PICOT Statement Paper
Art & science | management theory
Correspondence
GmitchellO8@qub.ac.uk
Gary Mitchell is a doctoral student at the school of nursing and midwifery. Queen's University, Belfast
Date of submission October 22 2012
Date of acceptance February 4 2013
Peer review
This article has been subject to
double-blind review and checked
using antipiagiarism software
Author guidelines
www.nursingmanagement.co.uk
Selecting the best theory to implement planned change Improving the workplace requires statf to be involved and innovations to be maintained. Gary Mitchell discusses the theories that can help achieve this
Abstract Planned change in nursing practice is necessary for
a wide range of reasons, but it can be challenging
to implement. Understanding and using a change
theory framework can help managers or other change
agents to increase the likelihood of success. This article
considers three change theories and discusses how one
in particular can be used in practice.
Keywords
Theory of change, implementing change,
organisational change
THERE ARE many ways of implementing change. However, planned change, which is a purposeful, calculated and collaborative effort to bring about improvements with the assistance of a change agent (Roussel 2006), is the most commonly adopted (Bennett 2003, Jooste 2004, Murphy 2006, Schifalacqua et al 2009a).
The Nursing and Midwifery Council (NMC) (2008) says nurses 'must deUver care based on the best available evidence or best practice', which suggests there is a continual need to update, or make changes to, practice. However, implementing change is more challenging than it is sometimes perceived. Szabla (2007), for example, estimates that two thirds of organisational change projects fail, while Burnes (2004a) suggests that the figure is even higher.
Various forces drive change in health care (Burritt 2005), including rising costs of treatments, workforce shortages, professional obligations, such as clinical governance and codes of conduct, advances in science, an ageing population, the potential to increase patient satisfaction, and promotion of patient and staff safety. These are invariably coupled
with restraining forces, such as poorly developed action plans, under-motivated staff. Ineffective communication and inappropriate leadership (Arkowitz 2002, O'Neal and Manley 2007). Price (2008) adds that nurses now feel 'bound by corporate policies' and that health care currently changes through 'revolution rather than evolution'.
Change is vital to progress, yet the nursing Uterature identifies numerous complexities associated with transforming plans into action, and attempts at change often fail because change agents take an unstructured approach to implementation (Wright 1998).
It is important, therefore, that managers, or change agents, identify an appropriate change theory or model to provide a framework for implementing, managing and evaluating change (Pearson ef al 2005).
Equally Important are the attributes of change agents who are, according to Marquis and Huston (2008), skOled in the theory and implementation of planned change and who are often nurse managers. This is discussed in more detail later in the article.
Change theories Many authors have attempted to address how and why changes occur, but the pioneer is, perhaps, Kurt Lewin. Lewin (1951) identified three stages through which change agents must proceed before change becomes part of a system (Figure 1): • Unfreezing (when change is needed). • Moving (when change is initiated). • Refreezing (when equilibrium is established). He also discussed how certain forces can affect change, which he called force-field analysis.
Lewin's work was expanded and modified by Rogers (2003), who described five phases of plarmed change: awareness, interest, evaluation, trial and
M April 2013 I Volume 20 | Number 1 NURSING MANAGEMENT
adoption. Another change theorist, Ronald Lippitt (lippitt et al (1958), identified seven phases.
Tomey (2009) suggests that Lippitt's seven phases 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 are made aware of the need for change during Lewin's unfreezing stage. The problem is identified and, through collaboration, the best solution is selected.
Roussel (2006) suggests that unfreezing occurs when disequilibrium is introduced into the system, creating a need for change. This corresponds directly to phase 1 of Rogers' theory: awareness.
Lippitt's theory, meanwhile, uses simuar language to the nursing process (Tomey 2009) (Box 2), a model of nursing that has been used by nurses in the UK for a number of years. It is comprised of four elements (Pearson et al 2005) that are intrinsically linked: • Assessment The nurse makes a detailed
assessment of the patient that includes biographical details, relevant clinical history, social details and medical observations. This phase is normally considered to be the initial part of the nursing process, even though activities continue throughout a patient's period of care.
• Planning Following assessment, the nurse collaborates with the patient, relatives and multidiscipUnary team wherever possible to determine how to address the needs of the patient.
• Implementation This phase relates to the nurse carrying out and documenting the care previously agreed at the planning stage.
• Evaluation This occurs often points during the
parison of change theories
Lewin
Unfreezing
Rogers Lippitt
Examine
status quo
Increase (Jriving
forces for change
Take action
Make changes
Involve people
Make ^
changes permanent
Establish new way
of things
VReward desired outcomes
period of care. Evaluation is ongoing and links back to the assessment phase of the nursing process. This provides opportunity for regular assessment of patient needs, which can become more or less important during the care period.
Lippitt's assessment stage, or phase 1, incorporates Lewin's unfreezing stage and Rogers' awareness phase, but it also offers much more of a framework for change agents and includes assessment of motivation.
During Lewin's movement stage and Rogers' interest, evaluation and trial phases, change agents gather all available information and solve any problems, develop a detailed plan of change and test the innovation (Marquis and Huston 2008).
This corresponds with lippitt's phase 2 (Box 2), which includes, for example, selection of 'progressive change objectives', and is the stage at which deadlines and responsibilities are assigned to team members.
Lewin's refreezing stage corresponds with Rogers' adoption stage and Lippitt's implementation and
IjWJL Lippitt's theory compared with the nursing process ^ ^ "
Nursing process elements Lippitt's theory
Awareness Phase 1. Diagnose the problem
Phase 2. Assess motivation
and capacity for change
Phase 3. Assess change agent's
motivation and resources
Moving
Refreezing
Interest
Evaluation
Trial
Adoption
Phase 4. Select progressive
change objective
Phase 5. Choose appropriate
role of the change agent
Phase 6. Maintain change
Phase 7. Terminate the helping
relationship
(Adapted from Roussel 2006)
Assessment* Phase 1. Diagnose the problem
Phase 2. Assess motivation/capacity for change
Phase 3. Assess change agent's motivation
and resources
Planning! Phase 4. Select progressive change objective
Implementation^:
Evaluation^:
Phase 5. Choose appropriate role of the
change agent
Phase 6. Maintain change
Phase 7. Terminate the helping relationship
Key: 'Assessment = Lewin's unfreezing stage t Planning/implementation = Lewin's moving stage t Implementation/evaluation = Lewin's refreezing stage
(Lewin 1 9 5 1 , Lippitt ei a / 1 9 5 8 , Pearson ef a / 2 0 0 5 )
NURSING MANAGEMENT April 2013 i Volume 20
Art & science management theory
evaluation stages (Box 2, phases 6 and 7). At this point, the change has been successftüly integrated in the system and strategies are developed to prevent a return to previous practices. Lippitt's stage of 'maintaining the change' is crucial because successftü change can often regress to former, outdated practices (Carney 2000, Cork 2005).
Whüe the three change theories described above are simuar problem-solving approaches to implementing planned change, they are also subtly different. It is up to nurse managers to select the most appropriate model based on the specific circumstances of their work environment. It is also worth noting that, although these three theories are the most widely used, there are many others, including Reddin (1989), Havelock (1995) and Leavitt (Leavitt and Bahrami 1988).
Bumes (2004b) acknowledges the relevance of Lewin's work half a century on, but highlights that his three-tiered approach attracts major criticisms. It is argued, for example, that it is only suitable for small change projects, that it ignores organisational powers and poUtics, that it is top down and management driven, and that it assumes that orgarüsations operate in stable states.
Lippitt's work is more detailed. Whüe it requires a greater level of understanding of change theory, it is likely to be more useful to nurse meinagers because it incorporates a more detaued plan of how to generate change and it is tmderpinned by the four elements of the nursing process: assessment, planning.
^^Qplhar'acteristics of three leadership styles ^ |
Autocratic
Strong control
maintained over group.
Others motivated by
coercion.
Others are directed by
commands.
Communication flows
downward.
Decision mai<ing does
not involve others.
Emphasis on different
status ('you' and T).
Criticism is punitive.
Democratic
Less control maintained.
Economic and ego awards
are used fo motivate.
Others are directed through
guidance and suggestions.
Communication flows up
and down.
Decision making involves
others.
Emphasis is on 'we' rather
than 'you' and '1'.
Criticism is constructive.
Laissez-faire
Little or no control.
Motivated by support
when requested.
Provides little or no
direction.
Uses upward-downward
communication.
Disperses decision making
throughout the group.
Places emphasis on group.
Does not criticise.
(Adapted from Marquis and iHuston 2 0 0 8 )
implementation and evaluation (Pearson et al 2005). Throughout the remainder of the paper, Lippitt's theory is therefore used to demonstrate how managers can implement planned change.
Leadership styles Before embarking on change, managers may first consider their strengths and weaknesses in terms of their leadership skills, because these can greatly affect the outcome of a change project (Cutcliffe and Bassett 1997). As various authors point out, good leadership is not a prerequisite of management (Gerrish 2003, Outhwaite 2003, Salter et al 2009).
The literature suggests that leadership, effective communication and teamworking are among the most important elements for planned change (Hewison and Stanton 2003, Jooste 2004, Schifalacqua et al 2009a).
The role of leaders is multifaceted. Schifalacqua et al (2009a) state that an 'impassioned champion' is essential in au change models, because they provide inspiration, vision and support to everyone involved. Murphy (2006), meanwhüe, suggests that leaders shotüd be seen as team players with the same goals as the rest of their team, rather than as stereotypical organisational leaders.
Jooste (2004) sets out attributes of effective leadership:
Influence: leaders have an enormous role to play in influencing foüowers in the right direction, and shortcomings in leaders' characteristics can lead to problems among followers.
Í Clarity: are workers clear about their tasks? E Commitment: what do workers need from
their leaders? • Self-image: do foUowers know their own abuities,
what they can and cannot accomphsh? • Price: what is the price foüowers pay or the
rewards they receive for working weü. • Behaviour: does the leadership style promote
positive and effective behaviours among foüowers? There are various leadership styles, including autocratic, democratic and laissez-faire (Marqtiis emd Huston (2008) (Box 3), and whichever one is adopted WÜ1 affect the change in question.
Autocracy Autocratic leadership is regarded as predictable, with a high level of productivity, but often with low motivation, creativity and morale (Marquis and Huston 2008). However, it can be useftü in crisis situations and is frequently seen in large bureaucracies. Autocracy is applicable when change is demanded, for example through the use of a top- down approach, whue democratic leadership is more appropriate for groups working together and where autonomy is promoted (Rycroft-Malone et al 2002).
April 2013 I Volume 20 | Number 1 NURSING MANAGEMENT
Democracy Democratic leadership is useful when co-operation and co-ordination between groups are necessary, so it is therefore a more appropriate style for implementing change (Tomey 2009). However, Marquis and Huston (2008) wam that it is often less efficient than authoritative leadership.
Laissez-faire MectnwhQe, a laissez-faire leadership style can be non-directional and frustrating, and managers who adopt it tend to allow their subordinates to take control (Roussel 2006). It is not generally a useful style for planned changes, but it can work when team members are highly motivated and self-directed, and can lead to greater creativity, motivation and autonomy than autocratic or democratic leaderships (Benton 1999).
This style does, however, require multiple change agents and often there is much resistance from group members (Delmas and Toffel 2008), where democracy tends to lead to better results in plarmed chcinge (Richens 2004).
Having considered which change theory to adopt and what style of leadership best suits the project, managers or change agents can begin to work towards achieving change.
Using Lippitt's change theory Uppitt's theory, alongside a democratic style of leadership, is a popular and effective combination. Phase 1 (Boxes 2 and 3) is concerned with diagnosing the problem and is when a need for change has been noticed. Bermett (2003) reconamends undertaking a comprehensive literature review at this point, or delegating this task to someone with good criticcd appraisal skills, to assess all available data and to use the findings to bolster the change agent's position.
Phase 1 Project management begins at this stage because this provides the framework for implementing change (Schifalacqua et al 2009a). It involves developing a detailed plan or draft guideline of the proposed change, which should be given to everyone likely to be affected (Bennett 2003, Guy and Gibbons 2003). However, Roussel (2006) warns nurse managers not to overplan and to leave some room for people to exercise their initiative.
It is also important to have an agreed and appropriate timescale, which can prevent alienation and increase the likelihood of success (Carney 2000). Schifalacqua et al (2009a) warn not to underestimate the 'power of the grapevine', so effective communication should begin at phase 1 (Snow 2001) and is, in fact, integral to the entire change process (Tomey 2009).
Ejcample of a force-field analj
Positive factors/driving forces
Boost job satisfaction
Reduce workload in medium term
Increase patient autonomy
Negative factors/restraining forces
Additional time costs in normal consultations
Resistance from patients
Closer working with local pharmacists
IVIore appropriate workload
•
Opportunities for professional development
Trouble insisting on staff conforming
Time spent inducting new staff
Once driving and restraining forces have been identified, change agents can
determine their relative strengths and rank these by numbers or, as illustrated,
by the thickness of arrows.
(Chambers ef al 2006)
Phase 2 At this stage, motivation and capacity for change are assessed. It involves communicating With those who might be affected, responding to concerns cind, if required, justifying the change. Focus group interviews are one way to achieve this (Carney 2000).
This phase should also address resistance or, as Lewin (1951) puts it, the 'driving and restraining forces'. He suggests that both driving forces (facilitators) and restraining forces (barriers) operate during change, with driving forces advancing a system towards change, while restraining forces impede it (Marquis and Huston 2008).
Resistance to change is inevitable, and managers would be naive to think otherwise (Baulcomb 2003, Cork 2005, Price 2008). Meanwhile, Roussel (2006) suggests that change induces stress that in turn leads to resistance. However, using force-field analysis can counter this resistance.
Force-field analysis This is a framework for problem solving and plaimed change, developed by Lewin (1951). It illustrates that restraining forces cannot be removed and they can be countered only by increasing driving forces. One simple example can be used to illustrate this. A staff nurse does not believe that a new infusion pump is better than a previous model. The change agent cannot remove this restraining force but can bolster the driving
NURSING MANAGEMENT April 2013 I Volume 20 | Number 1
Art & science | management theory
force by explaining why the new pump is more effective and by organising training in how to use it. Figure 2 provides an example of a force-field analysis.
When the force-field analysis is completed, change agents must develop strategies to reduce the restraining forces, which include issues such as fear of losing job satisfaction, or fataüsm based on previous faüed change attempts (Tomey 2009). They must also strengthen the driving forces by, for example, increasing remuneration, promotional incentive, better recognition (Marquis and Huston 2008).
Phase 3 With the capacity for change addressed, Lippitt turns to phase 3: assessment of the change agent's motivation (Box 2). Change agents are not always managers (Murphy 2006), nor do they have to be part of the organisation where chcinge is being introduced. Fxternal change agents can be more objective than internal ones, but can be costly, take more time to assimüate duties and be seen as a threat by other team members (Roussel 2006, Marquis and Huston 2008, Tomey 2009).
Phase 4 This phase, the planning stage, is the point at which the chiinge process is defined and a final draft of the plan is developed, taking into account the force-field analysis, change agents' status, staff attributes and cost. A timetable is drawn up to ensure cost-effective implementation of the change (Benton 1999) and each team member is assigned a responsibüity. At this stage, change agents might consider some broad change strategies.
Change strategies Bermis et al (1985) describe three groups of change strategies that are appropriate for nurses wishing to implement change:
Figure 3 Î Herzberg two-factor motivation theory
Motivators
• Promotion opportunities.
• Opportunities for personal growth.
• Recognition.
• Responsibility.
• Achievement.
Hygiene factors
• Quality of supervision.
• Pay.
• Organisational policies.
• Physical working conditions.
• Relations with others.
• Job security.
Job context
Job satisfaction
Job context
Job dissatisfaction
(Adapted from Cubbon 2000, Cork 2005)
• Empirical-rational. • Power-coercive. •I Normative re-educative. One of these can be selected at phase 5 to help guide change (McPhail 1997).
The empirical-rational strategy assumes that people are rational and wül adopt change if it can be justified and is in their self-interest. Meanwhile, power-coercive strategy is top down and assumes that people obey instructions from higher authorities, although CutcUffe and Bassett (1997) note that these instructions are usually accompanied by some sense of threat, such as job loss. Finally, the normative re-educative strategy assumes that providing information and education will change people's usual behaviour patterns and help them develop new ones (Tomey 2009). Most successful change projects require a combination of these strategies (Strurüc 1995).
Phase 5 This phase focuses on choosing an appropriate role for the change agent. Cooke (1997, 1998) says that change agents are an active part of the change process, particularly in terms of managing staff and supporting change, and will aim to transform intentions into actual change efforts at this stage. It might be useful to undertake another force-field analysis now, as resistance can intensify at this point (McPhaü 1997, Benton 1999, Roussel 2006, Tomey 2009).
Phase six This phase corresponds to the implementation stage of the nursing process (Box 2) (Pearson et al 2005) and is concerned with maintaining the change so that it becomes a stable part of the system (Cooke 1998). During this phase the emphasis is on communication, feedback on progress, teamwork and motivation.
Change agents need to use their interpersonal sküls to inspire change, and having an understanding of motivation theory can support this. For example, the Herzberg (1959) two- factor motivation theory (Figure 3) proposes that individuals have intrinsic and extrinsic needs, described as satisfiers (motivators) or dissatisfiers (hygiene factors), which need to be fulfüled (Bennett 2003).
If change agents strive to meet staff's intrinsic motivational needs, this is likely to increase job satisfaction and improve co-operation and performance, and could be achieved through praise, continual feedback and effective communication (Cubbon 2000).
Ongoing training is important in this phase. Martin (2006) recommends training to support
April 2013 I Volume 20 | Number 1 NURSING MANAGEMENT
change because it allows the change to be embraced more effectively. Conversely, Cork (2005) suggests that training shows only how to behave in a certain system and not how to change it. However, Schifalacqua et al (2009b) found that staff education and training was a pivotal part of the change process. They claim that the relationship between training and stabilising change is not accidental.
Good communication is a prominent feature of every phase of the change process and almost all researchers cite it as fundamental to effective implementation (Robb 2004). Strong, open communication across teams strengthens the chance of firmly embedding change by supporting the development of therapeutic relationships and removing barriers (Murphy 2006).
Phase 7 The final phase, 'terminating the helping process', is evaluation and withdrawal of the change agent on an agreed date, although Roussel (2006)
recommends that change agents remain available for advice and reinforcement, since past behaviours can re-emerge and render even successful change useless.
Finally, any change must be evaluated to determine whether standards have improved. This can be done through clinical audit or patient satisfaction surveys.
Conclusion Attempts to implement plarmed change face numerous barriers, but using a framework, such as Lippitt's, proactively rather than retrospectively can help eliminate some of the potential problems, and address and act on others.
However, while this wül not guarantee success, since planned changes are vulnerable to failure at every stage m all change theories, careful consideration of change theory can simpUfy the process for change agents and help those affected by change to be more receptive to it.
Online archive For related information, visit
our online archive of more
than 7,000 articles and
search using the keywords
Conflict of interest
None declared
References
Arkowitz H (2002) Toward an integrative perspective on resistance to change. Journal of Clinical Psychology. 58, 2, 219-227.
Baulcomb J (2003) Management of change through force field analysis. Journal of Nursing Management. 11,4, 275-280.
Bennett M (2003) The manager as agent of change. Nursing Management 10, 7, 20-23.
Bennis W, Benne K, Chin R (1985) The Planning of Change. Fourth ediUon. Holt, New York NY.
Benton D (1999) TVssertiveness, power and infiuence. Nursing Standard. 13. 52. 48-52.
Burnes B (2004a) Managing Change. Prentice Hall. London.
Burnes B (2004b) Kurt Lewin and the planned approach to change: a re-appraisal. Journal of Management Studies. 4 1 . 6, 977-1002.
Burritt J (2005) Organisational turnaround: the role of the nurse executive. Journal of Nursing Administration. 35. 11, 482-489.
Carney M (2000) The development of a model to manage change: reflection on a critical incident in a focus group setting. An innovative approach. Journal of Nursing Management. 8, 5. 265-272.
Chambers R, Wakley G, Blenkinsopp A (2006) Supporting Self-care in Primary Care. Raddiffe Publishitig, Abingdon.
Cooke B (1997) From process consultation to a clinical model of development practice. Public Administration and Development. 17, 3, 325-340.
Cooke B (1998) Participation, process and management: lessons for development in the history of organisation development. Journal of Intemational Development. 10, 1, 35-54.
Cork A (2005) A model for successful change management. Nursing Standard. 19. 25. 40-42.
Cubbon M (2000) Motivational theories for clinical managers. Nursing Management. 7, 6, 30-35.
CutcUffe J, Bassett C (1997) Introducing change in nursing: the case of research. Journal of Nursing Management. 5. 4. 241-247.
Delmas M, Toffel M (2008) Organizational responses to environmental demands: opening the black box. Strategic Management Journal. 29, 10, 1027-1055.
G e n i s h K (2003) Evidence-based practice: unravelling the rhetoric and making it real. Practice Development in Healthcare. 2. 2, 99-113.
Guy K, Gibbons C (2003) Doing it by yourself. Nursing Management. 10, 6. 19-23.
Hayelock R (1995) The Change Agent's Guide. Second editiotL Educational Technology Publications, Englewood Cliffs NJ.
Herzberg F, Mausner B, Snyderman BB (1959) The Motivation to Work. Second edition. John Wiley. New York NY.
Hewison A, Stanton A (2003) From conflict to collaboration: contrasts and convergence m the development of nursing and management theory Í2). Journal of Nursing Management. 11, 1, 15-24.
Jooste K (2004) Leadership: a new perspective. Journal of Nursing Management. 12, 3, 217-223.
Leayitt H, Babrami H (1988) Managerial Psychology: Managing Behaviour in Organisations. Fifth edition. University of Chicago Press, Chicago IL.
Lewin K (1951) Field Theory in Social Science. Tavistock Publications, London.
Uppitt R, Watson J, Westley B (1958) Dynamics of Planned Change. Harcourt, Brace. New York NY.
Marquis B, Huston C (2008) Leadership Roles and Management Functions in Nursing: Theory and Application. Sixth edition. Uppincott Williams & Wilkins. Philadelphia PA.
Martin V (2006) Learning to lead. Nursing Management. 12, 9, 34-37.
McPbail G (1997) Management of change: an essential skill for nursing in the 1990s. Joumal of Nursing Management. 5, 4,199-205.
Murphy F (2006) Using change in nursing practice: a case study approach. Nursing Management 13, 2, 22-25.
Nursing and Midwifery CouncB (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London.
O'Neal H, Manley K (2007) Action planning: making change happen in clinical practice. Nursing Standard. 21. 35, 35-39.
Outhwaite S (2003) The importance of leadership in the development of an integrated team. Journal of Nursing Management. 11. 6, 371-376.
Pearson A, Vaughan B, Fitzgerald M (2005) Nursing Models for Practice. Third edition. Butterworth-Heinemann. Oxford.
Price B (2008) Strategies to help nurses cope with change in the healthcare setting. Nursing Standard. 22, 48, 50-56.
Reddin W (1989) The Output Oriented Manager. Gower Publishing. Aldershot.
Richens Y (2004) Getting guidelines into practice. Nursing Standard. 18, 50, 33-40.
Robb M (2004) Changing methods of cormntmication. Nursing Management 10. 9. 32-35.
Rogers E (2003) Diffusion of Innovations. Fifth edition. Free Press, New York NY.
Roussel L (2006) Management and Leadership for Nurse Administrators. Fourth edition. Jones and Bartlett, London.
Rycroft-Malone J, Harvey G, Kitson A et al (2002) Getting evidence into practice: ingredients for change. Nursing Standard. 16, 37, 38-43.
Salter C, Green M, Ree M et al (2009) A study of follower's personality, implicit leadership perceptions and leadership ratings. Joumal of Leadership Studies. 2, 4, 48-60.
Schifalacqua M, Costello C, Demnan W (2009a) Roadmap for planned change, part 1: change leadership and project management. Nurse Leader. 7,2, 26-29.
Schifalacqua M, CosteUo C, Demnan W (2009b) Roadmap for planned change, part 2: bar-coded medication administration. Nurse Leader. 7, 2, 32-35.
Snow J (2001) Looking beyond nursing for clues to effective leadership. Joumal of Nursing Administration. 31, 9. 440-443.
Strunk B (1995) The dirucal nurse specialist as a change agent. Clinical Nurse Specialist 9, 3,128-132.
Szabla D (2007) A multidimensional view of resistance to organisational change: exploring cognitive, emotional and intentional responses to planned change across perceived change leadership strategies. Human Resource Development Quarterly. 18,4, 525-558.
Tomey A (2009) Guide to Nursing Management and Leadership. Eighth edition. Mosby Elsevier. St Louis MO. '
Wright S (1998) Changing Nursing Practice. Second edition. Hodder Arnold. London.
NURSING MANAGEMENT April 2013 I Volume 20 Number 1
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.