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Change Management

Barrow JM, Annamaraju P, Toney-Butler TJ.

De�nition/Introduction

Change is inevitable in health care. A significant problem specific to health care is that almost two-thirds of all change projects fail for many reasons,

such as poor planning, unmotivated staff, deficient communication, or excessively frequent changes[1]. All healthcare providers, at the bedside to the

boardroom, have a role in ensuring effective change. Using best practices derived from change theories can help improve the odds of success and

subsequent practice improvement.

Suppose a health care provider works in a hospital department that has experienced a 3-month increase in unwitnessed patient falls during the hours

surrounding shift change. Evidence-based changes in the current shift change process would likely decrease patient falls; however, departmental

leadership has attempted unsuccessfully to fix this problem twice in the past 3 months. Staff continues to revert to previous shift change protocols to

save time, which leaves patients unmonitored for extended periods. What can departmental leadership and staff do differently to create sustained,

positive change to serve the department’s patients and employees?

The answer may lie within the work of several change leaders and theorists. Although theories may seem abstract and impractical for direct healthcare

practice, they can be quite helpful for solving common healthcare problems. Lewin was an early change scholar who proposed a three-step process for

ensuring successful change[2]. Other theorists like Lippitt, Kotter, and Rogers have added to the collective change knowledge to expand upon Lewin’s

original Planned Change Theory. Although each change theory is different with unique strengths and weaknesses, the theories’ commonalities can

provide best practices for sustaining positive change.

Lewin’s Theory of Planned Change includes the following change stages[2]:

Unfreezing (understanding change is needed)

Moving (the process of initiating change)

Refreezing (establishing a new status quo).

Lippitt, building on Lewin’s original theory, created the Phases of Change Theory that encompass the following change phases[3]:

Becoming more aware of the need for change

Develop a relationship between the system and change agent

Define a change problem

Set change goals and action plan for achievement

Implement the change

Staff accept the change; stabilization

Redefine the relationship of the change agent with the system.

Kotter’s Eight-Step Change Model, created in 1995, include the following change management steps[3]:

Create a sense of urgency for change

Form a guiding change team

Create a vision and plan for change

Communicate the change vision and plan with stakeholders

Remove change barriers

Provide short-term wins

Build on the change

Make the change stick in the culture.

Finally, Rogers’ Diffusion of Innovation Theory introduced these five change phases[4]:

Knowledge (education and communication to expose staff to the change)

Persuasion (use of change champions to pique staff interest; peers persuading peers)

Decision (staff decide whether to accept or reject the change)

Implementation (putting new processes into practice)

Confirmation (staff recognize the value and benefits of the change and continue to use changed processes).

8/30/22, 7:42 PM Change Management - StatPearls - NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK459380/ 2/3

Issues of Concern

All change initiatives, no matter how big or small, unfold in three major stages: pre-change, change, and post-change. Within those stages, healthcare

providers working as change agents or change champions should select actions that match change theories. One of the most critical aspects of pre-

change planning is involving key stakeholders in problem identification, goal setting, and action planning[5]. Involving stakeholders in change

planning increases staff buy-in. These stakeholders should include staff from all shifts, including nights and weekends, to create peer change

champions for all shifts[5].

One particular portion of Rogers’ change theory identifies the various rates with which staff members accept changes through the process of

innovation diffusion. During pre-change planning, change agents should assess their departmental staff to determine which staff belong to each

category. Rogers described the different categories of staff as innovators, early adopters, early majority, late majority, and laggards[4]. He further

qualified those change acceptance categories with the following descriptions:

Innovator: passionate about change and technology; frequently suggest new ideas for departmental change

Early adopter: high levels of opinion leadership in the department; well-respected by peers

Early majority: Prefer the status quo; willing to follow early adopters when notified of upcoming changes

Late majority: Skeptical of change but will eventually accept the change once the majority has accepted; susceptible to increased

departmental social pressure

Laggard: High levels of skepticism; openly resist change[4].

Most departmental staff will likely belong to the early or late majority. Change agents should focus their initial education efforts on Innovator and

Early Adopter staff. Early adopters are often the most pivotal change champions that persuade early and late majority staff to embrace change

efforts[4].

One final critical assessment change leaders should incorporate a force field analysis, which is a significant component of Lewin’s early change theory.

A force field analysis involves a review of change facilitators and barriers at work in the department. Change leaders should work to reduce change

barriers through open communication and education while also aiming to strengthen change facilitators through staff recognition and various

incentives.

One of the biggest mistakes a change leader can make during the midst of change implementation is failing to validate that staff members are

performing new processes as planned. Ongoing leader engagement throughout change execution will increase the chances of success[5]. Staff

resistance remains common during this stage. Change leaders may find it helpful to conduct another Force Field Analysis during this changing phase

to ensure no new barriers have emerged[3]. Further strengthening of change facilitators through staff engagement, recognition, and sharing of short-

term wins will help maintain momentum. Staff may require additional on-the-spot training to overcome knowledge deficits as the change process

continues. Finally, leaders must continue to monitor progress toward goals using information like patient satisfaction, staff satisfaction, fall rates, and

chart audits[3].

Once the change has become part of the department’s new culture, change leaders still must periodically validate departmental processes and solicit

staff feedback. Change agents can redefine their relationship with the staff to take on a less active role in the change maintenance process. However,

once the change leader begins to release control over the change process, staff members may slowly revert to old, negative behaviors. Periodic spot-

checking and continued data monitoring can solidify the change as the department’s new status quo. Change managers should celebrate wins with staff

while continuing to share evidence of success in staff meetings or with departmental communication boards[5].

Clinical Signi�cance

Change is inevitable, yet slow to accomplish. While change theories can help provide best practices for change leadership and implementation, their

use cannot guarantee success. The process of change is vulnerable to many internal and external influences. Using change champions from all shifts,

force field analyses, and regular supportive communication can help increase the chances of success[5]. Knowing how each departmental staff member

will likely respond to change based on the diffusion of innovation phases can also indicate the types of conversations leaders should have with staff to

shift departmental processes.

Review Questions

Access free multiple choice questions on this topic.

Comment on this article.

8/30/22, 7:42 PM Change Management - StatPearls - NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK459380/ 3/3

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Figure

Change Management: Sample Force Field Analysis related to Lewin's Theory of Planned Change. Contributed by Jennifer Barrow, MSN

References

Nelson-Brantley HV, Ford DJ. Leading change: a concept analysis. J Adv Nurs. 2017 Apr;73(4):834-846. [PubMed: 27878849]

Shirey MR. Lewin's Theory of Planned Change as a strategic resource. J Nurs Adm. 2013 Feb;43(2):69-72. [PubMed: 23343723]

Mitchell G. Selecting the best theory to implement planned change. Nurs Manag (Harrow). 2013 Apr;20(1):32-7. [PubMed: 23705547]

Bowen CM, Stanton M, Manno M. Using Diffusion of Innovations Theory to implement the confusion assessment method for the intensive care

unit. J Nurs Care Qual. 2012 Apr-Jun;27(2):139-45. [PubMed: 22367153]

Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016 Sep 22;25(17):949-955. [PubMed: 27666095]

Publication Details

Author Information

Authors

Jennifer M. Barrow ; Pavan Annamaraju ; Tammy J. Toney-Butler.

A�liations

McNeese State University

Loma Linda University

Publication History

Last Update: October 9, 2021.

Copyright

Copyright © 2022, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use,

duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, a link is provided

to the Creative Commons license, and any changes made are indicated.

Publisher

StatPearls Publishing, Treasure Island (FL)

NLM Citation

Barrow JM, Annamaraju P, Toney-Butler TJ. Change Management. [Updated 2021 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

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