Nursing and Managing Change



• Change is a major characteristic in all activities of modern societies.

• It has been said that “When we talk about future we are discussing change”.

• “Change is the essence off life, it is as long as life goes on”.

• Nowadays , Nurses are seeing many changes in the field of patient’s care and health care agency management .

• New medications, new equipment and new methods of treatment are being introduced to the health care centers at rapid rate.

• Nurses face many changes result changes on the political situation

Definition of Change:

is the process of making something different from what it was.

Change Agent:

– is one who works to bring about change

– are persons who as catalysts and assume the responsibility for managing change activities


• Managers from within the organization who are knowledgeable about the situation


• Outside consultants who are experts at managing change


Need For Change

– Based on external or internal forces

– Performance Gap = disparity between existing and desired performance levels.

  • Current procedures are not up to standard
  • New idea or technology could improve current performance

Organizational Change:

• Refers to any transformation in the design or functioning of an organization.

• Movement of an organization away from its present state and toward some desired future state to increase its effectiveness

• But we tend to resist the changes introduced by management that affect our interpersonal and job relations.

• Why do we resist these changes?

• In order for health care agencies to meet the increasing demands for patient care services, changes in management of personnel must occur.

• The ability to introduce such changes with a minimum resistance is a key managerial skill.


Individual Reactions to Change

• How People Respond to Changes They Like

Three-stage process

• Unrealistic optimism

• Reality shock

• Constructive direction

How People Respond to Changes They Fear and Dislike


• Getting off on the wrong track

• Laughing it off

• Growing self-doubt

• Buying in

• Constructive direction

Why Do Employees Resist Change?


– Unannounced significant changes threaten employees’ sense of balance in the workplace.


– Employees have a desire to maintain a safe, secure, and predictable status quo.

Misunderstanding and lack of skills

– Without introductory or remedial training, change may be perceived negatively.

Emotional Side Effects

– Forced acceptance of change can create a sense of powerlessness, anger, and passive resistance to change.

Lack of Trust

– Promises of improvement mean nothing if employees do not trust management.

Fear of Failure

– Employees are intimidated by change and doubt their abilities to meet new challenges.

Personality Conflicts

– Managers who are disliked by their managers are poor conduits for change.

Poor Timing

– Other events can conspire to create resentment about a particular change.

Lack of Tact

– No showing sensitivity to feelings can create resistance to change.

Threat to Job Status/Security

– Employees worry that any change may threaten their job or security.

Breakup of Work Group

– Changes can tear apart established on-the-job social relationships.

Competing Commitments

– Change can disrupt employees in their pursuit of other goals.


Types of Change

A-  Planned Change (Anticipatory changes):

– Planned changes based on expected situations.

– Deliberate effort to make some thing happen.

This type requires the leadership skills of problem solving and decision-making as well as interpersonal competence (the ability to work well with others as a group and on one to one basis).

– occurs when managers make organizational modifications based on forecasts of upcoming events or early in the cycle of a new trend

Two Types of Planned Change

• Incremental Change

– based on efforts to improve basic work and organizational processes.

– ongoing process of evolution over time, during which many small adjustments occur

• Transformational Change

– involves redesign and renewal of the total organization.

B-  Accidental change

– Change by drift …. Unplanned. Occurs because of an imbalance in the system.

C- Reactive changes ( Adaptive change):

– changes made in response to unexpected situations.

– occurs when an organization is forced to adapt or innovate in response to some event in the external or internal environment

D- Strategic changes:

– altering the overall shape or direction of the organization.

E- Radical Change:

Organizations make major innovations in the ways they do business

F- Top-down Change:

Implemented by managers at a high- level in organization

• Result of radical restructuring and reengineering

• More resistance

G- Bottom-up Change:

• Implemented by employees at low levels and rises over time

• All levels involved in change process

• Less resistance


Rules for Implementing the Change:

• Change should whenever possible be implemented for positive reason. This is not always possible in reality, as it is often enforced from above.

• As manger, it is important to try and avoid this type of change.

• Much change fails because it is not implemented for the right reasons, it occurs too suddenly, individuals affected are not involved or there is not enough planning.

LEWIN (1951) :

• identified the following rules that should be followed when implementing change:

1- Change should be only implemented for good reasons.

– Change for change’s lead to unnecessary stress for employees.

There are 3 good reasons for change:

a. Change in order to solve a problem.

b. Change to make working procedures more efficient.

c. Change to reduce unnecessary workload.

2- Resistance should be anticipated and natural part of the change.

• Some theories perceive resistance as the most characteristic response to the change process.

Resistance may be:

a. Covert: such as delaying tactics or passive behaviors.

b. Overt: openly refusing to follow commands.

3. When ever possible, change should be planned and implemented gradually, not suddenly.

– Because change is such a complex process, it requires a great deal of planning and enough timing.

– Any change must allow enough time for those involved to be fully assimilated in that change.

4. Those who may be affected, should be involved in planning for that change.

– Good, open communication throughout the process can reduce resistance.

– The easiest way for the manager to assure that subordinated accept the change is to involve them in the change process.

– When information and decision-making are shared, subordinates feel that they have played a valuable role in the change.


The Change Process:

The change process can be divided into 3 main stages:

1. Planning.

2. Implementation.

3. Evaluation.


The Process of Organizational Change



Implementing Change: Common Methods for Creating Change





Technological Change

– Involves incremental adjustments or radical innovations that affect workflows, production methods, materials, and information systems

– Many new forms of information technology (IT)

– IT is enabling real time and any time links between suppliers, producers, distributors, and customers


Organization Redesign

– Involves incremental adjustments or radical innovations focused on realigning departments, changing who makes decisions, and merging or reorganizing departments that sell the organization’s products

Two basic approaches

• Change organization’s structure, such as from functional to product departmentalization

• Change organization’s processes, such as how customer complaints are handled


reconfiguring the distribution of authority, responsibility, and control in an organization


radical redesigning of an organization’s functions and business processes


Job Redesign

• Modifying specific employee job responsibilities and tasks

Job Simplification:

the scientific analysis of tasks

• Focus on efficient workflow process for employees in a particular job

• Frequent use of time and motion studies

Job Enrichment:

Changing job specifications to broaden and add challenge to the tasks required and to increase productivity

• Increases interesting and challenging work

• Increases autonomy and personal freedom

Organizational Development

– A planned, long-range behavioral science strategy for understanding, changing, and developing an organization’s workforce in order to improve its effectiveness

Focus group discussion:

a carefully planned discussion among several employees about a specific topic or
issue of interest, which is led by a trained facilitator

• Facilitator explains the topic to be discussed, the role of the scribe, and how the organization will use the results of the focus group discussion

• Participants come prepared to discuss a specific topic. If confidentiality is a concern, participants are chosen from different units of the organization, not the same work group

Scribe: the person who takes notes about what is said, but not who says it

Survey feedback:

a process that allows managers and employees to report their thoughts and feelings about the organization and to learn about how others think and feel about their own behaviors

• Feedback obtained by means of a questionnaire developed and distributed to employees, who complete it and turn it in anonymously

• Content of questionnaire depends on areas of most concern

Team building:

process that develops the ability of team members to collaborate effectively so they can perform the tasks assigned to them

• Often emphasizes developing a group climate that is safe

• Openness can be risky, but promotes creativity and effective problem solving


• A. Planning

The planning process should involve:

– Identifying the reasons for change.

– Identifying key change agents.

– Communicate with and involve those who are affected by the change.

The suggested steps for planning the change are:

1. State the goal: simple, concise terms should be used. Every one should understand, accept and willing to work with the objectives.

2. List alternatives: consider as many ways as possible to meet the objectives.

3-  Develop assumptions:

each alternative is based on assumption. Based on these assumption, the planner predicts the possible outcomes of each alternative.

4. Choose an alternative: the best alternative that meets the objectives should be selected.

5. Develop plans: once an alternative have been chosen, both strategic (long term ) plans and operational (short term) planning is begun. Action plans for implementing, monitoring, and evaluating are developed.

6. Put plans into action:

effective action plans provide both short term and long term directions for activity. This step includes the step of evaluating the alternative and planning for improvements.


There are 3 main extrinsic factors to be considered when planning for change:

1. People factor or human resources: include aspects of communication, attitudes, beliefs and values and leadership skills.

2. Structural factors: such as hierarchy, policies, procedures and politics.

3. Technological factors : includes the equipment and process that assist people to do their job.

– The employees must be informed about the reasons for the change in order to gain their support … any attempt to make them feel involved and consulted will have a positive effect in outcome of the change process.

– When planning change, it is important to identify the issues likely to cause conflict. Have key people on your side facilitating the change is helpful in persuading the rest of the employees.


B- Implementation

• All staff should by now be aware of the reason for the proposed change and many of them involved in the planning.

• Set an agenda for stages of the change to be implemented if it is a big change.

• Give staff the opportunity to voice concerns, and let them know of a fixed evaluation date when they can discussed what has happened.

• Use key change agents where possible to assist and support in the implementation .

• Ensure that communication channels are open and everyone is aware of what is expected of them and what is trying to be achieved.

• Be flexible and ready to adjust or revise plans.

• Focus on positive aspects of change but do not ignore the negative .


C- Evaluation

• After an agreed period of time, the implemented change should be evaluated . This should involve everyone who is affected or had a role in planning the change.

• Outstanding problem can be raised, the effectiveness of the change can be examined and goals re – set if necessary.

• If change fails , reasons/causes need to be identified and the planning process may to ….

• If change fails , reasons/causes need to be identified and the planning process may need to re-start again. At this point staff who have supported the change need positive reinforcement .

• Staff who still resisting the change need to be tackled and reasons for their resistance tackled.


Changes Theories (Lewin’s theory)

• Lewin provides a social- psychological view of the change process.

• He see behavior as a dynamic balance of forces working in opposite directions within a field.


Force-Field Model of Change



Lewin’s theory

Driving Forces: facilitate change.

• Restraining forces: forces that block or avoid the change.

• To plan change, one must analyze these forces (change agent begin the change process by analyzing the entire system in order to identify the forces against and forces with the change)


Stages of Lewin’s theory



Lewin’s change theory

• Lewin’s identify three phases through which change takes place.

1- Stage of unfreezing:

• Unfreeze the existing equilibrium.

• Gather data: there is a problem and need change.

• Actively participating in problem identification and alternate solutions. And Motivate participants by getting them ready to change.

• People become discontented and aware of a need to change.

• Build a trust and recognition for the need to change

Three Mechanism for Unfreezing Stage:

1- Lack of Confirmation disconfirmation):

staff feel un comfort or dissatisfied with present (focus on negative point).

2- Guilt and Anxiety:

its raise the tension level (reduce resistant).

3- Psychological Safety:

Its providing sufficient security to minimize the risk, many change are resisted result threat. If the threat is removed or reduced, people will feel comfortable and attempt to change.


2- Stage of Moving (Changing):

• This is the implementation phase of change, the leader put the planned change into effect.

• Move the target system to a new level of equilibrium

• The change agent identifies, plans and implements appropriate strategies , ensuring that driving forces exceeds restraining force.


The activities needed for a leader to engaged during the changing phase:

1- Get participants to agree that the equilibrium status is not beneficial to them.

2- Develop a plan include every one who
will be affected in planning.

3- Set goals and objectives.

4- Set target dates.

5- Introduce any new information that is needed to implement the change.

6- Encourage the new behavior so that it becomes part of the system’s behavior.

7- Continue to provide a supportive climate to avoid resistance to change.

8- Provide feedback on progress and clarification of goals to reinforce the change process.


3- Re-Freezing Phase :

– The change agent assists in stabilizing the change in the system

– In order to facilitate the integration of the planned change the leader continue to act as energizer, guide the new behavior and increasingly delegate responsibility for change behavior to other people in the target system.

– Creating an imbalance within the system by either increasing the driving forces or decreasing the restraining forces is a major task required for a change agent.

Strategies for effective change

The appropriate strategies for any situation depend on the power of the change agent and the amount of resistance expected from the subordinate.


• Rational empirical strategies.

• Normative re-educative strategies.

• Power coercive strategy.

1- Rational empirical strategies

• This strategies based on the assumption that people are rational.

• This type of strategy is used when there is little anticipated resistance to the change or when the change is perceived as reasonable.

• But people not always act rationally

2- Normative Re-educative strategies.

• This is the participative strategy.

• Based an the assumption that people act according to their commitment to socioculture norms.

• These strategies use group norms to socialize and influence individuals, so change will occur

• The change agent assumes humans are social animals, more easily influenced by others than by facts. No need for legitimate power

3- Power coercive strategy

• Are based on the application of power by legitimate authority, economic sanctions or political clout.

• Individuals will only change when rewarded for the change or are forced by some other power-coercive method.

• This strategy is used when high resistance is expected and when immediate change is necessary.

• The individual will change because there is a desire to avoid threat, peer pressure or loss of job.


Barriers of change (Resistance)

• Threatened self interest.

• Inaccurate perception.

• Objective disagreement.

• Psychological reactance.

•Low tolerance for change.


Techniques for Dealing with Resistance

• Participation and involvement.

• Manipulation and co-optation.

• Education and communication.

• External agent.

• Incentives.

• Supportive behavior (training, counseling).

• Gradual change.

• Facilitation and support

• Negotiation and agreement

• Explicit and implicit coercion


Tactics for Overcoming Resistance to Change

Education Communication

Change is technical; users need accurate information & analysis


Users need to feel involved; design requires information from others; have power to resist


• Group has power over implementation; will lose out in the change


•Crisis exists; initiators clearly have power; other techniques have failed

Top management support

• Involves multiple departments or reallocation of resources; users doubt legitimacy of change

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