can cause a major disruption in patient care. Overlooking the security department involvement with new facility orientation during the evening hours can compromise the safety of staff. Recognizing the medical staff as users of new defibrillator equipment and visualizing the underdeveloped communication channels to that group would lead to special training sessions at convenient times. Positioning a pulse oximeter product change high on the risk (information accuracy essential to patient care) and complexity (new technology, multiple staff roles, and interface with other clinical equipment) axis of the matrix directs the team to acquire high-level management involvement to problem solve issues across departments and with the vendor. Initiation of a new computerized documentation system or opening of a new patient care building implies a support strategy worthy of 24-hour go-live support with predetermined escalated levels of response as necessary at a command post. Including the adopters of a new dress code will assist in the selection of appropriate and useful styles as well as communication of the new look. Even planned managerial or staff changes may benefit from consideration of elements of the change process. It should be noted that this change process template is not meant to extend, delay, or prolong change. Our current healthcare environment grants little tolerance for prolonged projects. The tools provided here are meant to provide guidance to more rapidly move through the important and relevant JOURNAL FOR NURSES IN STAFF DEVELOPMENT 183

9 aspects of change management and to pilot the user around common pitfalls. As Schwartz & Tiffany (1994) summarize: Nurse planners must be open-minded and modest, learning from the realities of the change environment. They must make each change episode a learning event for those who experience the change... Change does not just happen when we think it should. We must carefully theorize, plot plan, and communicate with those in the planned change environment to make planned change successful. (p. 61) REFERENCES American Nurses Association. (2000). Scope and standards of practice for nursing professional development. Washington, DC: Author. Bhola, H. (1994). The CLER model: Thinking through change. Nursing Management, 25, Bozak, M. (2003). Using Lewin s force field analysis in implementing a nursing information system. Computers, Informatics, Nursing, 21, Geraci, E. (1997). Computers in home care: Application of change theory. Computers in Nursing, 15, Lane, A. (1992). Using Havelock s model to plan unit-based change. Nursing Management, 23, Menix, K. (2001). Educating to manage the accelerated change environment effectively: Part 2. Journal for Nurses in Staff Development, 17, Nowicki, C. (1996). Twenty-one predictions for the future of hospital staff development. Journal of Continuing Education in Nursing, 27, Schein, E. (2004). Kurt Lewin s change theory in the field and in the classroom: Notes toward a model of managed learning. Retrieved September 3, 2004, from Schwartz, K., & Tiffany, C. (1994). Evaluating Bhola s configurations theory of planned change. Nursing Management, 25, Spectrum Health. (2005). Change management toolkit. Grand Rapids, MI. Tiffany, C., Cheatham, A., Doornbos, D., Loudermelt, L., & Momadi, G. (1994). Planned change theory: Survey of nursing periodical literature. Nursing Management, 25, ADDRESS FOR CORRESPONDENCE: Keverne L. Lehman, MSN, RN-BC, Spectrum Health Blodgett Hospital, 1840 Wealthy SE, Grand Rapids, MI ( Keverne.lehman@spectrum-health.org). 184 July/August 2008