You and your colleagues have been talking about the possibility of developing self-scheduling on your unit. You believe that having RNs develop their own work schedule will promote professional collaboration, reduce absenteeism and overtime costs, and free up your manager’s time for other tasks. You’ve begun to do some homework — talking with nurses on other units who participate in self-scheduling and having the medical librarian provide you with articles on the topic. However, you’ve not been involved in leading a change project before, especially one that will directly affect your colleagues and manager. So how do you get started? What do you need to know about how change happens, what strategies to use to build support for your idea, and how to anticipate and manage possible resistance to a new way of doing things? This module will help you answer these questions.

You’re not the only person thinking about how your organization can perform more effectively. Chances are, you’ve been challenged to assume additional responsibilities, become cross-trained to cover another area, or learn to use sophisticated new equipment and technology. The pressure to flex and adapt to an unprecedented number of changes in the healthcare industry will continue to affect most aspects of your daily work life. By learning more about the process of change and how to make it work successfully, you can shape the future of nursing and healthcare.

Fire storm of change

Change in the healthcare industry is occurring at an unprecedented rate. In the last two decades, economic and political forces have combined to create tremendous pressure to control costs, ensure quality, and increase healthcare access.¹ Exciting advances in imaging technology, noninvasive treatments, sophisticated surgical procedures, increased spending for drugs, and the aging of the U.S. population continue to drive up costs. As a result of these forces, healthcare will continue to experience radical change. Organizations pursuing excellence must provide opportunities for individuals and groups to implement changes that are driven by evidence-based outcomes.²

Changes occur as a result of internal or external forces. Internal forces are created from within the organization or an individual. Examples of internal forces might involve a program for customer relations formulated by top management or a decision to purchase new technology. External forces for change originate outside the organization. Driven by regulatory requirements, consumer expectations, research findings, and technological advances, external forces can affect healthcare organizations dramatically. For example, the Health Insurance Portability and Accountability Act mandated specific privacy protections for patients and has required significant changes in ways patient information is managed in healthcare organizations.

Change can also be unplanned or planned. Nurses make unplanned changes every day. Unanticipated admissions, the need to transfer a patient to intensive care, or a staff member’s sick call are examples of unplanned change to which nurses respond skillfully. Planned change involves a deliberate analysis of the need for change, consideration of appropriate change strategies, and the selection of a change agent — the person who seeks to create the change.^1,3

Because the rising cost of hospital care is a major driving force necessitating change, coming up with ways to reduce costs while maintaining or improving quality can have a significant impact. Nurses have an astounding influence on the cost of care. The overall nursing department budget often accounts for over 50% of an acute care hospital’s total operating budget, and the majority of supplies are controlled by nurses as well.¹ Nursing’s ability to devise and champion ideas that can reduce the time spent on paperwork, manage supply costs, and evaluate procedures and processes plays a large role in cost containment.¹ Most importantly, the RN’s skill in assessing patients carefully, recognizing potential problems at an early stage, and using appropriate interventions quickly to prevent complications is vital for cost containment.¹

Change recipients or change agents?

The nursing profession has often been viewed as the target of change rather than a force that proposes, leads, and implements change. To be seen as powerful and effective change agents, nurses must learn more about change theory, change strategies, and ways to anticipate and manage resistance to change. Social theorist Kurt Lewin, PhD, developed a change model that is often used successfully in healthcare settings.^4,5 Lewin’s model views human behavior as a dynamic balance of forces that work in opposite directions. Driving forces are behaviors that help promote change while restraining forces are behaviors that impede change.⁵ For example, an organization that wants to change its staff mix to include more unlicensed assistive personnel will benefit from doing a force field analysis — an exercise that identifies both driving and restraining forces. Driving forces might include increased patient care hours, decreased costs, elimination of nonprofessional duties for RNs, and increased time for patient and family teaching. Restraining forces might be loss of control over patient care, concerns about supervising unlicensed staff, comfort with the status quo, and resistance to training new staff.¹ By doing a force field analysis, the change agent can evaluate the driving and restraining forces and devise strategies to increase driving forces while decreasing restraining forces.

Lewin’s change theory proposes that change occurs as a three-step process known as unfreezing, moving, and refreezing.⁵ Unfreezing refers to techniques that motivate staff to be aware of the coming change and that build recognition of the need for change. In the unfreezing phase, discomfort with the present state is felt, and the status quo is questioned. In the moving phase, problems are assessed and analyzed, options and alternatives are identified, and action occurs. In the refreezing phase, new ways of behavior are integrated into working relationships, and efforts are made to ensure the change will be sustained.⁵

Making changes on the front lines

Nurse managers face many challenges as change agents. Let’s say two nurse managers are faced with implementing a change in their staffing mix. To successfully implement such a change, the managers must select the most appropriate change strategy. Frequently used options include power-coercive, rational-empirical, and normative-re-educative strategies.^3,6

People with legitimate organizational authority can use a power-coercive strategy to produce change.^1,7 Changing from fee-for-service reimbursement to prospective payment using diagnostic related groups (DRGs) to help control Medicare costs is an example of a power-coercive strategy implemented by the federal government.⁷ Those affected by a power-coercive strategy have the choice of accepting the change or leaving the organization. However, using power and coercion often creates considerable resistance. Although a power-coercive strategy may appear draconian, it is an appropriate and effective strategy in selected situations. For example, organizational leadership may have no choice but to use this strategy when faced with significant resistance to change that is crucial for the survival of the organization.

A power-coercive strategy may also be used to force a change for the common good when there is an expectation that implementing the change will lead to a change in values. The racial desegregation laws of the 1960s are examples of changes mandated by law to provide equal opportunity, based on the assumption that promoting interracial contact would lead to a change in attitudes and beliefs.⁷

A rational-empirical strategy is based on the assumption that people are rational and will act in their own self-interest if they have enough information.^1,3,7 This strategy assumes that a change agent can persuade others to accept a change through a rational appeal to self-interest.^1,3,7 For example, if your manager outlined a new method of giving a report that would save you time, it would be consistent with your personal self-interest — finishing your shift on time. Rational-empirical strategies are appropriate when the change is seen as reasonable and little resistance is expected, such as when introducing new technology, especially when staff can be convinced that the change will save nursing time and improve patient care.

Normative-re-educative strategies are based on the assumption that people are strongly influenced by social norms and values. A normative re-educative strategy depends on the change agent’s skill with interpersonal relationships.⁷ Using this strategy, the change agent involves those who will be most affected by the change. The change agent considers people factors as important to the success of the change process as knowledge and technology.¹

When the change agent and the group planning the change have conflicting views, the process is halted until the conflict is resolved.¹ In most situations, a normative-re-educative strategy is effective in stimulating creativity and reducing resistance; the downside is the time required for group consensus and conflict resolution.^1,7

Two nurse managers faced with making a change in their staffing mix chose different strategies. The first used a rational-empirical strategy, educating the staff about the reasons for the change and the positive results the change would produce. Staff attitudes or feelings about the change were not discussed. When presented with a new staffing plan and an implementation date, the nursing staff rebelled and threatened to resign.¹ The second manager, faced with the same problem, selected a normative-re-educative strategy. He introduced the proposed change and invited staff reactions. The manager listened carefully to staff opinions and concerns and invited the staff to propose suggestions to make the change more acceptable to them. After further discussion, the staff agreed to use a trial unit to test the new staffing model.¹

In using the rational-empirical strategy, the first nurse manager failed to take into account the strong beliefs and attitudes RNs often have about care delivery models and the quality of patient care. When a change affects the use of time or beliefs about nursing practice and quality of care, a normative-re-educative strategy is often a more appropriate strategy for successful change. A recent research study looked at cultural changes in three large nursing homes. The researchers found that enabling factors included having a critical mass of “change champions;” staff, residents, and family members sharing goals; and supporting empowerment at the unit level. ⁸

‘It won’t work’

Although change is necessary for growth, it often produces anxiety.⁷ And even when change is carefully planned and anticipated, such as a move into a new facility, it can create negative stress because change always involves the experience of loss.⁷ Most people prefer what is familiar and comfortable and have a natural tendency to question change, especially if it means a change in values or beliefs.¹ In healthcare, some old habits are hard to change. For example, all physicians and nurses are familiar with the safety measure of prolonged preoperative fasting. However, research has shown that pulmonary aspiration is rare with modern anesthesia techniques. As a result, the American Society of Anesthesiology published recommendations in 1999 to allow clear liquids up to two hours before elective surgery, a light breakfast six hours before a procedure, and a heavier meal eight hours preoperatively. Despite these research-based recommendations, studies show that the majority of patients are NPO a great deal longer than the recommended time frame.⁹

Innovators and laggards

Reaction to change ranges from eager acceptance to frank resistance and even sabotage. Rogers a noted researcher on the diffusion of innovations, identified five types of response to change:¹⁰

• Innovators — those who love change and thrive on it
• Early adopters — those who are usually receptive to change. They are opinion leaders and willing to try out new ideas in a thoughtful way.
• Early majority — thoughtful people who accept change more quickly than the average
• Late majority — people who initially resist change, but accept change after the majority
• Laggards — those who dislike change and are openly critical and antagonistic

Based on Rogers’ work, a change agent should not try to persuade the majority of people to accept a controversial idea. Instead, he or she can start influencing innovators and early adopters and enlist their support. Because change disrupts the status quo, resistance should be anticipated as part of the process. Resistance may be overcome by involving those who will be most affected and helping them to see the benefits of the change.² Some resistance to change can improve the process because it forces the change agent to be very clear about why the change is needed and the steps needed to implement it. However, if resistance persists after a change is carried out, it can divert energy away from making the change successful.⁷ To manage resistance, the change agent can use techniques such as determining the root cause of concern, clarifying information, and outlining the negative consequences of resistance and the positive aspects of the change.

One expert emphasizes that change agents should not spend an inordinate amount of time analyzing reasons for resistance, because resistance often arises from irrational beliefs.⁷ Whatever the change anticipated, throughout the process, the change agent should maintain a climate of trust, support, and confidence.⁷

There are losses in any change process, and failure to acknowledge losses is one reason some change efforts fail.¹ For example, nurses who have viewed themselves as experts with a current documentation system may feel threatened at being novices when using a new computerized system.¹ Factors often associated with resistance to change include poor timing of the change, inadequate presentation of the need for change, weaknesses in the change proposal, fear of loss of control, lack of trust, comfort with the status quo, uncertainty about the effects of the change, and the need to expend additional personal energy to adapt to the change.¹

They took the lead

RNs can stimulate change in nearly any setting. Here are examples of nurses who changed the “system” to improve patient care:

School nurses in San Diego, Calif., changed their approach to managing students with asthma. Students who received at least one school nurse case management intervention were more likely the following year to have an asthma medication at school, use a peak flow meter at school, and have an improvement in asthma severity.¹¹

Nurses at a hospital in Wisconsin changed the frequency and timing of activated clotting time (ACT) levels for patients who had percutaneous coronary interventions. The change saved the hospital about $5,000 in nursing time.¹²

Nurses in a day surgery unit in England used change strategies collaboratively to develop a nurse-led elective cardioversion service for patients with atrial fibrillation. Patient waiting times, procedural success, and complication rates are improved as a result of this change project.¹³

Canadian neuroscience nurses working on an acute stroke unit used a decision-making algorithm to improve the dietary management of patients with dysphagia.

The change to early and ongoing assessment of swallowing function and focused interventions resulted in substantial increases in swallowing function during hospitalization.¹⁴

Nurses working in today’s healthcare environment must view change as a part of life and seek ways to become involved in the change process. As the largest healthcare profession, nurses make the healthcare system run — and many nurses have great ideas about how to make healthcare organizations run better. Nurses who can propose and implement changes that help control costs, improve patient care, or provide new services can strengthen nursing’s image and experience a high level of professional satisfaction.