Change is inevitable in health care, just as it is in life. Nurses today are accustomed to change in their environments. Many have seen changes in the acuity of patients, changes in practice models and skill mixes, a change to evidence-based practice, changes in educational requirements, and changes within their own roles. Some nurses report that changes in practice are so frequent that they are taken for granted (Copnell & Bruni, 2006). Yet they also indicate that the very basis of nursing, providing care and support for patients, has not changed (Copnell & Bruni, 2006). TABLE 2-1 Evidence supports this emergent view of change (Shanley, 2007). There is little evidence in the literature showing whether any of the specific approaches to planned change actually work. There is evidence about what does work (Balogun, 2006). The literature points to the decreased importance of executives and increased importance of those affected by any change. The planned approach is too simplistic, takes too much for granted, and does not allow the analysis of the complex aspects of change over time. Organizational change has been defined as any modification in organizational composition, structure, or behavior (Bowditch & Buono, 2001). Most often, it refers to management efforts to move an organization from a current state to “some desired future state to increase organizational functioning” (Weimer et al., 2008, p. 381). These efforts are often described as planned change and involve top-down conception, communication, and implementation. Literature on organizational change is extensive. Lewin’s (1947, 1951) unfreezing, moving, and refreezing three stages of change theory is the classic model. In addition, newer approaches to organizational change, consistent with the emergent views, and can be found in the literature. In the 1990s, Senge (1990) introduced the idea of learning organizations. Learning organizations are ones that learn to adapt to change (Alas, 2007). How organizations adapt is related to their ability to be open, dynamic, and responsive to changes in the environment. The success of the learning organization is directly related to the people within the organization and their own learning. Workers need to be empowered themselves to be open and responsive to changes and to become “lifelong learners” (Senge et al., 1994). Within the learning organizations, Senge (1990) described the following five learning disciplines: • Personal mastery: Refers both to individual capacity to create desired results and to the creation of an environment or culture in which others can do the same • Mental models: How individuals develop, create, and project the personal vision they have of the world and understand how these personal views affect their decisions and actions • Shared vision: Sharing preferred future visions within a group for developing plans to get to that preferred future • Team learning: A sharing of learning skills and conversations so that the group can develop skills and learning greater than the individual parts • Systems thinking: Envisioning the organization as an interrelated system rather than unrelated parts Learning organizations are about change and helping people embrace change. Although Senge and colleagues (1994) noted that change and learning are certainly not synonymous, they believe they are clearly linked. Senge (1990) also emphasized that developing learning organizations equal to the challenges of today’s societal issues will require moving away from hierarchical leadership models and towards a new evolving idea of leadership. Anderson and Anderson (2009) also challenged hierarchical approaches to organizational change. They described how organizational leaders realized that traditional top-down, manager-driven approaches were no longer working. On encountering obstacles and resistance, leaders learned that they had to focus more on the process of change and human relationship aspects. Anderson and Anderson (2009) call the old way of viewing change as the industrial mind-set, and that organizational leaders need to move towards an emerging mindset. The industrial mindset is a mechanistic world view, relying on power and control, certainty and predictability. Anderson and Anderson (2009) identified the emerging mindset, like other complexity views, as one grounded in wholeness and relationship, embracing co-creation and participation. A component of this emerging mindset is that leaders need to move to what they call conscious change leadership. Conscious change leaders are aware of the dynamics of change and learn to lead from the principles of the emerging mindset. Conscious change leaders must be willing to look internally to transform their own mind-set, expand their thinking about process, and evolve their own leadership style. Nurse leaders, from the bedside to the executive suite, need to understand and be able to apply a variety of change theories. The majority of change theories originate from the work of Kurt Lewin. Most nurses have heard of Lewin and his three elements for a successful change: (1) unfreezing, (2) moving, and (3) refreezing (Figure 2-1). Since his work outlining the basic concepts of the change process was first published in 1947, it has been influential to those interested in change. It might be tempting to consider his ideas more consistent with the older, more traditional views of planned change (Burnes, 2004). However, Lewin was not only a remarkable thinker but also a humanitarian who believed that it was essential for democratic values to permeate all aspects of society. His model is also meant to help increase understanding about how groups and organizations change, and not as a rigid strategy to impose change. Lewin’s basic change process is still useful and applicable today and is the basis for many newer theories. TABLE 2-2 Similarities of Change, Nursing Process, and Problem Solving Data from Workman, R., & Kenney, M. (1988). The change experience. In S. Pinkerton, & P. Schroeder (Eds.), Commitment to excellence: Developing a professional nursing staff (pp. 17-25). Rockville, MD: Aspen. Lewin’s (1947, 1951) work forms the classic foundation for change theory. Other change theorists have elaborated further understanding and application of change theory. Bennis and colleagues (1961) assembled a book of readings on planned change that emphasized planner-adopter cooperation and high levels of adopter participation. Because actually implementing planned change is more dynamic and complex than Lewin’s model, Lippitt (1973) refined and expanded Lewin’s (1947, 1951) work on unfreezing, moving, and refreezing to identify the following seven phases of the change process that more fully describe planned change: 2. Assessment of motivation and capacity to change 3. Assessment of the change agent’s motivation and resources 4. Selecting progressive change objectives 5. Choosing an appropriate role for the change agent 6. Maintaining the change once it is started 7. Termination of the helping relationship with the change agent The first three steps can be compared to Lewin’s unfreezing (1947, 1951). Steps 4 and 5 match moving, and steps 6 and 7 are comparable to refreezing. Similar to Lippitt (1973), Havelock (1973) listed the following six elements in the process of planned change: TABLE 2-3 Comparisons of the Process of Change Theories Change and innovation are companion terms, but innovation has been differentiated from change by many authors over time. Change is a disruption; innovation is the use of change to provide some new product or service (Romano, 1990). An innovation is defined as something new—the introduction of a new process or new way of doing something. Innovation also has been viewed as the use of a new idea to solve a problem (Kanter, 1983). Kanter (1983) said that innovation refers to the process of bringing any new or problem-solving idea into use. Innovation is often linked with creativity. Organizations need to promote environments that encourage creativity and opportunities for innovation (Hughes, 2006). Leaders are essential to innovation because they must help create the environment and opportunities for innovation. Innovation is a complex phenomenon. It is of interest in many fields from business to science, and, of course, in health care. In some views, innovation is considered a radical act, such as the introduction of a new product or process (Aranda & Molina-Fernandez, 2002). Others, such as Drucker (1992), believe that it can be a purposeful and systematic use of opportunity from changes in the economy, technology, and demographics. In this view, innovation is systematic, takes hard work, and has little to do with genius and inspiration. A purposeful and organized search for change is the basis for systematic innovation. A careful analysis of the opportunities for change is the best hope for successful economic or social innovation. This occurs because successful innovations exploit change. Drucker noted that the challenge is to make institutions capable of innovation; innovation depends on “organized abandonment” (1992, p. 340). This is a process of eliminating the obsolete and the no longer productive efforts of the past. A willingness to view change as an opportunity is needed. 1. First knowledge of an innovation’s existence and functions 2. Persuasion to form an attitude toward the innovation 3. Decision to adopt or reject 4. Implementation of the new idea 5. Confirmation to reinforce or reverse the innovation decision 1. Relative advantage: The degree to which the change is thought to be better than the status quo 2. Compatibility: The degree to which the change is compatible with existing values of the individuals or group 3. Complexity: The degree to which a change is perceived as difficult to use and understand 4. “Trialability”: The degree to which a change can be tested out on a limited basis 5. “Observability”: The degree to which the results of a change are visible to others
Change and Innovation
evolve.elsevier.com/Huber/leadership/
BACKGROUND
Planned Change (Traditional View)
Emergent View
Direction
Top-down, linear
Multidirectional, multidimensional
Initiator
Leader initiated
Diffuse
Process
Planned, step-by-step process
Principles to guide process
Organizational culture
May be considered
Essential to consider
Power issues
Not considered, or not spoken
Essential to consider
Role of staff/recipients of change
Resisters
Participants in change process
View of the change recipients
May be assessed so they can be changed or manipulated
Essential to process
PERSPECTIVES ON CHANGE
Types of Change
Organizational Change
CHANGE THEORIES
Lewin’s Change Process
Change
Nursing Process
Problem Solving
Unfreezing
Assessing
Problem identification and definition
Moving
Planning and implementing
Problem analysis and seeking alternatives
Refreezing
Evaluation
Implementation and evaluation
Lewin
Rogers
Lippitt
Havelock
Unfreezing
Awareness, interest, evaluation
Steps 1, 2, 3
Steps 1, 2, 3
Moving
Trial
Steps 4, 5
Steps 4, 5
Refreezing
Adoption
Steps 6, 7
Step 6
Innovation Theory
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