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It has been said that the only peo-ple who like change are babies with wet diapers. This statement rings true whether it involves design- ing and building a new hospital, an additional tower, or even renovating an existing unit. It seems that we have great difficulty letting go of what is familiar even when the familiar does not work well. In a recent article, one chief nursing officer expressed sur- prise that physicians and staff who were heavily involved in the design of a new children’s hospi- tal were voicing discontent about the design once the building was open and functional (Stichler, 2008). How could this be? Some were the very same people who met with the design teams, par- ticipated in the design decisions, and even signed off on documents indicating their approval of the design.

Unfortunately, this is not an isolated incident. Even with the excitement of opening a new building, people resist change. It is likely that there are few organizational initiatives that can compare to the change process that occurs with the design and opening of a new hospital, yet few organizational leaders provide the same due dili-

Adapting to Change Jaynelle F. Stichler, DNS, RN, EDAC, FACHE, FAAN

Jaynelle F. Stichler, DNS, RN, EDAC, FACHE, FAAN

gence to the change process as they do to structural change. The change associated with individual and orga- nizational adaptation to moving into a new environment is complex and convoluted, and the change process must be as carefully orchestrated as the design process as a whole. Orga- nizational leaders must guide physi- cians and staff through the process of discarding their current realities,

introduce new practice patterns, and encour- age the adoption of new behavioral paradigms. Moving into a new facility forces organizational culture change even when such change is not an- ticipated.

Leading Change Using Classic Change Theories Leading change is one of a leader’s most impor- tant and difficult roles. Although there are many excellent change theories that can be used to guide the change process, not all change is alike, nor can all organizational changes be approached in the same way to yield expected results. Perhaps the greatest failure is not addressing the change process at all and expecting everyone to be ex- cited about a new facility. Using change theories

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as a framework for developing the structure and process of organizational change can enhance positive adaptation to a new patient care envi- ronment.

Lewin’s Change Theory

Lewin was the first to develop the notion that change should be planned rather than allowing unintentional or accidental processes to occur, and he first described three levels of change: un- freezing, changing, and refreezing (Lewin, 1951). This classic theory still guides many planned organizational processes with great success. Us- ing this theory, an organization’s leaders would first demonstrate the need to change and explain why maintaining the status quo would be detri- mental to patients, employees, the organization, and even the community. Kotter (1995) would describe this as creating a “sense of urgency.” At the same time, leaders must assess an organiza- tion’s readiness for change and identify those who may be resistant to the vision and “trench in” to the current status, situation, or even care delivery models.

Applying the unfreezing stage of Lewin’s theory, physicians and staff must be motivated to change by means of exposure to new ideas and creating a sense of urgency around the shared vision of how patient care outcomes and the work environment could be enhanced by the proposed change. The critical step of developing a shared vision is not only important in the design process, but it is also a critical part of the change process that must be orchestrated concurrently with the design and construction phases of a new facility. In the un-

freezing stage, leaders at the departmental level must begin to examine existing work flow pro- cesses and design new processes in the context of the new building, equipment, or departmen- tal relationships. Some healthcare professionals might need orientation to new equipment or have to be certified to perform new procedures or patient care activities that result from the changes in facility design or processes.

As with all complex systems, changes to the facil- ity result in changes to other systems such as care delivery systems, supply processing and distri- bution, informational systems, communication systems, data management, and even financial systems. All of these complex systems are inter- related, and one change affects the entire organi- zational systems’ structure. Therefore, a system- atic change process with a defined structure for change process teams to address, coordinate, and plan the future in the new facility is critical. A milestone chart of the various processes and sys- tems that must change can be an excellent visual marker of progress along the design and construc- tion timeline.

The second step of change described by Lewin (1951) and later amplified by other contemporary theorists (Bennis, Benne, & Chin, 1969; Kouzes & Posner, 2007) includes the actual change or moving phase where the staff begins to develop a new perspective that “life will not be the same” in the new facility. During this adoption stage, the staff can be cross-trained to develop new skills and competencies, and new procedures and equipment can be tested and implemented long

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before the actual physical move-in occurs. The earlier new behaviors can be adopted, the easier the transition to the new facility.

The refreezing stage occurs when individuals ac- tually adopt and integrate the new practices and behavioral norms into daily operational life. To make the new changes stick, leaders must rein- force and encourage the new behaviors and prac- tices and reward and recognize those who are early adopters of the new way of doing things.

Building on Theories of Change Lippitt, Watson, and Westley (1958) focused more on the role and responsibilities of the lead- er as change agent rather than emphasizing the change evolution. Using this theory as a guide, organizational leaders and design team leaders identify a few individuals who will act as change champions because of their transformational leadership attributes, which encourage others to get involved and engaged in the design process and in planning how operations will change. Lip- pitt et al. emphasize the importance of maintain- ing and sustaining changes with communication plans, feedback, group work, and organizational celebrations at each phase of design, during con- struction, and after move-in. Many organizations have adopted specific Web pages or e-mail blasts to employees and physicians to communicate progress in the construction process or celebrate new milestones in departmental changes that oc- cur as a result of planned change.

Another important theory for planning change to organizational processes and culture that re-

sult from the design and construction of a new building is Ajzen’s theory of reasoned action and planned behavior (Ajzen, 1991, 2002). This theo- ry proposes that the rate of change acceptance and adoption is related to an individual’s perception of being engaged in the process and the sense of in- ternal and external control over the opportunities, resources, and skills needed for the change. This theory supports the importance of engaging staff at all levels of an organization in the design pro- cess and in the change processes required for work behaviors and performance in the new facilities. When engaged in design and change processes from the beginning, staff members are quicker to adopt a sense of “authorship” and “ownership” toward the change because of their involvement. The key word in this scenario, however, is “en- gaged” (insiders looking in and out) in contrast to being simply “involved” (outsiders looking in).

Everett Rogers’ diffusion theory (Rogers, 2003) speaks to the attitudes of those affected by change and categorizes them as innovators, early adopters, early majority, late majority, and laggards. Leaders must develop strategies to address the diffusion of innovation (rate of acceptance of change). By leveraging the enthusiasm and wisdom of innova- tors and early adopters as change champions, the knowledge, attitudes, and practices of those most resistant to change (the late majority and laggards) can be managed.

Change Must Be Planned and Managed These different theories illustrate the need for planning and managing change related to both

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the structure (facility design) and processes (or- ganizational and work practices and cultural changes) to ensure a positive outcome once a new facility is complete. Not all change is successful, and Kotter is most noted for a classic article in the Harvard Business Review that describes why change efforts often fail (Kotter, 1995). Kotter provides words of wisdom to prevent the nega- tive attitudes and the poor adoption of change described earlier in this article. Kotter indicates the necessity of (1) creating a sense of urgency about a project; (2) forming a powerful coali- tion to guide the process (change champions and leaders); (3) developing a compelling vision and guiding principles to guide the design and orga- nizational change process; (4) communicating the vision throughout the entire organization; (5) engaging and empowering individuals to act on decisions that support the vision; (6) measuring and celebrating short-term wins that sustain the gains (milestone charts, e-mail blasts, other vi- sual indicators); (7) consolidating improvements that support the vision (changing processes, poli- cies, beliefs, behaviors, and operations); and (8) communicating and integrating the connections among the new behaviors, processes, and struc- ture to the overall success of the organization, to patient care, and to enhanced work environments for healthcare professionals. Kotter contends that

without these eight steps, early adoption of sus- tained change cannot be achieved.

It is hoped that reviewing these change theories emphasizes the importance of planning and man- aging organizational change with the same dili- gence as planning a new healthcare facility. Each theory provides a framework for the structures and processes that are necessary to ensure a suc- cessful outcome for building a new care culture within a new facility.

References Ajzen, I. (1991). The theory of planned behavior. Organizational

Behavior and Human Decision Processes, 50, 179–211.

Ajzen, I. (2002). Perceived behavioral control, self-efficacy, lo- cus of control, and the theory of planned behavior. Journal of Applied Social Psychology 32(4), 665–683.

Bennis, W. G., Benne, K., & Chin, R. (1969). The planning of change. The American Journal of Nursing, 69(8), 1754.

Kotter, J. P. (1995). Leading change: Why transformation ef- forts fail. Harvard Business Review, 73(2), 59–65.

Kouzes, J. M., & Posner, B. Z. (2007). The leadership challenge (4th ed.). San Francisco, CA: Jossey-Bass.

Lewin, K. (1951). Field theory in social science: Selected theo- retical papers. New York, NY: Harper & Row.

Lippitt, R., Watson, J., & Westley, B. (1958). The dynamics of planned change: A comparative study of principles and techniques. New York, NY: Harcourt, Brace & World.

Rogers, E. M. (2003). Diffusion of Innovations (5th ed.). New York, NY: Free Press.

Stichler, J. F. (2008). Staff nurse engagement in health facil- ity design. Journal of Nursing Administration, 38(7/8), 315– 318.

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