Chapter 13: Managing Change
Learning Outcome 1
Explain the theoretical perspective of change.
Concepts for Lecture
1. Change is a natural social phenomenon that impacts individuals or groups, and can be
planned or managed, or can occur haphazardly. Changes can be major or minor, positive
2. There are twelve categories (or concepts) that affect nursing in the conceptual framework
for nursing change management:
a. Characteristics: Include constancy, inevitability, unpredictability, variation in rate
and intensity, and the need for adaptation.
b. Change process: the ongoing efforts of change agents and participants when
implementing and managing change
g. Principles: accepted truths that predict that applying a particular action will result in a
specific outcome.
h. Planned change: change that is expected and deliberately prepared for; supports
systematic, directional approaches to achieve desired goals. Goals might not be met if
there is chaos within the group.
PowerPoint Slides
1. A theoretical perspective of change
• Natural, social phenomenon impacting individuals, groups, and society
• Can be:
o Planned, managed, or occur haphazardly
o Major or minor
o Permanent or temporary
2. 12 categories in the expanded conceptual framework
• Characteristics
• Change process
• Innovation
• Strategies
• Responses
• Role
• Learning dimensions
Suggestions for Classroom Activities
• As a homework assignment or in-class activity, split the class into pairs or small groups
and assign each pair or group one of the twelve categories listed in the conceptual
framework for nursing change management. Ask students to research their category
Reference
• Koerner, J.G., Bunkers, S.S., and Nelson, J.N. (1991). Change: A professional
Learning Outcome 2
List the strategies used in the planned change process.
Concepts for Lecture
1. Empirical–rational strategy is based on the philosophy that rational human beings will
follow their own self-interests. If a person perceives some personal benefit or gain from
2. Power-coercive strategy is an option that is adopted when there is a belief that power lies
3. Normative–re-educative strategy is based on the philosophy that humans are driven by a
commitment to norms and values. Re-education ensures opportunities to gain knowledge
PowerPoint Slides
1. Planned change process strategies: empirical–rational
• Based on philosophy that rational humans will follow their own self-interests
2. Planned change process strategies: power-coercive
• Adopted when there is a belief that power lies with the most influential individual
3. Planned change process strategies: normative–re–educative
• Based on philosophy that humans are driven by a commitment to norms and
values
• Re-education ensures opportunities to:
Suggestions for Classroom Activities
• Have a student-led discussion about the strategies used in planned change. Why are the
first two strategies not appropriate for nursing? What makes the normative–re-educative
strategy appropriate for nursing? Ask students to share their ideas and personal
Reference
• Tiffany, C.R., Cheatham, A.B., Doornbos, D., Loudermelt, L., and Momadi, G.G.
Learning Outcome 3
Identify the internal and external basis of change in nursing.
Concepts for Lecture
1. External forces of change are social and economic factors influencing how nursing is
practiced. In the last two decades of the 20th century, 828 U.S. hospitals closed due to
2. Internal forces of change are dictated by client acuity levels, treatment modalities, and the
increased use of technologies. Professional nurses resist the utilization of technicians for
PowerPoint Slides
1. External forces of change
• Social and economic factors influencing nursing practice
• Example: In last 2 decades of the 20th century, 828 U.S. hospitals closed.
o Similar downsizing continues today.
2. Internal forces of change
• Client acuity levels, treatment modalities, and increased use of technologies
• Example: Professional nurses resist using technicians for client care to cut costs.
o Research has demonstrated cost-effectiveness of professional care.
o Collaborative efforts of nurses in the four functional roles (PERM, below)
can significantly influence the maintenance of professional practice:
▪ Practitioners
Figure 13-1: The PERM complex depicts the interaction among nurses in the four major
functional roles.
Table 13-1: The PERM Complex—Independent (I) and Shared (S) Responsibilities
Suggestions for Classroom Activities
• Have the students respond to the following: Practice is influenced by many outside
forces beyond the control of typical staff nurses. They are the group expected to give
safe, skilled, professional care to patients with high acuity levels of illness. At the same
time, upper administration is changing the configuration of caregivers to incorporate
more and more trained assistants who function under the direction and supervision of
the professional nurse. It is a change that affects nurses but that had no nurse
practitioner input.
What are some implications for nurses for the kinds of responsibilities they must
assume for patient safety when care is delivered by trained assistants? How can nurses
influence the outcome? Is the return to an all–RN staff feasible? Why or why not?
Reference
Learning Outcome 4
Explain the steps in the change process.
Concepts for Lecture
1. The driver of change has its root in some perceived conflict, so identification of the
problem is the first step in the change process. The perceived need must be accompanied
2. Gaining support for change cannot be left to chance. The leadership behavior of selling
can be used to gain support by sharing with the group all the known information
3. Changes can be made in different ways. A swift intervention would be to make a decision
and act upon it without giving consideration to any other possible solution. Another
4. Radical intervention is needed when change is sudden, and it is an autocratic method;
changes are made by an individual or a select few, without input from others. Radical
5. Change through nonintervention can be deliberate, or it can be a form of neglect.
Deliberate nonintervention is a form of planned change, and is employed to eliminate
PowerPoint Slides
1. Steps in the change process: problem identification
• A perceived conflict drives change, and identification of the conflict is the first
step.
• The perceived need must be accompanied by a feeling that change must occur.
2. Steps in the change process: gaining support
• Cannot be left to chance.
• Use “selling” leadership behavior by sharing all known information to the group.
3. Steps in the change process: making changes and planned change
• Changes can be made in different ways: swift or planned.
• Swift interventions
o Involve making a decision and acting upon it without giving consideration
4. Steps in the change process: radical intervention
• Needed when change is sudden
• Autocratic; changes are made by an individual or a select few.
• Can have both positive and negative consequences.
• Negative radical intervention
5. Steps in the change process: nonintervention
• Can be deliberate or a form of neglect.
• Deliberate nonintervention
o A form of planned change
Case Study: New Program Change
Suggestions for Classroom Activities
• Create three different typical situations requiring change in the health care setting: one
requiring planned change, one requiring radical intervention, and one requiring
Reference
Learning Outcome 5
Define the three stages in implementing change.
Concepts for Lecture
1. Unfreezing involves letting go of established and familiar practices, and is a preparation
for instituting activities to facilitate the change. Adequate time is needed for the gradual
introduction of new ideas and information that will serve as positive motivation.
2. Moving is characterized by cognitive redefinition of how group goals can be met based
on new understanding. This transition stage is a pilot of the larger plan, and has its own
3. Refreezing occurs when there is consistent evidence that the new practice is stabilized,
integrated, and internalized by the staff. Ongoing monitoring for continued quality must
PowerPoint Slides
1. Stages in implementing change: unfreezing
• Preparation for instituting activities to facilitate the change
• Involves letting go of established and familiar practices.
• Adequate time is needed for gradual introduction of new ideas.
• Information given to workers should include:
2. Stages in implementing change: moving
• Transitional stage characterized by cognitive redefinition of how group goals can
3. Stages in implementing change: refreezing
• When there is consistent evidence that the new practice is stabilized, integrated,
and internalized by staff
• Ongoing monitoring for continued quality to provide information on effectiveness
• Knowing ideal about change process enables all staff to participate constructively:
Case Study: New Equipment Planned Change
Suggestions for Classroom Activities
• As a homework assignment, have students create a diagram outlining the stages in
implementing change, how each stage is interrelated, and how change flows through
Reference
• Bassett, L., & Metzger, N. (1986). Achieving excellence: A prescription for health care
managers, Rockville, MD: Aspen, p. 94.
Learning Outcome 6
Describe the skills of the change agent.
Concepts for Lecture
1. Characteristics of change agents include experience, success, being respected, leadership
skills, and management competencies. Change agents are individuals who are willing to
2. The first responsibility of the change agent is to develop a plan of action, including: a
description of, and rationale for, the change; objectives expressed in measurable terms;
3. Strategies for change agents are:
a. Defining how much choice there is about whether to change;
PowerPoint Slides
1. Characteristics of change agents
• Experience, success, being respected, leadership skills, and management
2. Responsibilities of change agents
• Develop a plan of action, including:
o A description of, and rationale for, the change;
3. Strategies for change agents
• Defining how much choice there is about whether to change
• Delivering clear messages that change action is an essential part of work
• Developing a system of control and information flow
• Establishing a mechanism to monitor progress
• Planning for long-range evaluation
Suggestions for Classroom Activities
• Ask students if they feel they could be change agents in the future. What strengths and
weaknesses do they possess that will lead to their success or failure as change agents?
What skills do they wish to gain that would make them more successful in this area?
Why are change agents so important when implementing a change? What is their
Reference
• Pritchett, P., & Pound, R. (1990). The employee handbook for organizational change.
Dallas: Pritchett & Associates, p. 30.
Learning Outcome 7
Identify strategies to improve responses to change.
Concepts for Lecture
1. Attitudes toward change are formed by a combination of the change itself, the personal
history of individuals who will be affected by change, and the social situation at work.
2. Strategies to improve responses to change:
a. Persuade staff that the change will improve mission attainment and not add to their
work or reduce staff size; for example, ask staff to list important things they’d like to
do but don’t have time for under the current way of doing things.
PowerPoint Slides
1. Attitudes toward change
• Formed by a combination of:
o The change itself;
2. Strategies to improve responses to change
• Convince staff that change will improve mission attainment, not add to their
work.
• Give encouragement.
Figure 13-2: Formulation of attitudes toward change in work settings. Response is
determined by attitude.
Suggestions for Classroom Activities
• Create a typical situation involving a change in the health care setting. Split the class
into six groups, and assign each group one of the strategies to improve responses to
Reference
• Davis, K. (1981). Organizational behavior at work: Organizational behavior. St. Louis:
McGraw-Hill, p. 200.
Learning Outcome 8
Describe the role of evaluation in the change process.
Concepts for Lecture
1. Change is incomplete without evaluation, which provides proof that the change is stable
and justification of cost. Evaluating change is critical for effective operation to ensure
PowerPoint Slides
1. Role of evaluation in the change process
• Change is incomplete without evaluation.
• Provides proof that change is stable and justifies the cost of change.
• Critical for effective operation and ensures answers to:
o Whether the change effort was worthwhile;
Suggestions for Classroom Activities
• Have an in-class discussion about the role of evaluation in the change process, and
correlate the change process with the nursing process. Why is evaluation such a crucial
step in the change process? What if the evaluation is overlooked? Make sure to mention
GENERAL CHAPTER CONSIDERATIONS
1. Have students study and learn key terms listed at the beginning of the chapter.
2. Have students complete end-of-chapter exercises either in their book or on the MyNursingKit
Web site.
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