document8

C H A P T E R

8

Planned Change

Most importantly, leaders must be able to

translate the demand for change into a clear and

understandable plan for those who must manage

the change and incorporate it into their lives

and work.

—Tim Porter-O’Grady

170

171CHAPTER 8 � Planned Change

Most organizations today find themselves undertaking a number of projects aspart of change efforts directed at organizational restructuring, quality improve-ment, and employee empowerment. Many things drive change in contemporaryhealth care, among them are increasing technology, information availability, andgrowing populations.

In the nursing profession the need for change has never been greater. Bednash(2003) maintains that change is needed in both the practice of nursing and in thesystems that nurses use to deliver care. A fundamental difference in managementand leadership is that managers maintain the status quo and leaders embracechange (Trent, 2003). Learning how to manage change was listed as one of themajor components necessary when developing future nurse leaders (Scobie andRussell, 2003). The integrated leader–manager is well grounded in change theoriesand applies such theory appropriately.

Regardless of the type of change, all major change brings feelings of achieve-ment, loss, pride, and stress. What differentiates a successful change effort from anunsuccessful one is often the ability of a change agent—a person skilled in the theoryand implementation of planned change—to deal appropriately with these very realhuman emotions and to connect and balance all aspects of the organization thatwill be affected by that change.

It becomes clear, then, that initiating and coordinating change requires well-developed leadership and management skills. Dye (2000) goes so far as to say that oneof the most fundamental values that differentiate effective leaders from average leadersis the desire to “make a difference.” This value encourages effective leaders (changeagents) to become high achievers, to seek out and address flaws and to implement pos-itive change to improve the organizations in part and society as a whole.

Being an effective change agent requires expert planning skills. This includesplanning for changing needs. The failure to reassess goals proactively and initiatethese changes results in misdirected and poorly used fiscal and human resources.Not only must leader–managers be visionary in identifying where change is neededin the organization, but they also must be flexible in adapting to change they havedirectly initiated or by which they have been indirectly affected.

Planned change, in contrast to accidental change or change by drift, is change thatresults from a well thought-out and deliberate effort to make something happen.Planned change is the deliberate application of knowledge and skills by a leader tobring about a change. This type of planning requires the leadership skills of problemsolving and decision making and interpersonal and communication skills.

Planned change occurs because of an intended effort by a change agent to deliber-ately move the system. A change agent is the person responsible for moving others whoare affected by the change through its stages. Changes are implemented slowly afterconsultation with others. In planned change, the manager is often the change agent. Insome large organizations today, multidisciplinary teams of individuals, representing allkey stakeholders in the organization, are assigned the responsibility for managing thechange process. In such organizations, this team manages the communication betweenthe people leading the change effort and those who are expected to implement the newstrategies. In addition, this team manages the organizational context in which changecan occur and the emotional connections essential for any transformation.

Planned change occursbecause of an intendedeffort by a changeagent to deliberatelymove the system.

172 UNIT 3 � Roles and Functions in Planning

Display 8.1 delineates selected leadership roles and management functions nec-essary for leader–managers acting either in the change agent role or as a coordinatorof the team.

THE DEVELOPMENT OF CHANGE THEORY

Most of the current research on change builds on the classic change theories devel-oped by Kurt Lewin in the mid-20th century. Lewin (1951) identified three phasesthrough which the change agent must proceed before a planned change becomespart of the system: unfreezing, movement, and refreezing.

Leadership Roles1. Is visionary in identifying areas of needed change in the organization and the health-

care system.2. Demonstrates risk taking in assuming the role of change agent.3. Demonstrates flexibility in goal setting in a rapidly changing healthcare system.4. Anticipates, recognizes, and creatively problem solves resistance to change.5. Serves as a role model to subordinates during planned change by viewing change as a

challenge and opportunity for growth.6. Role models high-level interpersonal communication skills in providing support for fol-

lowers undergoing rapid or difficult change.7. Demonstrates creativity in identifying alternatives to problems.8. Demonstrates sensitivity to timing in proposing planned change.9. Takes steps to prevent aging in the organization and to keep nursing current with the

new realities of nursing practice.

Management Functions1. Forecasts unit needs with an understanding of the organization’s and unit’s legal, polit-

ical, economic, social, and legislative climate.2. Recognizes the need for planned change and identifies the options and resources avail-

able to implement that change.3. Appropriately assesses the driving and restraining forces when planning for change.4. Identifies and implements appropriate strategies to minimize or overcome resistance to

change.5. Seeks subordinates’ input in planned change and provides them with adequate infor-

mation during the change process to give them some feeling of control.6. Supports and reinforces the individual efforts of subordinates during the change process.7. Identifies and uses appropriate change strategies to modify the behavior of subordi-

nates as needed.8. Periodically assesses the unit/department for signs of organizational aging and plans

renewal strategies.

Leadership Roles and Management Functionsin Planned Change

Display 8.1


In the unfreezing stage, the change agent unfreezes forces that maintain the statusquo. Thus, people become discontented and aware of a need to change. Unfreezingis necessary because before any change can occur, people must believe the change isneeded. Unfreezing occurs when the change agent convinces members of the groupto change or when guilt, anxiety, or concern can be elicited. For effective change tooccur, the change agent needs to have made a thorough and accurate assessment ofthe extent of and interest in change, the nature and depth of motivation, and theenvironment in which the change will occur. Change should be implemented onlyfor good reasons. Because human beings have little control over many changes intheir lives, the change agent must remember that people need a balance between sta-bility and change in the workplace. Change for change’s sake subjects employees tounnecessary stress and manipulation.

Unnecessary ChangeTry to remember a situation in your own life that involved unnecessarychange. Why do you think the change was unnecessary? What types ofturmoil did it cause? Were there things a change agent could have donethat would have increased unfreezing in this situation?

Learning Exercise 8.1

The second phase of planned change is movement. In movement, the changeagent identifies, plans, and implements appropriate strategies, ensuring thatdriving forces exceed restraining forces. Whenever possible, change should beimplemented gradually. Because change is such a complex process, it requires agreat deal of planning and intricate timing. Recognizing, addressing, and over-coming resistance may be a lengthy process. Any change of human behavior, orthe perceptions, attitudes, and values underlying that behavior, takes time.Therefore, any change must allow enough time for those involved to be fullyassimilated in that change.

The last phase is refreezing. During the refreezing phase, the change agentassists in stabilizing the system change so it becomes integrated into the status quo.If refreezing is incomplete, the change will be ineffective and the pre-changebehaviors will be resumed. For refreezing to occur, the change agent must be sup-portive and reinforce the individual adaptive efforts of those affected by the change.Because change needs at least three to six months before it will be accepted as partof the system, change should never be attempted unless the change agent can makea commitment to be available until the change is complete.

It is important to realize that refreezing does not eliminate the possibility of furtherimprovements to the change. Display 8.2 illustrates the change agent’s responsibilitiesduring the various stages.


Lippitt, Watson, and Westley (1958) built on Lewin’s theories in identifyingseven phases of planned change:

1. The patient must feel a need for change. Unfreezing occurs.2. A helping relationship begins between the change agent and his or her

patients. Movement begins.3. The problem is identified and clarified. Data are collected.4. Alternatives for change are examined. Resources are assessed.5. Active modification or change occurs. Movement is complete.6. Refreezing occurs as the change is stabilized.7. The helping relationship ends, or a different type of continuing relationship

is formed.

Murphy (1999), in a more contemporary model, suggests that there are fourpredictable stages that people pass through when exposed to any change: resist-ance, confusion, exploration, and commitment. There are predictable behaviorsassociated with each of these stages, and the most effective managers study thesebehaviors and are able to respond appropriately to get their team back on tracktoward the goals.

Stage 1—Unfreezing1. Gather data2. Accurately diagnose the problem3. Decide if change is needed4. Make others aware of the need for change; often involves deliberate tactics to raise

the group’s discontent level; do not proceed to Stage 2 until the status quo has beendisrupted, and the need for change is perceived by the others

Stage 2—Movement1. Develop a plan2. Set goals and objectives3. Identify areas of support and resistance4. Include everyone who will be affected by the change in its planning5. Set target dates6. Develop appropriate strategies7. Implement the change8. Be available to support others and offer encouragement through the change9. Use strategies for overcoming resistance to change

10. Evaluate the change11. Modify the change, if necessary

Stage 3—RefreezingSupport others so the change remains

Stages of Change and Responsibilities of the Change Agent

Display 8.2


Perlman and Takacs (1990), building on Lewin’s work, identified 10 suchbehaviors or emotional phases in the change process (Display 8.3). The phases ofequilibrium, denial, anger, and bargaining reflect Lewin’s unfreezing phase; chaos,depression, and resignation, the movement phase; and openness, readiness, andreemergence, the refreezing phase. Regardless of the number of phases or theirnames, it is critical that the manager recognizes that organizations must consciouslyand constructively deal with the human emotions associated with all phases ofplanned change.

Quinn, Spreitzer, and Brown (2000) state that any real adaptive change can beachieved only by mobilizing people to make painful adjustments in their attitudes,work habits, and lives. They must “surrender their present selves and put themselvesin jeopardy of becoming part of an emergent system. This process usually requiresthe surrender of personal control, the toleration of uncertainty, and the developmentof a new culture at the collective level and a new self at the individual level” (p. 147).

DRIVING AND RESTRAINING FORCES

Lewin also theorized that people maintain a state of status quo or equilibrium bythe simultaneous occurrence of both driving and restraining forces operating withinany field. The forces that push the system toward the change are driving forces,whereas the forces that pull the system away from the change are called restrainingforces. Lewin’s model maintained that for change to occur, the balance of drivingand restraining forces must be altered. The driving forces must be increased or therestraining forces decreased.

1. Equilibrium: Characterized by high energy and emotional and intellectual balance.Personal and professional goals are synchronized.

2. Denial: Individual denies reality of the change. Negative changes occur in physical,cognitive, and emotional functioning.

3. Anger: Energy is manifested by rage, envy, and resentment.4. Bargaining: In an attempt to eliminate the change, energy is expended by bargaining.5. Chaos: Characterized by diffused energy, feelings of powerlessness, insecurity, and

loss of identity.6. Depression: Defense mechanisms are no longer operable. No energy left to produce

results. Self-pity apparent.7. Resignation: Change accepted passively but without enthusiasm.8. Openness: Some renewal of energy in implementing new roles or assignments that

have resulted from the change.9. Readiness: Willful expenditure of energy to explore new event. Physical, cognitive, and

emotional reunification occurs.10. Reemergence: Person again feels empowered and begins initiating projects and ideas.

Adapted from Perlman, D., & Takacs, G. J. (1990). The ten stages of change. Nursing Management, 21(4), 33–38.

Ten Emotional Phases of the Change ProcessDisplay 8.3


Driving forces may include a desire to please one’s boss, to eliminate a problemthat is undermining productivity, to get a pay raise, or to receive recognition.Restraining forces include conformity to norms, an unwillingness to take risks, anda fear of the unknown. In Figure 8.1, the person wishing to return to school mustreduce the restraining forces or increase the driving forces to alter the present stateof equilibrium. There will be no change or action until this occurs. Therefore, cre-ating an imbalance within the system by increasing the driving forces or decreasingthe restraining forces is one of the tasks required for a change agent.

Making Change PossibleIdentify a change that you would like to make in your personal life (suchas losing weight, exercising daily, or stopping smoking). List the restrain-ing forces keeping you from making this change. List the driving forcesthat make you want to change. Determine how you might be able tochange the status quo and make the change possible.

Learning Exercise 8.2A

Figure 8.1 Driving and restraining forces.

Numerous factors affect successful implementation of planned change. Manygood ideas are never realized because of poor timing or a lack of power on the partof the change agent. For example, both organizations and individuals tend to rejectoutsiders as change agents because they are perceived as having inadequate knowl-edge or expertise about the current status, and their motives often are not trusted.Therefore, there is less widespread resistance if the change agent is an insider. Theoutside change agent, however, tends to be more objective in his or her assessment,whereas the inside change agent is often influenced by a personal bias regardinghow the organization functions.

Many good ideas arenever realized becauseof poor timing or a lackof power on the part ofthe change agent.

Likewise, some greatly needed changes are never implemented because thechange agent lacks sensitivity to timing. If the organization or the people withinthat organization have recently undergone a great deal of change or stress, anyother change should wait until group resistance decreases.

CHANGE STRATEGIES

Three commonly used strategies for effecting change in others were described byBennis, Benne, and Chinn (1969). The appropriate strategy for any situationdepends on the power of the change agent and the amount of resistance expectedfrom the subordinates. One of these strategies is to give current research as evidenceto support the change. This group of strategies is often referred to as rational–empirical strategies. The change agent using this set of strategies assumes that resist-ance to change comes from ignorance or superstition (Quinn, Spreitzer, & Brown,2000) and that humans are rational beings who will change when given factualinformation documenting the need for change. This type of strategy is used whenthere is little anticipated resistance to the change or when the change is perceived asreasonable.

Because peer pressure is often used to effect change, another group of strategiesthat uses group process is called normative–re-educative strategies. These strategiesuse group norms to socialize and influence people so change will occur. Thechange agent assumes humans are social animals, more easily influenced by othersthan by facts. This strategy does not require the change agent to have a legitimatepower base. Instead, the change agent gains power by skill in interpersonal rela-tionships. He or she focuses on noncognitive determinants of behavior, such aspeople’s roles and relationships, perceptual orientations, attitudes, and feelings, toincrease acceptance of change.

The third group of strategies, power–coercive strategies, are based on the appli-cation of power by legitimate authority, economic sanctions, or political clout ofthe change agent. These strategies include influencing the enactment of new lawsand using group power for strikes or sit-ins. Using authority inherent in an indi-vidual position to effect change is another example of a power–coercive strategy.These strategies assume that people often are set in their ways and will changeonly when rewarded for the change or are forced by some other power–coercivemethod. Resistance is handled by authority measures; the individual must acceptit or leave.

Often the change agent uses strategies from each of these three groups. Anexample would be the change agent who wants someone to stop smoking. Thechange agent might present the person with the latest research on cancer andsmoking (the rational–empirical approach); at the same time, the change agentmight have friends and family educate the person socially (normative–re-educativeapproach). The change agent also might refuse to ride in the car if the personsmokes while driving (power–coercive approach). By selecting from each set ofstrategies, the manager increases the chance of successful change.



RESISTANCE: THE EXPECTED RESPONSE TO CHANGE

Because change disrupts the homeostasis or balance of the group, resistance shouldalways be expected. The level of resistance generally depends on the type of changeproposed. Technological changes encounter less resistance than changes that areperceived as social or that are contrary to established customs or norms. For exam-ple, nursing staff are more willing to accept a change in the type of intravenouspump to be used than a change regarding who is able to administer certain types ofIV therapy. Nursing leaders also must recognize that subordinates’ values, educa-tional levels, cultural and social backgrounds, and experiences with change (positiveor negative) will have a tremendous impact on their degree of resistance. It also ismuch easier to change a person’s behavior than it is to change an entire group’sbehavior. Likewise, it is easier to change knowledge levels than attitudes.

In an effort to eliminate resistance to change in the workplace, managers histor-ically used an autocratic leadership style with specific guidelines for work, an exces-sive number of rules, and a coercive approach to discipline. The resistance, whichoccurred anyway, was both covert (such as delaying tactics or passive–aggressivebehavior) and overt (openly refusing to follow a direct command), and resulted inwasted managerial energy and time and a high level of frustration.

Today, resistance is recognized as a natural and expected response to change.Instead of wasting time and energy trying to eliminate opposition, contemporarymanagers immerse themselves in identifying and implementing strategies to minimizeor manage this resistance to change. One such strategy is to encourage subordinates to

Using Change Strategies to Increase Sam’s ComplianceYou are a staff nurse in a home health agency. One of your patients, SamLittle, is a 38-year-old man with Type 1 diabetes. He has developed someloss of vision and had to have two toes amputated as consequences of hisdisease process. Sam’s compliance with four times a day Accu-checks andsliding-scale insulin administration has never been particularly good, but hehas been worse than usual lately. However, he does seem willing to followa prescribed diabetic diet and has kept his weight to a desired level.

Sam’s wife called you at the agency yesterday and asked you to workwith her in developing a plan to increase Sam’s compliance with hisblood sugar monitoring and insulin administration. She said that Sam,while believing it “probably won’t help,” has agreed to meet with youto discuss such a plan.Assignment: What change strategy or combination thereof(rational–empirical, normative–reeducative, power–coercive) do youbelieve has the greatest likelihood of increasing Sam’s compliance? Howcould you use this strategy? Who would be involved in this change effort?What efforts might you undertake to increase the unfreezing so Sam ismore willing to actively participate in such a planned change effort?


Resistance is recognizedas a natural andexpected response to change.


speak openly so options can be identified to overcome objections. Likewise, workersare encouraged to talk about their perceptions of the forces driving the planned changeso the manager can accurately assess change support and resources.

Bushy and Kamphuis (1993) identified six behavioral patterns commonly seenin response to change: innovators, early adopters, early majority, late majority, lag-gards, and rejecters (see Display 8.4). Innovators are enthusiastic, energetic peoplewho thrive on change and are almost obsessed with adventure. Described by someas disruptive radicals, they are able to effect change, often amidst controversy with-in the organization. Early adopters are open and receptive to new ideas but are lessobsessed with seeking out changes than innovators. Early majority individualsadhere to the adage, “Be not the last to lay the old aside, nor the first by which thenew is tried.” Early majority individuals prefer the status quo but adopt new ideasshortly before the average person. Late majority individuals are followers, skepticalof innovation, and frequently express their negative views. Only after a majority ofthe organization accepts an innovation will the late majority favor it. Laggards, thelast to adopt an innovation, are dedicated to tradition. They interact primarily withother traditionalists and are highly suspicious of innovations and innovators. Rejec-tors openly oppose innovation and actively encourage others to do so. Althoughcovert in nature, their activities may completely immobilize the change process, thechange agent, or the system, even to the extent of sabotaging an innovation.

Similarly, Pesut (2000) classifies individuals as either crusaders or tradition bear-ers in response to their propensity to seek change. Crusaders are change agents who

• Innovators: enthusiastic and thrive on change• Early adopters: open and receptive to new ideas• Early majority: adopt new ideas before the average person• Late majority: skeptical of innovation and change• Laggards: dedicated to tradition and the last to adopt a change• Rejecters: openly oppose innovation and encourage others to also oppose changeSource: Bushy, A., & Kamphuis, J. (1993). Response to innovation: Behavioral patterns. Nursing Management,

24(3), 62–64.

Common Responders and Responses to ChangeDisplay 8.4

What Is Your Attitude Toward Change?Which behavioral pattern do you most commonly assume in response tochange: innovator, early adopter, early majority, late majority, laggard, orrejecter? Is this behavioral pattern similar to your friends’ and family’s?Has your behavior always fit this pattern, or has the pattern changedthroughout your life? If so, what life events have altered how you viewand respond to change?



see problems in the present and want to make things better for the future. Traditionbearers are the preservers of what is best from the past and the present.

Perhaps the greatest factor contributing to the resistance encountered withchange is a lack of trust between the employee and the manager or the employee andthe organization. Workers want security and predictability. That’s why trust erodeswhen the ground rules change, as the assumed “contract” between the worker andthe organization is altered. Subordinates’ confidence in the change agent’s ability tomanage change depends on whether they believe they have sufficient resources tocope with it. In addition, the leader–manager must remember that subordinates inan organization will generally focus more on how a specific change will affect theirpersonal lives and status than on how it will affect the organization.

Heifetz and Laurie (2001) maintain that most followers want comfort, routinestability, and good problem solving. Change creates chaos and order is disturbed.Leaders must recognize this and continue to “push the walls” even as they meetresistance. Porter-O’Grady (2003) feels that this is the time of great challenge forthe leader. The skills necessary to move reticent groups cannot be understated. Theleader must use developmental, political, and relational expertise to ensure thatneeded change is not sabotaged.

PLANNED CHANGE AS A COLLABORATIVE PROCESS

Often times, the change process begins with a few people who meet to discuss theirdissatisfaction with the status quo, and an inadequate effort is made to talk withanyone else in the organization. This approach virtually guarantees that the changeeffort will fail. People abhor “information vacuums,” and when there is no ongoingconversation about the change process, gossip usually fills the void. These rumorsare generally much more negative than anything that is actually happening.

Whenever possible, all those who may be affected by a change should beinvolved in planning for that change. Ayers (2002) suggests that the empirical pic-ture that is emerging is that communication and organizational change processesare inextricably linked. When change agents fail to communicate with the rest ofthe organization, they prevent people from understanding the principles that guidedthe change, what has been learned from prior experience, and why compromiseshave been made. Research by Knox and Irving (1997) found that communicationabout the goals and progression of organizational change by healthcare executiveswas the most important factor for subordinate managers in ensuring a successfulchange effort. The importance of being perceived as a legitimate and informed par-ticipant in the change process was critical to their role success.

Likewise, subordinates affected by the change should thoroughly understand thechange and how it affects them as individuals. Good, open communication throughoutthe process can reduce resistance. Leaders must ensure that group members share per-ceptions about what change is to be undertaken, who is to be involved and in what role,and how the change will directly and indirectly affect each person in the organization.

The easiest way for the manager to ensure that subordinates share this percep-tion is to involve them in the change process. When information and decisionmaking are shared, subordinates feel that they have played a valuable role in the

change. Change agents and the elements of the system—the people or groupswithin it—must openly develop goals and strategies together. All must have theopportunity to define their interest in the change, their expectation of its outcome,and their ideas on strategies for achieving change.

It is not always easy to attain grassroots involvement in planning efforts. Evenwhen managers communicate that change is needed and that subordinate feedbackis wanted, the message often goes unheeded. Some people in the organization mayneed to hear a message repeatedly before they hear, understand, and believe themessage. If the message is one they do not want to hear, it may take even longer forthem to come to terms with the anticipated change.

THE LEADER–MANAGER AS A ROLE MODEL DURING PLANNED CHANGE

Leader–managers must act as role models to subordinates during the change process.The leader–manager must attempt to view change positively and to impart this viewto subordinates. It is critical that managers not view change as a threat. Instead, itshould be viewed as a challenge and the chance or opportunity to do something newand innovative. Porter-O’Grady (2003) suggests that these dramatically changingtimes in the practice of nursing have given leaders a more demanding role in healthcare, and that the manager’s behavior is the single most important factor in how peo-ple in the organization accept change. Presently, the need for change is so important inhealthcare organizations and in the nursing profession that Porter-O’Grady says lead-ers should accelerate disruptive change as a vehicle for making sure change occurs.

The leader has two responsibilities in facilitating change in nursing practice.First, leader–managers must be actively engaged in change in their own work androle model this behavior to staff. Secondly, leaders must be able to assist staff mem-bers make the needed change requirements in their work. For a change to becomepart of the organization, staff must internalize it. One way to assist staff with inter-nalization is to show a relationship between the process of change and outcome,when this can be measured then the evidence to support the change is convincing(Porter-O’Grady, 2003).

Managers must believe that they can make a difference. This feeling of control isprobably the most important trait for thriving in a changing environment. Friends,family, and colleagues should be used as a support network for managers duringchange. Likewise, managers should learn to recognize their own stress signals duringchange and take appropriate steps when the stress level becomes too high.

ORGANIZATIONAL AGING: CHANGE AS A MEANS OF RENEWAL

Organizations progress through developmental stages, just as people do—birth,youth, maturity, and aging. As organizations age, structure increases to providegreater control and coordination. The young organization is characterized by highenergy, movement, and virtually constant change and adaptation. Aged organiza-tions have established “turf boundaries,” function in an orderly and predictable



fashion, and are focused on rules and regulations. Change is limited. Other charac-teristics of aged organizations include hierarchical structures and bureaucraticprocesses that are resistant to change (Ayers, 2002).

It is clear that organizations must find a critical balance between stagnation andchaos, between birth and death. In the process of maturing, workers within the organ-ization can become prisoners of procedures, forget their original purposes, and allowmeans to become the ends. Gardner (1990) argues that organizations must be everrenewing. The ever-renewing organization is infant-like—curious and open to newexperience and change. Gardner says that the only way to conserve an organization isto keep it changing. Without change, the organization may stagnate and die.

The other term Gardner uses to describe the aged organization is organizationaldry rot. Gardner states that organizational dry rot can be prevented by having effec-tive programs for the recruitment and development of young talent; providing a hos-pitable organizational environment that fosters individuality; building in provisionsfor self-criticism by providing an atmosphere in which uncomfortable questions canbe raised; and being forward-thinking. The organization needs to keep foremostwhat it is going to do, not what it has done.

ORGANIZATIONAL CHANGE ASSOCIATED WITH NONLINEAR DYNAMICS

Most organizations frequently experience stability followed by intense transforma-tion. Some later organizational theorists feel that Lewin’s refreezing to establish equi-librium should not be the focus of contemporary organizational change. Ayers (2002)maintains that when change was predictable and rare in the industrial age, Lewin’stheory worked well for organizations. However, during the information age of the21st century, change is unforeseeable and ever present. In the past, organizations havelooked at change and organizational dynamics as linear, both occurring in steps andsequential, but some theorists maintain that the world is so unpredictable that thedynamics are nonlinear and do not occur in any order (Wagner and Huber, 2003).

Chaos Theory

Because of the rapidly changing nature of health care and healthcare organizations,long-term outcomes are unpredictable, resulting in the potential for chaos (Thi-etart & Forgues, 1995). The basic tenets of chaos theory are that organizations canno longer rely on rules, policies, and hierarchies, or afford to be inflexible; and thatsmall changes in the initial conditions of a system can drastically affect the long-term behavior of that system (Wagner & Huber, 2003). Organizations are opensystems operating in a complex environment that changes rapidly and much of thechange is unpredictable. “The richness of the interactions among parts andbetween the system and its environment allows the system as a whole to undergospontaneous self-organization” (McDaniel, 1998, p. 356).

System thinking refers to the need for both individuals and organizations tounderstand how each is an open system with constant input from both visible andinvisible interactions. Senge (1990) maintains that the dialogue necessary in system


thinking promotes both organizational and individual learning. Organizations thatuse this learning approach to deal with constant change are often referred to aslearning organizations (Senge). Continuous learning as a concept of organizationalphilosophy promotes adaptation to change within the organization.

Complex Adaptive Systems Change Theory

Highly unstable environmental conditions require today’s organizations to deal withchange in a manner that allows for constant fluidity and continuous renewal (Ayers,2003). A contemporary approach to changing organizations, which is quite differentfrom traditional change, is Olson and Eoyang’s (2001) theory of complex adaptivesystems (CAS). The authors say that the self-organizing nature of human interac-tions in a complex organization leads to surprising effects. Rather than focusing onthe macro level of the organization system, complexity theory suggests that mostpowerful change processes occur at the micro level where relationships, interactions,and simple rules shape emerging patterns. Olson and Eoyang summarize the mainfeatures of the CAS approach to change as follows:

• Change should be achieved through connections between change agents,instead of from the top-down.

• There should be an adaptation during the change to uncertainty instead oftrying to predict stages of development.

• Goals, plans, and structures should be allowed to emerge instead of depend-ing on clear, detailed plans and goals.

• Value differences should be amplified instead of focusing on consensus.• Self-similarity should be created instead of differences between levels of change.• Success should be regarded as a matter of fit with the organizational envi-

ronment instead of focusing on one-dimensional success measurement.

IS THE NURSING PROFESSION IN NEED OF RENEWAL?

This is a time of changing nursing practice, a change that often creates crisis whennurses try to defend existing models of practice instead of embracing change.

Young or Old Organization?Reflect on the organization in which you work or the nursing school youattend. Do you believe this organization has more characteristics of ayoung or aged organization and do you believe that nonlinear dynamicsis at work in the organization? Diagram on a continuum from birth todeath where you feel this organization would fall. What efforts has thisorganization taken to be ever renewing? What further efforts could bemade? Do you agree or disagree that most organizations change unpre-dictably? Can you support your conclusions with examples?

Learning Exercise 8.5A


Porter-O’Grady (2003) posits that the profession must examine and adapt to thechanging context of nursing practice. The traditional realities are:

• institutional based care• process oriented• procedurally driven• based on mechanical and manual intervention• provider driven• treatment based• late-stage intervention• based on vertical clinical relationships

According to Porter-O’Grady the emerging realities of nursing practice for thiscentury will be the following:

• mobility based or multisettings• outcome driven• best-practice oriented• technology and minimal-invasive intervention• user driven• health based• early intervention• based on horizontal clinical relationships

Perhaps there is no greater need for the leader, at this point in the changing pro-fession, than to be the catalyst for change. Many people attracted to the professionnow find that their values and traditional expectations no longer fit as they oncedid. It is the leader’s role to help the staff turn around and confront the opportuni-ties and challenges of the realties of emerging nursing practice: to create enthusi-asm and passion for renewing the profession; to embrace the change of locus ofcontrol, which now belongs to the healthcare consumer; and to engage a new socialcontext for nursing practice.

INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN PLANNED CHANGE

It should be clear that leadership and management skills are necessary for successfulplanned change to occur. The manager must understand the planning process andplanning standards and be able to apply both to the work situation. The manager,then, is the mechanic who implements the planned change.

The leader, however, is the inventor or creator. Leaders today are forced to planin a chaotic healthcare system that is changing at a frenetic pace. Out of this chaos,leaders must identify trends and changes that may affect their organizations andunits and proactively prepare for these changes. Thus, the leader must retain a big-picture focus while dealing with each part of the system. In the inventor or creatorrole, the leader displays such traits as flexibility, confidence, tenacity, and the abilityto articulate vision through insights and versatile thinking.


Both leadership and management skills are necessary in planned change. Thechange agent fulfills a management function when identifying situations wherechange is necessary and appropriate and when assessing the driving and restrainingforces affecting the plan for change. The leader is the role model in plannedchange; he or she is open and receptive to change and views change as a challengeand an opportunity for growth. Perhaps the most critical element in successfulplanned change is the change agent’s leadership skills—interpersonal communication,group management, and problem-solving skills.

❊ Key Concepts

• Change should not be viewed as a threat but as a challenge or the chance todo something new and innovative.

• Change should be implemented only for good reason.• Because change disrupts the homeostasis or balance of the group, resistance

should be expected as a natural part of the change process.• The level of resistance to change generally depends on the type of change

proposed. Technological changes encounter less resistance than changesthat are perceived as social or that are contrary to established customs or norms.

• Perhaps the greatest factor contributing to the resistance encountered withchange is a lack of trust between the employee and the manager or theemployee and the organization.

• It is much easier to change a person’s behavior than it is to change anentire group’s behavior. It also is easier to change knowledge levels than attitudes.

• Change should be planned and thus implemented gradually, not sporadicallyor suddenly.

• Those who may be affected by a change should be involved in planning forit. Likewise, workers should thoroughly understand the change and itseffect on them.

• The feeling of control is critical to thriving in a changing environment.• Friends, family, and colleagues should be used as a network of support

during change.• The change agent has the leadership skills of problem solving and decision

making and has good interpersonal skills.• In contrast to planned change, change by drift is unplanned or accidental.• Historically, many of the changes that have occurred in nursing or have

affected the profession are the results of change by drift.• People maintain status quo or equilibrium when both driving and restraining

forces operating within any field simultaneously occur. For change to happen,this balance of driving and restraining forces must be altered.

• Organizations are preserved by change and constant renewal. Withoutchange, the organization may stagnate and die.

• Some modern theorists believe that change is unpredictable, occurs atrandom, and small changes can effect the entire organization.


More Learning Exercises and Applications

Implementing Planned Change in a Family Planning ClinicYou are an Hispanic RN who has recently received a two-year grant toestablish a family planning clinic in an impoverished, primarily Hispanicarea of a large city. The project will be evaluated at the end of the grantto determine whether continued funding is warranted. As project direc-tor, you have the funding to choose and hire three healthcare workers.You will essentially be able to manage the clinic as you see fit.

The average age of your patients will be 14 years, and many come fromsingle-parent homes. In addition, the population with which you will beworking has high unemployment, high crime and truancy levels, and greatsuspicion and mistrust of authority figures. You are aware that manyrestraining forces exist that will challenge you, but you feel strongly com-mitted to the cause. You believe that the exorbitantly high teenage preg-nancy rate and maternal and infant morbidity can be reduced.Assignment:1. Identify the restraining and driving forces in this situation.2. Identify realistic short- and long-term goals for implementing such a

change. What can realistically be accomplished in two years?3. How might the project director use hiring authority to increase the

driving forces in this situation?4. Is refreezing of the planned change possible so that changes will con-

tinue if the grant is not funded again in 2 years?


Retain the Status Quo or Implement Change?Assume that morale and productivity are low on the unit where you arethe new manager. In an effort to identify the root of the problem, youhave been meeting informally with staff to discuss their perceptions ofunit functioning and to identify sources of unrest on the unit. You believethat one of the greatest factors leading to unrest is the limited advance-ment opportunity for your staff nurses. You have a fixed charge nurse oneach shift. This is how the unit has been managed for as long as everyonecan remember. You would like to rotate the charge nurse position but areunsure of your staff’s feelings about the change.Assignment: Using the phases of change identified by Lewin, identify theactions you could take in unfreezing, movement, and refreezing. What arethe greatest barriers to this change? What are the strongest driving forces?



How Would You Handle This Response to Change?You are the unit manager of a cardiovascular surgical unit. The work sta-tion on the unit is small, dated, and disorganized. The unit clerks havecomplained for some time that the chart racks on the counter above theirdesk are difficult to reach, that staff frequently impinge on their workspace to discuss patients or to chart, that the call-light system is antiquated,and that supplies and forms need to be relocated. You ask all eight ofyour shift unit clerks to make a “wish list” of how they would like thework station to be redesigned for optimum efficiency and effectiveness.

Construction is completed several months later. You are pleased thatthe new work station incorporates what each unit clerk included in his orher top three priorities for change. There is a new revolving chart rack inthe center of the work station, with enhanced accessibility to both staffand unit clerks. A new state-of-the-art call-light system has been installed.A small, quiet room has been created for nurses to chart and conference,and new cubbyholes and filing drawers now put forms within arm’s reachof the charge nurse and unit clerk.

Almost immediately, you begin to be barraged with complaints aboutthe changes. Several of the unit clerks find the new call-light system’scomputerized response system overwhelming and complain that patientlights are now going unanswered. Others complain that with the chartrack out of their immediate work area, charts can no longer be monitoredand are being removed from the unit by physicians or left in the chartingroom by nurses. One unit clerk has filed a complaint that she was injuredby a staff member who carelessly and rapidly turned the chart rack. Sherefuses to work again until the old chart racks are returned. The regularday-shift unit clerk complains that all the forms are filed backward forleft-handed people and that after 20 years, she should have the right toput them the way she likes it. Several of the nurses are complaining thatthe work station is “now the domain of the unit clerk” and that access tothe telephones and desk supplies is limited by the unit clerks. There havebeen some rumblings that several staff members believe that you favoredthe requests of some employees over others.

Today, when you make rounds at change of shift, you find the day-shiftunit clerk and charge nurse involved in a heated conversation with theevening-shift unit clerk and charge nurse. Each evening, the charge nurseand unit clerk reorganize the work station in the manner that theybelieve is most effective, and each morning, the charge nurse and unitclerk put things back the way they had been the prior day. Both believethat the other shift is undermining their efforts to “fix” the work stationorganization and that their method of organization is the best. Bothgroups of workers turn to you and demand that you “make the othershift stop sabotaging our efforts to change things for the better.”Assignment: Despite your intent to include subordinate input into thisplanned change, resistance is high and worker morale is plummeting. Isthe level of resistance a normal and anticipated response to plannedchange? If so, would you intervene in this conflict? How? Was it possibleto have reduced the likelihood of such a high degree of resistance?



Old and New Roles of Nursing PracticeExamine the old and new realities of nursing practice as identified on p.184.Assignment: In a small group discuss the old and new roles of nursingpractice. In your observations, based on your nursing school clinicalexperiences, theory based classes, and watching other nurses in theirroles, what type of nursing practice do you see being practiced? Givespecific examples. Are the practice models in evidence provider driven oruser driven? Is the nursing practice process oriented or outcome driven?As an organization do you believe nursing would be classified as a) anaging organization, b) in constant motion and ever renewing, or c) aclosed system that does not respond well to change?


Web Links

Orlikowski, W. J., & Hofman, D. An Improvisational Model of Change Managementhttp://ccs.mit.edu/papers/CCSWP191/CCSWP191.htmlThe Case of Groupware Technologies: Massachusetts Institute of Technology, SloanSchool of Management. Examines a dynamic and variable “improvisational” approachto technological change in which the major steps of change are defined in advance and theorganization then strives to implement these changes in a specified period of time.

Kurt Lewinhttp://muskingum.edu/%7Epsychology/psycweb/history/lewin.htmBiography, overview of planned change theory, timeline of his theoretical developments,and bibliography.

Kurt Lewin Institute homepagehttp://www.psy.vu.nl/kliDescribes the institute’s mission, training program, and current research.

ReferencesAyers, D. F. (2002). Developing climates for renewal in the community college: A case

study of dissipative self-organization. Community College Journal of research and practice,26, 165–185.

Bednash, G. (2003). Leadership redefined. Policy, Politics, & Nursing Practice, 4(4), 257–258.Bennis, W., Benne, K., & Chinn, R. (1969). The planning of change (2nd ed.). New York:

Holt, Rinehart, & Winston.


Bushy, A., & Kamphuis, J. (1993). Response to innovation: Behavioral patterns. NursingManagement, 24(3), 62–64.

Dye, C. F. (2000). Leadership in healthcare. Values at the top. Chicago: Health Adminis-tration Press.

Gardner, J. W. (1990). On leadership. New York: The Free Press.Heifetz, R. & Laurie, D. (2001). The work of leadership. Harvard Business Review, 79,

(11), 121–130.Knox, S., & Irving, J. A. (1997). Nurse manager perceptions of healthcare executive behaviors

during organizational change. Journal of Nursing Administration, 27(11), 33–39.Lewin, K. (1951). Field theory in social sciences. New York: Harper & Row.Lewis, L. K. (1999). Disseminating information and soliciting input during planned

organizational change. Management Communication Quarterly, 13(1), 43.Lippitt, R., Watson, J., & Westley, B. (1958). The dynamics of planned change. New York:

Harcourt, Brace & World.McDaniel, R. R. (1998). Strategic leadership: A view from quantum and chaos theories. In

W. J. Duncan, P. Ginter & L. Swayne (Eds.). Handbook of health care management.Oxford, England: Basil Blackwell Publishing.

Murphy, S. (1999). Mindshift for managers: Change is inevitable, growth is optional. HomeHealth Care Management and Practice, 11(2), 6–14.

Olson, E. E., & Eoyang, G. H. (2001). Facilitating Organization Change: Lessons fromComplexity Science. San Francisco: Jossey-Bass/Pfeiffer.

Perlman, D., & Takacs, G. J. (1990). The ten stages of change. Nursing Management,21(4), 33–38.

Pesut, D. (2000). Crusaders and tradition bearers. Nursing Outlook, 48(6), 262.Porter-O’Grady, T. (2003). A different age for leadership part 2: New rules, new roles. Journal

of Nursing Administration, 33(3), 173–178.Quinn, R. E., Spreitzer, G. M., & Brown, M. V. ( June 2000). Changing others through

changing ourselves. Journal of Management Inquiry, 9(2), 147–165.Scobie, K. B. & Russell, G. (2003). Vision 2020, Part I: Profile of the future nurse leader.

Journal of Nursing Administration, 33(6), 324–330.Senge, P. M. (1990). The Fifth Discipline. New York: Doubleday.Thietart, R. A., & Forgues, B. (1995). Chaos theory organization. Organization

Science,6(1), 19–31.Trent, B. A. (2003). Leadership myths. Reflections on Nursing Leadership, 29(3), 8–9.Wagner, C. M., & Huber, D. L. (2003). Catastrophe and nursing turnover: Nonlinear mod-

els. Journal of Nursing Administration, 33(9), 486–492.

BibliographyBozak, M. G. (2003). Using Lewin’s force field analysis in implementing a nursing

information system. Computers, Informatics, Nursing, 21(2), 80–87.Hallowell, B. (2003). Leadership and management. Tips on transforming an organization.

Healthcare Financial Management, 57(8), 64–65.Hill, J. E. (2003). New directions in nursing management. Journal of Nursing

Management,11(1), 4–5.Hilz, L. M. (2000). The informatics nurse specialist as change agent: Application of

innovation-diffusion theory. Computers in Nursing, 18(6), 272–281.


Jost, S. G. (2000). An assessment and intervention strategy for managing staff needs duringchange. Journal of Nursing Administration, 30(1), 34–40.

Lam, S. S. K., & Schaubroeck, J. (2000). A field experiment testing front-line opinion leadersas change agents. Journal of Applied Psychology, 85(6), 987.

McCarthy, A., Hegney, D., & Pearson, A. (2000). The perceptions of rural nurses towardsrole change within the context of organizational change. Australian Journal of AdvancedNursing, 17(4), 21–28.

Mee, C. L. (2003). Research, change, and reap the rewards. Nursing, 33(11), 6.Navarra, T. (March 6, 2000). Perspectives in leadership. A recipe for becoming a change

agent. Nursing Spectrum (New York/New Jersey Metro Edition), 12A(5), 6–7.Parse, R. R. (2003). Reflections on change. Illuminations, 11(3/4), 1.Sproat, S. B. (2003). Using organizational artifacts to influence change. Journal of Nursing

Administration, 31(11), 524–526.Szarmach, R. (2000). President’s message: Are you a change agent for the future? Surgical

Technologist, 32(8), 3.

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