LEADERSHIP ASSIGNMENT PART 2

EVIDENCE- BASED CARE SHEET

Authors Mary Woten, RN, BSN

Cinahl Information Systems, Glendale, CA

Arsi L. Karakashian, RN, BSN Armenian American Medical Society of

California

Reviewers Darlene Strayer, RN, MBA

Cinahl Information Systems, Glendale, CA

Sara Richards, MSN, RN Cinahl Information Systems, Glendale, CA

Nursing Executive Practice Council Glendale Adventist Medical Center,

Glendale, CA

Editor Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

November 30, 2018

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Change Theory

What We Know › Healthcare organizations are continuously undergoing change at the organizational level

and in areas that promote quality improvement and employee retention. Successful change requires well-developed leadership skills and planning by an individual who functions as a change agent(1,3,4,6,7)

• A change agent is an individual who is skilled in the theory and implementation of planned change. Because inherent resistance and suspicion of change is common, change is typically a complex process. In planned change, effective leaders apply their expert knowledge, efforts, and skills to purposely implement change. Managers or nurse educators often function as change agents in healthcare organizations; multidisciplinary teams of individuals who have varying expertise can also collaborate to promote planned change.(1,3,4,6,7) (For more information on leadership, strategic management and planning, see the series of related Evidence-Based Care Sheets) – Change agents can come from inside the organization (e.g., a manager in an

organization who functions as a change agent) or outside the organization (e.g., an expert consultant hired to function as a change agent). Insider change agents can be influenced by personal bias and often experience more resistance to change than outsider change agents; outsider change agents tend to be more objective, but might be not trusted by staff members(3)

› Change cannot occur unless the change agent correctly identifies facilitators (also called driving forces) and barriers (also called restraining forces) to change that are specific to the organization and to group members (e.g., staff, employees) involved in the change(3,4,7)

• Examples of facilitators/driving forces include pay raises, professional recognition, the desire to please others, and the desire to eradicate activities that undermine work productivity

• Examples of barriers/restraining forces include a lack of willingness to take risks, the desire to remain in one’s comfort zone, fear of the unknown, and the desire to conform to established norms

› Numerous theories and models for planned changed and change management (i.e., the process of controlling and implementing change to achieve desired outcomes) exist, including Everett Rogers’ Diffusion of Innovation Theory; the 7-step Phases of Change by Lippitt, Watson, and Westley; Bhola’s Configurations Theory of Planned Change; Havelock’s Model; and Lewin’s Change Theory(1)

• Social psychologist and pioneer Kurt Lewin developed Change Theory (also called Lewin’s Theory of Planned Change) in the mid-20thcentury as a model for managing change. According to Lewin, change occurs in a three-stage process that hetermed “unfreezing-change-refreezing” (also referred to as unfreezing-movement-refreezing). Before a planned change becomes realized, a change agent must work through the three stages(1,2,3,4,5,6)

– The unfreezing process is the most important stage because it involves the desire or motivation for change. The unfreezing process requires the change agent to accurately diagnose problems in the organization and decide that change is warranted. The change agent must conduct a thorough and accurate assessment to identify facilitators for

change, find appropriate data to support the need for change, and overcome restraining forces that would impede implementation of the change - The unfreezing process involves either increasing the driving forces that direct behavior away from the existing process/

status quo or decreasing the restraining forces that restrict change and maintain the existing process/status quo; a combination of the two methods can be used

- Feelings of anxiety, guilt, or concern in groups or individuals can be provoked during the unfreezing process; resistance is common and to be expected because the balance of a group or organization is being altered

– The change, or movement, stage requires actual change in the thought processes, feelings, and/or behaviors of individuals or groups in an effort to make them more productive and progressive in their thinking patterns. The change agent is responsible for discovering methods for change that increase the possibility that groups or individuals will cease performing an activity or pattern that is counterproductive, and must identify, plan, and implement strategies to enact the change; tasks include determining goals and objectives, identifying areas of support and resistance, and setting target dates implementation/completion - During this stage, the change should be evaluated for efficacy and modified as necessary - The change agent should be available to provide education, support, and encouragement to others throughout the change

process; effective communication skills are essential in a change agent – The final stage, the refreezing process, is achieved by establishing the defined change as accepted policy or habit; the

old patterns of thinking and behaviors will resume if this stage is not successfully met. The change agent should assist in integrating and stabilizing the changes in the organizational system - Change requires 3–6 months to be permanently integrated; the change agent should remain involved in the change

process until the change is accepted and firmly established • The American Organization of Nurse Executives (AONE) supports Lewin’s Change Theory as a framework for

implementing planned change in healthcare organizations. The AONE established five nurse executive competencies, each of which encourages nurse executives to be proficient in change management. Lewin’s Change Theory is best implemented using a “top-down approach”(i.e., initiated at a higher level of management) and when sufficient time is allowed to produce change in an organization(6)

› A hematology unit in the United Kingdom with 17 inpatient/overnight beds and 11 day care beds aimed to establish staff roles in the day care unit that were independent of those in the inpatient area. Identified indications for change included the increasing demand for improved quality of care, customer service, and satisfaction; increasing flexibility in daily nursing management and work processes; and the changing nature of the workforce in a rapidly changing healthcare climate; the unit manager functioned as the change agent. Prior to implementing the change process, management identified several driving and restraining forces(7)

• Driving forces included the need to increase opportunities for nurse autonomy and professional development. Restraining forces included the self-doubt nurses experienced regarding their ability to manage an autonomous role

• Organizational management utilized Lewin’s Change Theory to meet six defined objectives for change, which involved the following: – Unfreezing, which involved empowering and supporting staff, providing staff opportunities to develop professional skills

and strengths, encouraging staff feedback regarding the planned change, and providing staff the freedom to independently think, organize, and plan to promote an autonomous role

– Movement, which involved communicating to staff the positive outcomes of change which included increased nurse abilities and skills (e.g., performing phlebotomy), the development of managerial skills, and better understanding of autonomous roles on the day care unit

– Refreezing, which involved stabilizing the newly developed autonomous roles and supporting staff during busy days

What We Can Do › Learn about change, particularly Lewin’s Change Theory, so you can accurately assess your organization’s need for and

ability to enact change; share this information with your colleagues › Collaborate with others in your organization to

• develop a multidisciplinary team of individuals with varying expertise to promote planned change • identify and support change agents in your organization • implement the three stages of Lewin’s Change Theory when change is needed • identify driving and restraining forces for change so you can provide support for change

› Refer to the AONE for more information about leadership competency development at http://www.aone.org/resources/nurse-leader-competencies.shtml

Note Recent review of the literature has found no updated research evidence on this topic since previous publication on June 9, 2017.

Coding Matrix References are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentations or other such materials

CP Conference proceedings, abstracts, presentation

References 1. Batras, D., Duff, C., & Smith, B. J. (2017). Organizational change theory: Implications for health promotion practice. Health Promotion International, 31(1), 231-241.

doi:10.1093/heapro/dau098 (RV)

2. Lewin, K. (2011). Change theory. Current Nursing. Retrieved November 19, 2018, from http://currentnursing.com/nursing%5Ftheory/change%5Ftheory.html (GI)

3. Marquis, B. L., & Huston, C. J. (2017). Planned change. In Leadership roles and management functions in nursing (9th ed., pp. 186-203). Philadelphia, PA: Wolters Kluwer. (GI)

4. Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1), 32-37. (GI)

5. Rufo, R. Z. (2012). Use of change management theories in gaining acceptance of telemedicine technology. Critical Care Nursing, 35(4), 322-327. doi:10.1097/ CNQ.0b013e3182684f67 (GI)

6. Shirey, M. R. (2013). Lewin's Theory of Planned Change as a strategic resource. Journal of Nursing Administration, 43(2), 69-72. doi:10.1097/NNA.0b013e31827f20a9 (GI)

7. Vlaev, I., & Dolan, P. (2015). Action change theory: A reinforcement learning perspective on behavior change. Review of General Psychology, 19(1), 69-95. doi:10.1037/ gpr0000029 (C)