Art & science I' ma nagement theory

Selecting the best theory to implement planned change

Improving the workplace requires staff to be involved and innovations to be maintained. Gary Mitchell discusses the theories that can help achieve this

Correspondence [email protected] .uk Abstract with restraining forces, such as poorly developed action plans, under-motivated staff, ineffective Gary Mitchell is a doctoral Planned change in nursing practice is necessary for communication and inappropriate leadership student at the school of nursing and midwifery, a wide range of reasons, but it can be challenging (Arkowitz 2002, O'Neal and Manley 2007). Price (2008) Queen's University, Belfast to implement. Understanding and using a change adds that nurses now feel 'bound by corporate theory framework can help managers or other change policies' and that health care currently changes Date of submission agents to increase the likelihood of success. This article October 22 2012 through 'revolution rather than evolution'. considers three change theories and discusses how one Change is vital to progress, yet the nursing Date of acceptance in particular can be used in practice. literature identifies numerous complexities associated February 42013 with transforming plans into action, and attempts Peer review Keywords at change often fail because change agents take This article has been subject to Theory of change, implementing change, an unstructured approach to implementation double-blind review and checked using anti plagiarism software organisational change (Wright 1998). It is important, therefore, that managers, or Author guidelines THERE ARE many ways of implementing change. change agents, identify an appropriate change theory www.nursingmanagement.co.uk However, planned change, which is a purposeful, or model to provide a framework for implementing, calculated and collaborative effort to bring about managing and evaluating change (Pearson et aI2005). improvements with the assistance of a change Equally important are the attributes of change agent (Roussel 2006), is the most commonly agents who are, according to Marquis and Huston adopted (Bennett 2003, Jooste 2004, Murphy 2006, (2008), skilled in the theory and implementation of Schifalacqua et aI2009a). planned change and who are often nurse managers. The Nursing and Midwifery Council (NMC) (2008) This is discussed in more detail later in the article. says nurses 'must deliver care based on the best available evidence or best practice', which suggests Change theories there is a continual need to update, or make changes Many authors have attempted to address how and to, practice. However, implementing change is more why changes occur, but the pioneer is, perhaps, challenging than it is sometimes perceived. Szabla Kurt Lewin. Lewin (1951) identified three stages (2007), for example, estimates that two thirds of through which change agents must proceed before organisational change projects fail, while Burnes change becomes part of a system (Figure I): (2004a) suggests that the figure is even higher. • Unfreezing (when change is needed). Various forces drive change in health care • Moving (when change is initiated). (Burritt 2005), including rising costs of treatments, • Refreezing (when equilibrium is established). workforce shortages, professional obligations, such He also discussed how certain forces can affect as clinical governance and codes of conduct, advances change, which he called force-field analysis. in SCience, an ageing population, the potential to Lewin's work was expanded and modified by increase patient satisfaction, and promotion of Rogers (2003), who described five phases of planned patient and staff safety. These are invariably coupled change: awareness, interest, evaluation, trial and adoption. Another change theorist, Ronald Lippitt (Lippitt et al (1958), identified seven phases. Tomey (2009) suggests that Lippitt's seven phases ( Unfreezing )I-----I.~( Moving )r-----t.~( RefreeZing ) and Rogers' five can be clustered within Lewin's three (Box 1). Box 1 also shows how change agents are motivated to change and affected members of staff Make are made aware of the need for change during Lewin's Take action changes permanent unfreezing stage. The problem is identified and, Make changes Establish new way through collaboration, the best solution is selected. Involve people of things Roussel (2006) suggests that unfreezing occurs '-Reward desired outcomes when disequilibrium is introduced into the system, creating a need for change. This corresponds directly period of care. Evaluation is ongoing and links to phase 1 of Rogers' theory: awareness. back to the assessment phase of the nursing Lippitt's theory, meanwhile, uses similar language process. This provides opportunity for regular to the nursing process (Tomey 2009) (Box 2), a model assessment of patient needs, which can become of nursing that has been used by nurses in the UK for more or less important during the care period. a number of years. It is comprised of four elements Lippitt's assessment stage, or phase 1, incorporates (Pearson et al2005) that are intrinsically linked: Lewin's unfreezing stage and Rogers' awareness • Assessment The nurse makes a detailed phase, but it also offers much more of a framework assessment of the patient that includes for change agents and includes assessment biographical details, relevant clinical history, social of motivation. details and medical observations. This phase is During Lewin's movement stage and Rogers' normally considered to be the initial part of the interest, evaluation and trial phases, change agents nursing process, even though activities continue gather all available information and solve any throughout a patient's period of care. problems, develop a detailed plan of change and test • Planning Following assessment, the nurse the innovation (Marquis and Huston 2008). collaborates with the patient, relatives and This corresponds with Lippitt's phase 2 multidisdplinary team wherever possible to (Box 2), which includes, for example, selection of determine how to address the needs of the patient. 'progressive change objectives', and is the stage at • Implementation This phase relates to the nurse which deadlines and responsibilities are assigned carrying out and documenting the care previously to team members. agreed at the planning stage. Lewin's refreezing stage corresponds with Rogers' • Evaluation This occurs often points during the adoption stage and Lippitt's implementation and

B 2 !l7'tt~~~~..:;;.;."",,~~~··~<,; : L-" ,'- ;,' '" ,. ox ~~:..~!~. .:~~ ...i<"''''~':-'~L.'''.':.L'l.!; ". __ , ;.' • Lewin Rogers Li ppitt Nursing process elements Li ppitt's theory

Unfreezing Awareness Phase 1. Diagnose the problem Assessment* Phase 1. Diagnose the problem Phase 2. Assess motivation Phase 2. Assess motivation/capacity for change and capacity for change Phase 3. Assess change agent's motivation I Phase 3. Assess change agent's and resources motivation and resources I Planningt Phase 4. Select progressive change objective Mov ing Interest I Phase 4. Select progressive Phase 5. Choose appropriate ro le of the Eva luation cha nge objective change agent I Trial f Phase 5. Choose appropriate Implementation:j: Phase 6 . Maintain change role of the change agent I Phase 6. Maintain change - Evaluation:j: Phase 7. Terminate the helping relationship Key: * Assessment = Lewin's unfreezing stage Refreez ing Adoption I Phase 7. Terminate the helping t Planning/implementation = Lewin's moving stage L relationship ~ Implementation/evaluation = Lewin's refreez ing stage (Adapted from Roussel 2006) (Lewin 1951, Lippitt et al1958, Pearson et a12005) Art & science management theory

evaluation stages (Box 2, phases 6 and 7). At this implementation and evaluation (Pearson et a12005). point, the change has been successfully integrated Throughout the remainder of the paper, Lippitt's in the system and strategies are developed to prevent theory is therefore used to demonstrate how a return to previous practices. Lippitt's stage of managers can implement planned change. 'maintaining the change' is crucial because successful change can often regress to former, outdated Leadership styles practices (Carney 2000, Cork 2005). Before embarking on change, managers may first While the three change theories described consider their strengths and weaknesses in terms above are similar problem-solving approaches to of their leadership skills, because these can greatly implementing planned change, they are also subtly affect the outcome of a change project (Cutcliffe different. It is up to nurse managers to select the and Bassett 1997). As various authors point out, most appropriate model based on the specific good leadership is not a prerequisite of management circumstances of their work environment. It is also (Gerrish 2003, Outhwaite 2003, Salter et a12009). worth noting that, although these three theories The literature suggests that leadership, effective are the most widely used, there are many others, communication and teamworking are among the most including Reddin (1989), Havelock (1995) and Leavitt important elements for planned change (Hewison and (Leavitt and Bahrami 1988). Stanton 2003, Jooste 2004, Schifalacqua et aI2009a). Burnes (2004b) acknowledges the relevance The role of leaders is multifaceted. Schifalacqua of Lewin's work half a century on, but highlights et al (2009a) state that an 'impassioned champion' is that his three-tiered approach attracts major essential in all change models, because they provide criticisms. It is argued, for example, that it is only inspiration, vision and support to everyone involved. suitable for small change projects, that it ignores Murphy (2006), meanwhile, suggests that leaders organisational powers and politics, that it is top should be seen as team players with the same goals down and management driven, and that it assumes as the rest of their team, rather than as stereotypical that organisations operate in stable states. organisational leaders. Lippitt's work is more detailed. While it requires Jooste (2004) sets out attributes of a greater level of understanding of change theory, it is effective leadership: likely to be more useful to nurse managers because it • Influence: leaders have an enormous role to play incorporates a more detailed plan of how to generate in influencing followers in the right direction, change and it is underpinned by the four elements and shortcomings in leaders' characteristics of the nursing process: assessment, planning, can lead to problems among followers. • Clarity: are workers clear about their tasks? Box 3 ~" .. __ ,_ , .' ~.; • Commitment: what do workers need from their leaders? Autocratic Democratic Laissez-faire I • Self-image: do followers know their own abilities, what they can and cannot accomplish? Strong control Less control mainta ined. I Little or no control. ma intai ned over group. • Price: what is the price followers payor the rewards they receive for working well. Oth ers motivated by Economi c and ego awards Motivated by support • Behaviour: does the leadership style promote coercion. are used to motivate, when requested. positive and effective behaviours among followers? There are various leadership styles, including Others are directed by Others are directed thro ugh Provides little or no autocratic, democratic and laissez-faire (Marquis and commands. gu idance and suggestio ns. direction , Huston (2008) (Box 3), and whichever one is adopted will affect the change in question. Co mmunicatio n flows I Comm un ication flows up Uses upwa rd-downward dow nward . and down. tco mmuni cati on. Autocracy Autocratic leadership is regarded as predictable, with a high level of prodUctivity, but Decision making does r Decision making invo lves Disperses decision maki ng often with low motivation, creativity and morale not invo lve others. others. throughout the group. (Marquis and Huston 2008). However, it can be useful Emphasis on different Emphasis is on 'we' ratd;er Pl aces emphasis on group . in crisis situations and is frequently seen in large status ('you' and 'I'). tha n 'you' and 'I'. bureaucracies. Autocracy is applicable when change is demanded, for example through the use of a top­ Critic ism is puni t iv e ' ~ ic i s m is constructive. Does not cri ticise. down approach, while democratic leadership is more appropriate for groups working together and where (Adapted from Marquis and Huston 2008) autonomy is promoted (Rycroft-Malone et a12002). Democracy Democratic leadership is useful when co-operation and co-ordination between groups are Positive factors/driving forces Negative factors/restraining forces necessary, so it is therefore a more appropriate style ----- l for implementing change (Tomey 2009). However, Boost job satisfaction Additional time costs in Marquis and Huston (2008) warn that it is often less normal consultations efficient than authoritative leadership.

Reduce workload in medium term Laissez-faire Meanwhile, a laissez-faire leadership Resistance from patients style can be non-directional and frustrating, and managers who adopt it tend to allow their Increase patient autonomy subordinates to take control (Roussel 2006). It is not • generally a useful style for planned changes, but it Closer working with local pharmacists can work when team members are highly motivated and self-directed, and can lead to greater creativity, motivation and autonomy than autocratic or Trouble insisting on staff conforming democratic leaderships (Benton 1999). More appropriate workload This style does, however, require multiple change agents and often there is much resistance from group • members (Delmas and Toffel 2008), where democracy Opportunities for professional Time spent inducting new staff tends to lead to better results in planned change development (Richens 2004). Having considered which change theory to adopt Once driving and restraining forces have been identified, change agents can and what style of leadership best suits the project, determine their relative strengths and rank these by numbers or, as illustrated, managers or change agents can begin to work by the thickness of arrows. towards achieving change. (Chambers et a/ 2006) Using Lippitt's change theory Lippitt's theory, alongside a democratic style of Phase 2 At this stage, motivation and capacity for leadership, is a popular and effective combination. change are assessed. It involves communicating with Phase 1 (Boxes 2 and 3) is concerned with diagnosing those who might be affected, responding to concerns the problem and is when a need for change and, if required, justifying the ch ge. Focus group has been noticed. Bennett (2003) recommends interviews are one way to achieve this (Carney 2000). undertaking a comprehensive literature review at This phase should also address resistance or, this pOint, or delegating this task to someone with as Lewin (1951) puts it, the 'driving and restraining good critical appraisal skills, to assess all available forces'. He suggests that both driving forces data and to use the findings to bolster the change (facilitators) and restraining forces (barriers) agent's position. operate during change, with driving forces advanCing a system towards change, while restraining forces Phase 1 Project management begins at this impede it (Marquis and Huston 2008). stage because this provides the framework for ReSistance to change is inevitable, and managers implementing change (Schifalacqua et aI2009a). would be naive to think otherwise (Baulcomb It involves developing a detailed plan or draft 2003, Cork 2005, Price 2008). Meanwhile, Roussel guideline of the proposed change, which should be (2006) suggests that change induces stress given to everyone likely to be affected (Bennett 2003, that in turn leads to resistance. However, using Guy and Gibbons 2003). However, Roussel (2006) force-field analysis can counter this resistance. warns nurse managers not to overplan and to leave some room for people to exercise their initiative. Force-field analysis This is a framework for problem It is also important to have an agreed and solving and planned change, developed by Lewin appropriate timescale, which can prevent alienation (1951). It illustrates that restraining forces cannot and increase the likelihood of success (Carney 2000). be removed and they can be countered only by Schifalacqua et al (2009a) warn not to underestimate increasing driving forces. One simple example can the 'power of the grapevine', so effective be used to illustrate this. A staff nurse does not communication should begin at phase 1 (Snow 2001) believe that a new infusion pump is better than a and is, in fact, integral to the entire change process previous model. The change agent cannot remove (Tomey 2009). this restraining force but can bolster the driving Art & science management theory

force by explaining why the new pump is more • Empirical-rational. effective and by organising training in how to use it. • Power-coercive. Figure 2 provides an example of a force-field analysis. • Normative re-educative. When the force-field analysis is completed, One of these can be selected at phase 5 to help guide change agents must develop strategies to reduce change (McPhail 1997). the restraining forces, which include issues such The empirical-rational strategy assumes that as fear of losing job satisfaction, or fatalism based people are rational and will adopt change if it can on previous failed change attempts (Tomey 2009). be justified and is in their self-interest. Meanwhile, They must also strengthen the driving forces by, power-coercive strategy is top down and assumes for example, increasing remuneration, promotional that people obey instructions from higher incentive, better recognition (Marquis and authorities, although Cut cliffe and Bassett (1997) Huston 2008). note that these instructions are usually accompanied by some sense of threat, such as job loss. Finally, Phase 3 With the capacity for change addressed, the normative re-educative strategy assumes that lippitt turns to phase 3: assessment of the change prOviding information and education will change agent's motivation (Box 2). Change agents are not people's usual behaviour patterns and help them always managers (Murphy 2006), nor do they have develop new ones (Tomey 2009). Most successful to be part of the organisation where change is being change projects require a combination of these introduced. External change agents can be more strategies (Strunk 1995). objective than internal ones, but can be costly, take more time to assimilate duties and be seen Phase 5 This phase focuses on chOOSing an as a threat by other team members (Roussel 2006, appropriate role for the change agent. Cooke Marquis and Huston 2008, Tomey 2009). (1997, 1998) says that change agents are an active part of the change process, particularly in terms Phase 4 This phase, the planning stage, is the point of managing staff and supporting change, and will at which the change process is defined and a final aim to transform intentions into actual change draft of the plan is developed, taking into account efforts at this stage. It might be useful to undertake the force-field analysis, change agents' status, staff another force-field analysis now, as resistance can attributes and cost. A timetable is drawn up to intensify at this point (McPhail 1997, Benton 1999, ensure cost-effective implementation of the change Roussel 2006, Tomey 2009). (Benton 1999) and each team member is assigned a responsibility. At this stage, change agents might Phase six This phase corresponds to the consider some broad change strategies. implementation stage of the nursing process (Box 2) (Pearson et a12005) and is concerned with I Change strategies Bennis et al (1985) describe maintaining the change so that it becomes a stable three groups of change strategies that are part of the system (Cooke 1998). During this phase appropriate for nurses wishing to implement change: the emphasis is on communication, feedback on progress, teamwork and motivation. Change agents need to use their interpersonal skills to inspire change, and having an Motivators understanding of motivation theory can support • Promotion opportun ities. this. For example, the Herzberg (1959) two- • Opportun iti es fo r persona l growth. Job factor motivation theory (Figure 3) proposes that • Recogn it io n. Job context satisfaction individuals have intrinsic and extrinsic needs, • Responsibility. described as satisfiers (motivators) or dissatisfiers • Achievement. (hygiene factors), which need to be fulfilled Hygiene factors (Bennett 2003). • Qu ali ty of supervision. If change agents strive to meet staff's intrinsic motivational needs, this is likely to increase • Pay. Job • Orga ni sati onal po li cies. job satisfaction and improve co-operation and dissatisfaction • Phys ical wo rk ing cond iti ons. ,.---,J....,Ob-CO~ performance, and could be achieved through praise, • Relations with others. 1.-<- continual feedback and effective communication • Job security. (Cubbon 2000). Ongoing training is important in this phase. (Adapted from Cubbon 2000, Cork 2005) Martin (2006) recommends training to support

• April 2013 I Volume 20 I Number 1 NURSING MANAGEMENT change because it allows the change to be recommends that change agents remain available embraced more effectively. Conversely, Cork for advice and reinforcement, since past behaviours (2005) suggests that training shows only how to can re-emerge and render even successful change behave in a certain system and not how to change useless. it. However, Schifalacqua et al (200gb) found that Finally, any change must be evaluated staff education and training was a pivotal part of to determine whether standards have improved. the change process. They claim that the relationship This can be done through clinical audit or patient between training and stabilising change is satisfaction surveys. not accidental. Good communication is a prominent feature Conclusion of every phase of the change process and almost Attempts to implement planned change face all researchers cite it as fundamental to effective numerous barriers, but using a framework, such as implementation (Robb 2004). Strong, open Lippitt's, proactively rather than retrospectively can communication across teams strengthens the help eliminate some of the potential problems, and Online archive chance of firmly embedding change by supporting address and act on others. the development of therapeutic relationships and However, while this will not guarantee success, For related information, visit since planned changes are vulnerable to failure our online archive of more removing barriers (Murphy 2006). than 7,000 articles and at every stage in all change theories, careful search using the keywords Phase 7 The final phase, 'terminating the helping consideration of change theory can Simplify the process', is evaluation and withdrawal of the change process for change agents and help those affected Conflict of interest agent on an agreed date, although Roussel (2006) by change to be more receptive to it. None declared

References Arkowitz H (2002) Toward an integrative Cubbon M (2000) Motivational theories for Marquis B, Huston C (200B) Leadership Roles Roussel L (2006) Management and Leadership perspective on resistance to change. Journal of clinical managers. Nursing Management. and Management Functions in Nursing: Theory for Nurse Administrators. Fourth edition. Jones Clinical Psychology. 58. 2. 219·22 7. 7,6,30-35. and Application. Sixth edition. lippincott and Bartlett, London. Williams & Wilkins, Philadelphia PA. Baulcomb J (2003) Management of change Cutcliffe J, Bassett C (1997) Introdudng change Rycroft-Malone J, Harvey G, Kitson A er al Ulrougb force field analysis. journal of Nursing in nursing: tbe case of research. Journal of Martin V (2006) Learning to lead. Nursing (2002) Getting evidence into practice: ingredients Management. 11.4.275-280. Nursing Management. 5.4,241-247. Management. 12,9, 34-37. for change. NurSing Standard. 16, 37, 38-43.

Bennett M (2003) The manager as agent of Delmas M, Toffel M (2008) Org-arnz-'-' -ati'-on-;'al -­ McPhail G (1997) Management of change: an Salter C, Green M, Ree M er al (2009) A study change. Nursing Management. 10. 7. 20-23. responses to environmental demands: opening essential skill for nursing in the I 990s. journal of of follower's personality, implidt leadership the black box. Strategic Management Journal. Nursing Management. 5,4, 199-205. perceptions and leadership ratings. journal of Bennis W. Benne K, Chin R (1985) The Planning 29, 10, 1027-1055. Leadership Studies. 2, 4, 48-60. of Change. Fourth edition. Holt, New York NY. Murpby F (2006) Using change in nursing Gerrisb K (2003) Evidence-based practice: practice: a case study approach. Nursing Scbifalacqua M, Coste!Jo C, Denman W (2009a) Benton D (1999) Assertiveness, power and unravelling the rhetoric and making it real. Management. 13,2,22-25. Roadmap for planned change, part 1: change influence. Nursing Standard. 13,52,48-52. Practice Development in Healthcare. 2, 2, 99-113. leadership and project management. Nurse Nursing and Midwifery Council (2008) The Burnes B (2004a) Managing Cha nge. Prentice Leader. 7, 2, 26-29. Guy K, Gibbons C (2003) DOing it by yourself. Code: Standards of Conduct, Performance and Hall, London. Nurs ing Management. 10.6. 19-23. Ethics for Nurses and Midwives. NMC. London. Schifalacqua M, Coste!Jo C, Denman W (2009b) Burnes B (2004b) Kurt Lewin and the planned Roadmap for planned change, part 2: bar-coded Havelock R (1995) The Change Agent's Guide. O'Neal H, Manley K (2007) Action planning: approach to change: a re-appraisal. journal of medication administration. Nurse Leader. Second edition. Educational Technology making change happen in clinical practice. Management Studies. 41, 6, 977-1002. 7,2, 32-35. Publications, Englewood Cliffs Nj. Nursing Standard. 21, 35, 35-39. Burritt J (2005) Organisational turnaround: the Snow J (2001) Looking beyond nursing for Herzberg F, Mausner H, Snyderman HB Outhwaite S (2003) The importance of leadership role of the nurse executive. Journal of Nursing dues to effective leadership. j ournal of NurSing (1959) The Motivation to Work. Second edition. in the development of an integrated team. Administration. 35, 11,482-489. Administration. 31, 9, 440-443. John Wiley, New York NY. journal of Nursing Management. 11, 6, 371-376. Carney M (2000) The development of a model to Strunk B (1995) The clinical nurse spedalist Hewison A, Stanton A (2003) From conflict to Pearson A, Vaughan B, Fitzgerald M (2005) manage change: reflection on a critical inddent as a change agent. Clinical Nurse Specialist. collaboration: contrasts and convergence in the Nurs ing Models for Practice. Third edition. in a focus group setting. An innovative approach. 9, 3, 128-132. development of nursing and management theory Butterworth-Heinemann, Oxford. journal of Nursing Management. 8, 5, 265-272. (2). journal of NurSing Management. 11 , 1, 15-24. Szabla D (2007) A multidimensional view of Price B (2008) Strategies to help nurses cope Chambers R, Wakley G, Blenkinsopp A (2006) resistance to organisational change: exploring Jooste K (2004) Leadership: a new perspective. with change in the healthcare setting. Nursing Supporting Self-care in Primary Care. Radcliffe cognitive, emotional and intentional responses journal of Nursing Management. 12, 3, 217-223. Standard. 22, 48, 50-56. Publishing. Abingdon. to planned change across perceived change Leavitt H, Babrami H (1988) Managerial Reddin W (1989) The Output Oriented Manager. leadership strategies. Human Resource Cooke B (1997) From process consultation to a Psychology: Managing Behaviour in Gower Publishing, A1dershot. Development Quarterly. 18,4,525-558. clinical model of development practice. Public Organisations. Fifth edition. University of Chicago Administration and Development. 17,3,325-340. Ricbens Y (2004) Getting guidelines into practice. Tomey A (2009) Guide to NurSing Management Press, Chicago IL Nursing Standard. 18, SO, 33-40. and Leadership. Eighth edition. Mosby Elsevier, Cooke B (1998) Partidpation, process and Lewin K (1951) Field Theory in Social Science. St Louis MO. management: lessons for development in the Robb M (2004) Changing methods of Tavistock Publications, London. history of organisation development. journal of communication. Nursing Management. Wright S (1998) Changing Nursing Practice. International Development. 10, 1, 35-54. lippitt R, Watson J, Westley-:B:-:: (1C::95:=8)-:::Dynamics 10,9, 32-35. Second edition. Hodder Arnold, London. of Planned Change. Harcourt, Brace, New Cork A (2005) A model for successful change Rogers E (2003) Diffusion of innovations. Fifth York NY. management. Nursing Standard. 19, 25,40-42. edition. Free Press, New York NY. Copyright of Nursing Management - UK is the property of RCN Publishing Company and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.