NURS 236A

Module 7

Phyllis M. Connolly, PhD, APRN-BC, CNS

 

Change is inevitable

Purpose

The need for change within yourself as a leader will be explored. You will review and analyze a variety of change theories and models. Completion of this module will assist you in selecting an appropriate change theory/model for a specific nursing administration problem.

 

Learning Outcomes

After completing this module you will be able to:

 

        Analyze and apply change theories

        Select a change theory to be used in your synthesis paper

        Apply strategies for change

        Explore multiple online resources related to change

 

 

Required Learning Activities

1. Read

 

a.      AACN (January 2002). White Paper: Hallmarks of the Professional Nursing Practice Environment available at http://www.aacn.nche.edu/Publications/positions/hallmarks.htm

 

b.      AACN (May, 2003) Draft AACN White Paper: The  Role of the Clinical Nurse Leader, May 2003 is available at http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htm

 

c.       Baulcomb, J. S. (2003). Management of change through force field analysis. Journal of Nursing Management, 11(4), 275 � 280.

 

d.      Bennet, M. (2003). Implementing new clinical guidelines: The manager as agent of change. Nursing Management, 10(7), 20 � 23.

 

e.      Fontaine, D., Gerardi, D. (2005). Healthier hospitals? Nursing Management, 36(10),34 � 44.

 

f.        Larrabee, S. B. (1999). Benner�s novice to expert nursing theory applied to the implementation of laptops in the home care setting. Home Health Care Management & Practice, 11(5), 41 � 47.

 

g.      Ritter-Teitel, J. (2002). The impact of restructuring on professional nursing practice. The Journal of Nursing Administration, 32(1), 31 � 41.

 

h.      Valentine, N. (2001). Quality measures essential to the transformation of the Veterans Health Administration: Implications for nurses as co-creators of change. Journal of Nursing Care Quality, 15(4), 48 � 59.

 

i.        View http://atn7.sjsu.edu/webcontent/nurs236a010904/trainer.rm for a discussion about change from one of the community nurse leaders, Joan P. Smith, Director of Patient Care Services at Santa Clara Valley Medical Center

 

2. Post Responses by December 1, 5:00 PM to the following situations:

 

Situation A: You are the nurse managers responsible for organizing and implementing the change to implement the AACN�s new nursing role: The �new nurse� the Clinical Nurse Leader (AACN) draft  Role of the Clinical Nurse Leader, May 2003 is available at http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htm and the update at http://www.aacn.nche.edu/Publications/positions/cnssupport.htm . Briefly describe which change theory or theories and strategies that will facilitate the change. Support your approach from the assigned readings.

 

If your name begins with an �A� through �M� you will respond in the Discussion Board to Situation A.The first person whose name begins with �M� will summarize the responses for the group include (N = ) and the name of each person. The person who is summarizing will present the summary during class on December 7.

 

Situation B: You are the staff nurses on the unit where the new nursing role of Clinical Nurse Leader (AACN) will be implemented. Describe what is happening on the unit with the introduction of the change. Refer to assigned readings to label what processes are being used and the reactions of the staff nurses.You are all BSN nurses. You will want to review the draft AACN White paper The  Role of the Clinical Nurse Leader, May 2003available at http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htmand the Statement of Support for the CNS found at http://www.aacn.nche.edu/Publications/positions/cnssupport.htm

 

If your name begins with �N� through �Z� you will respond in the Discussion Board to Situation B. The first person whose name begins with an �R� will summarize the responses for the group; include (N = ) and the name of each person. The summarizer will presentthe summary during class on December 7.

 

Note: for both participants in Situation A and B, review comments from both groups as you prepare your responses. The Clinical Nurse Leader is in �Draft� form thus still demands discussion.

 

�Mini-Lecture�

 

�When you change yourself you change the world� (Wilson & Porter-O�Grady, 1999, p. 230)

 

Clearly, change is inevitable however, how and what leaders do to prepare for change is as important as planning and implementing change. Wilson and Porter-O�Grady (1999) claim that some leaders exposed to the fast-paced information age and high tech life-style may find themselves obsessed with outcomes and products. They tend to focus on the doing of something rather than the process. The authors (1999) state that �the greatest challenge for health care organizations is not change but the capacity to respond to change in a manner that does not diminish integrity in service� (p. 276). There is a need to create what does not exist rather than reinventing the past. Emphasis must be placed on organizing around process which meets customer, competition and change,--the driving forces of today�scompanies. The challenge is to create a new context of health care across the continuum of care which calls for new views of how work is organized, authority relationships, and control of work, flexible roles and the interdependence of stakeholders (1999). Challenging limiting beliefs is one of the basic tasks as we move towards creating a new context of care. Go to the Communication initiative website for some examples of techniques which help people to challenge limiting beliefs based on Neuro Linguistic Programming (NLP)  they can be found at http://www.comminit.com/ctheories/sld-4122.html

 

Determining where the nurse administrator may need to change before requiring others to change is accomplished through reflection and journaling as suggested by Wilson and Porter-O�Grady (1999).The following are questions to consider (pp. 228 � 230).

 

1. Am I current? Do I appreciate contemporary events, philosophy, religion economics, art and music, literature, science, psychology and business development?

 

2. Am I plugged in? Am I connected to the main body of people and events shaping my profession and my personal life?

 

3. Do I see the dark side of good? The dark side of joy is sadness. The dark side of achievement isno time for family.

 

4. Do I accept the fact that anything carried to an extreme can become absurd? Values can lead to absurd actions.

 

5. Am I sure that I have not become self righteous in my choices about my professional and personal life?Pride in the illusion that one has achieved the right answer is disastrous for leaders.

 

6. Do I recognize that I will never become ideologically correct ifIam to grow as a leader? This is a tough question for the rigid, the fearful, or the opinionated.

 

7. Am I willing to grow with those I lead to the cutting edge and in so doing evoke the censure of those who do not wish to grow? Cutting edge people are pushing the boundaries of the frontiers of knowledge and experience.

 

8. Am I sensitive to the needs and aspirations of all those who may be affected by what I say, think, or do? Do you take the time to listen and reflect upon what you are hearing?

 

9. How well do I accept that compromise is the right answer? What is the right action for me may not fit with the diversity of right actions of others involved in certain situations.

 

10. Do I have a realistic view of myself upon which greater leadership can be built? This is the most difficult of perspectives to see oneself as one really is.

 

The practice environment for nursing is frequently cited as the most demanding across all settings and therefore must change (AACN, 2002). This change is also identified as a major factor in patient safety and quality care as well as a strategy in counteracting the nursing shortage and increasing tenure. Go to  the American Association of Colleges of Nursing (AACN) website for the AACN White Paper: Hallmarks of the Professional Nursing Practice Environment http://www.aacn.nche.edu/Publications/positions/hallmarks.htmfor the characteristics of the practice setting which supports professional nursing practice. The characteristics are believed to  allow baccalaureate and higher degree nurses to practice at their fullest. AACN has identified the �Clinical Nurse Leader� also called the �New Nurse� as the nurse prepared to respond to the changes needed in the health care system across all settings. A draft White Paper: The Role of the Clinical Nurse Leader, May 2003 is available at http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htm and the Statement of Support for Clinical Nurse Specialist found athttp://www.aacn.nche.edu/Publications/positions/cnssupport.htm . One of the Power Point Presentations on the topic,a View from Practice by Cathy Rick, Chief Nursing Officer, Department of Veterans Affairs during the Pre-Conference on the New Nursing, October 24 � 25, 2003,is available with this module with the Power Points for this course.

There are a number of models and theories of change which you will find in the literature and several of the assigned articles provide examples of applications of change based on specific models (Baulcomb, 2003;Larrabee, 1999). Many are very similar to the nursing process, all require energy. Larrabee (1999) utilized Benner�s novice to expert framework to guide the implementation of laptops for nurses working in home health. The work is an example of the performance expectations that need to be incorporated when instituting a new task at each of Benner�s  stages (a) novice , (b) advanced beginner, (c) competent, (d) proficient, and (e) the expert. Keeping the perspective of the continuous learner the use of the Benner stages facilitates growth and development and can be applied to many introductions of innovations.

There are a number of theories and models of change which you can explore at the Communication Initiative web site http://www.comminit.com/change_theories.html. Each of the pages with the various models can be evaluated and you can submit your evaluation which will be helpful to the Project. A visual of the steps of change, the Diffusion Model, which you may find helpful is located at http://www.comminit.com/ctheories/sld-2937.html. Another interesting model is the Innovation Process in Organizations found at http://www.comminit.com/ctheories/sld-2938.html. Organizing stakeholders can be found at http://www.comminit.com/ctheories/sld-8722.html. Yet, another theory which you may be familiar with from NURS 204 and NURS 200 is Precede-Proceed used for implementing health promotion programs. To see several change theories/models compared go to http://www.comminit.com/ctheories/sld-2928.html. Finally, a visual of a planning model, the COAST Model can be seen at http://www.comminit.com/pmodels/sld-2781.html.

Below a table compares some of the more common models of Change.

 

Lewin�s Force Field Model

Havelock�s Model, Six-Step

Roger�s Diffusion Model

Lippitt�s Seven Step

Increase driving forces

 

Decrease restraining forces

 

1. Building a relationship

 

2. Diagnosing the problem

 

1. Knowledge, awareness

Based on the consultant model

 

1. Diagnose the problem

1. Unfeezing

 

Motivate participants, get them ready for change

Active participation & generation of alternative solutions

 

3. Acquiring resources

 

4. Choosing the solution

 

5. Gaining acceptance

2. Persuasion

 

2. assess motivation, emphasis is on involvement of key members of target system

Communication skills

Rapport building

Problem solving

 

3. Assess change agent�s motivation & resources

 

4. Select progressive change objects

 

5. Choose change agent role

 

2. Moving

Participants agree status quo must go

View problem with new perspective

Link with view of respected or powerful leader who supports change

Help scan environment to search for relevant information

 

 

3. Decision

 

 

4. Implementation

 

3. Refreezing

Reinforce new patterns of behavior

Institutionalize through formal and informal mechanisms e.g. policies, communication channels

6. Stabilization & self renewal

5. Confirmation , adoption

6. Maintain change

 

Terminate helping relationships

From a system�s perspective any change in one part results in change in any other part of the system. It is extremely important to identify the relationship between subsystems to anticipate possible unintended reactions. For quick review of systems properties go to http://ide.ed.psu.edu/change/theory/systems-characteristics-3.htm. In general, all change models include the following steps:

1. Recognizing the need for change

2. Diagnosing the problem

3. Analyzing alternative solutions

4. Selecting the change, if needed

5. Planning the change

6. Implementing the change

7. Evaluating the change

8. Stabilizing the change.

How people respond to change is very important, Rodgers (1983) categorized the types of responses in the following ways:

        Innovators, love change and thrive

        Early adopters

        Early majority, prefer status quo, but change

        Late majority, resistive, accept after most others

        Laggards, dislike change and are openly antagonistic

        Rejectors, actively oppose, and may even sabotage.

Some have compared the responses to change to those responses labeled in the Kubler-Ross grief response: denial, anger, bargaining, depression and acceptance. However, caution should be taken in applying the grief model in organizational settings since this research was completed on folks in the process of dying.

 

Strategies for change vary and will depend on the amount of anticipated resistance, and the degree of power of the change agent (Sullivan & Decker, 2001). The chart below provides and overview of change strategies. Please note that the strategy of timing and Incrementalism are based on my own 43 years of nursing experience.

 

Strategy

 

Definition

Power-coercive

Legitimate authority, economic sanctions, or political clout e.g. Laws, policies, financial appropriations, regulations, accrediting bodies

 

Empirical-rational model

Assume that people are rational and will follow self-interest if that self-interest is made clear e.g. new technology will save person time & improve care.

 

Normative-reeducative

Based on the assumption that people act in accordance with social norms & values, e.g. evidence-based practice, quality circles, CQI results.

 

Timing

The opportunity for a change frequently is enhanced because of timing, e.g. a change in organizational structure; a new law, or a new administrator. A proposed change may not have been possible earlier, however, at a future point in time it may be feasible.

 

Incrementalism

A smaller piece of a whole change may be possible and builds toward the desired change.

 

You will need to apply one of the theories/models of change in your synthesis paper and having completed this module you should have the knowledge and skills to complete the assignment.

 

Please go to URL http://atn5.sjsu.edu:8080/ramgen/presenter/nurs236a010904/trainer.smi���� for a discussion about change from one of the community nurse leaders, Joan P. Smith, Director of Patient Care Services at Santa Clara ValleyMedical Center.

 

References

 

 

AACN (January 2002). White Paper: Hallmarks of the Professional Nursing Practice

Environmentretrieved December 9, 2003, from http://www.aacn.nche.edu/Publications/positions/hallmarks.htm.

 

AACN (May, 2003). Draft AACN White Paper: The  Role of the Clinical Nurse

Leader, May 2003 retrieved January 1, 2004 from http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htm

 

AACN (2005). Position Statement: Statement of Support for Clinical Nurse Specialist, retrieved July 2, 2006 from

����������� http://www.aacn.nche.edu/Publications/positions/cnssupport.htm

 

Baulcomb, J. S. ( 2003). Management of change through force field analysis. Journal

of Nursing Management, 11(4), 275 � 280.

 

Bennet, M. (2003). Implementing new clinical guidelines: The manager as agent of

����������� change. Nursing Management, 10(7), 20 � 23.

 

Fontaine, D., Gerardi, D. (2005). Healthier hospitals? Nursing Management, 36(10), 34 � 44.

 

Larrabee, S. B. (1999). Benner�s novice to expert nursing theory applied to the

implementation of laptops in the home care setting. Home Health Care Management & Practice, 11(5), 41 � 47.

 

Nyberg, J. (1998). ). A caring approach in nursing administration. eBook ISBN 

0585042446, Niwot, CO: University Press of Colorado. On reserve in SJSU 

library.

 

Nyberg, J. (1998). A caring approach in nursing administration. Niwot, CO: University

�������� Press of Colorado.

 

Ritter-Teitel, J. (2002). The impact of restructuring on professional nursing practice.

The Journal of Nursing Administration, 32(1), 31 � 41.

 

Rogers, E. (1983). Diffusion of innovations(3rded.). New York: Free Press.

 

Sullivan, E. & Decker, P. (2001). Effective leadership and management in nursing (5th 

����������� ed.). Upper Saddle River, NJ: Prentice Hall.

 

Swansburg, R. C, & Swansburg, R. J. (1999). Introductory management and leadership 

����������� for nurses (2nded.). Sudbury, MA: Jones and Bartlett Publishers.

 

Valentine, N. (2001). Quality measures essential to the transformation of the Veterans

Health Administration: Implications for nurses as co-creators of change. Journal of Nursing Care Quality, 15(4), 48 � 59.

 

Wilson Krueger, C., & Porter-O�Grady, T. (1999). Leading the revolution in health care: 

���� Advancing systems, igniting performance ( 2nd ed.). Gaithersburg, MD: Aspen.

 

Last Modified: Jan 14, 2015