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PLANNING FOR CHANGE Change occurs over time, often fluctuating between intervals of change then a time of settling

and stability. Change management entails thoughtful planning and sensitive implementation, and above all, consultation with, and involvement of, the people affected by the changes. If you force change on people normally problems arise. Change must be realistic, achievable and measurable. These aspects are especially relevant to managing personal change. Definition Planning: Planning refers to thinking ahead of time and formulation of preliminary thoughts. Planned change: Planned change entails planning and application of strategic actions designed to promote movement towards a desired goal. o Planned change is a change that results from a well thought out and deliberates effort to make something happen. It is the deliberate application of knowledge and skills by a leader to bring about a change. Tappen, 1995 Change agent: A change agent is one who generates ides, introduces the innovation, and works to bring about the desired change. Change agent A change agent is someone who deliberately tries to bring about a change or innovation, often associated with facilitating change in an organization or institution. To some degree, change always involves the exercise of power, politics, and interpersonal influence. It is critical to understand the existing power structure when change is being contemplated. A change agent must understand the social, organizational, and political identities and interests of those involved; must focus on what really matters; assess the agenda of all involved parties; and plan for action. The change agent should have the following qualities;

Assumptions regarding change the change is positive, there is a loss of stability. The leader of change must be sensitive to the loss experienced by others.

beliefs, the more likely the change is to be accepted. Likewise the more difficult the goal is from the individuals personal values; the more likely it is to be rejected.

outcome. ch successive change in a series of changes, individuals psychological adjustment to the change occurs more slowly. And for this reason the leader of change must avoid initiating too many changes at once.

The key principles driving the elements of the Change Management are: 1. Targeted Commitment Levels 2. Executive Ownership 3. Visible, sustained

sponsorship 4. Deployment/Implementation Support and Monitoring 5. Employee Support 6. Post Deployment Preparation Strategies for planned change In general, three categories of change models exist: empirical-rationale, powercoercive, and normative-educative model. (Bennis, Benne and Chin [1969], The planning of change) Rationale- empirical: This strategy emphasizes reason and knowledge. People are considered rational beings and will adopta change if it is justified and in their self- interest. Here the change agents role is communicating the merit of the change to the group. If the change is understood by the group to be justified and in the best interest of the organization, it is likely to be accepted. This strategy is useful when little resistance to change is expected. It is assumed that once if the knowledge and rationales are given, people will internalize the need for change and value the result. Normative- re-educative: This is based on the assumption that group norms are used to socialize individuals. The success of this approach often requires a change in attitude, values, and/ or relationships. This strategy is most used when the change is based on culture and relationships within the organization. The power of the change agent, both positional and informal, becomes integral to the change process. Power- coercive: This approach is based on power, authority, and control. Desired change is brought about by political or economic power. It requires that the change agent have the positional power to mandate the change. The outcome of change is often based either on followers desire to please the leader or fear of the consequences for not complying with the change. This strategy is effective for legislated changes, but other changes using this strategy are often short- lived.

Barriers to change and strategies to overcome It is important to identify all potential barriers to change, to examine them contextually with those affected by proposed change, and to develop strategies collectively to reduce or remove the barriers. Change requires movement, which as physics indicates, is a kinetic activity that that requires energy to overcome resistance.

Types of changes Hohn (1998) identified four different types of change: Change by exception, Incremental Change, Pendulum Change and Paradigm Change. This occurs when someone makes an exception to an existing belief system. For instance, if a client believes that all nurses are bossy, but then experiences nursing care from a much modulated nurse, they may change their belief about that particular nurse, but not all nurses in general.

not aware of it.

view. l rethinking of premises and assumptions, and involve a changing of beliefs, values and assumptions about how the world works.

Change Theories in Nursing Change theories are used in nursing to bring about planned change. Planned change involves, recognizing a problem and creating a plan to address it. There are various change theories that can be applied to change projects in nursing. Choosing the right change theory is important as all change theories do not fit every change project. Some change theories used in nursing are Lewins, Lippitts, and Havelocks theories of change. The characteristics of change theories are Problem identification

Kurt Lewins change theory: The theoretical foundations of change theory are robust: several theories now exist, many coming from the disciplines of sociology, psychology, education, and organizational management. Kurt Lewin (1890 1947) has been acknowledged as the father of social change theories and presents a simple yet powerful model to begin the study of change theory and processes. He is also lauded as the originator of social psychology, action research, as well as organizational development. "Unfreezing" involves finding a method of making it possible for people to let go of an old pattern that was counterproductive in some way. In this stage, the need for change is recognized, the process of creating awareness for change is begun and acceptance of the proposed change is developed "Moving to a new level" involves a process of change--in thoughts, feelings, behavior, or all three, that is in some way more liberating or more productive. The need for change is accepted and implemented in this stage. "Refreezing" is establishing the change as a new habit, so that it now becomes the "standard operating procedure." Without some process of refreezing, it is easy to backslide into the old ways.The new change is made permanent here. Lewin also created a model called force field analysis which offers direction for diagnosing situations and managing change within organizations and communities. According to Lewins theories, human behavior is caused by forces beliefs, expectations, cultural norms, and the like within the "life space" of an individual or society. These forces can be positive, urging us toward a behavior, or negative, propelling us away from a behavior. Driving Forces- Driving forces are those forces affecting a situation that are pushing in a particular direction; they tend to initiate a change and keep it going. In terms of improving productivity in a work group, pressure from a supervisor, incentive earnings, and competition may be examples of driving forces. Restraining Forces- Restraining forces are forces

acting to restrain or decrease the driving forces. Apathy, hostility, and poor maintenance of equipment may be examples of restraining forces against increased production. Equilibrium - This equilibrium, or present level of productivity, can be raised or lowered by changes in the relationship between the driving and the restraining forces. Equilibrium is reached when the sum of the driving forces equals the sum of the restraining forces. Lippitts phases of change theory: Lippitts theory is based on bringing in an external change agent to put a plan in place to effect change. There are seven stages in this theory. The first three stages correspond to Lewin's unfreezing stage, the next two to his moving stage and the final two to his freezing change. In this theory, there is a lot of focus on the change agent. The third stage assesses the change agents stamina, commitment to change and power to make change happen. The fifth stage describes what the change agents role will be so that it is understood by all the parties involved and everyone will know what to expect from him. At the last stage, the change agent separates himself from the change project. By this time, the change has become permanent. The seven phases shift the change process to include the role of a change agent through the evolution of the change. Phase 1:Diagnose the problem Phase 2:Assess the motivation and capacity for change Phase 3:Assess the resources and motivation of the change agent(commitment the change, power, and stamina) Phase 4:Define progressive stages of change Phase 5: Ensure the role and responsibility of the change agent is clear and understood (communicator, facilitator, and subject matter expert.

Phase 6:Maintain the change through communication, feedback, and group coordination Phase 7:Gradually remove the change agent from the relationship, as the change becomes part of an organizational culture. Havelock's change model: Havelock's change theory has six stages and is a modification of the Lewin's theory of change. The six stages are building a relationship, diagnosing the problem, gathering resources, choosing the solution, gaining acceptance and self renewal. In this theory, there is a lot of information gathering in the initial stages of change during which staff nurses may realize the need for change and be willing to accept any changes that are implemented. The first three stages are described by Lewin's unfreezing stage the next two by his moving stage and the last by the freezing stage. John P Kotter's 'eight steps to successful change' John Kotter's highly regarded books 'Leading Change' (1995) and the follow-up 'The Heart Of Change' (2002) describes a helpful model for understanding and managing change. Each stage acknowledges a key principle identified by Kotter relating to people's response and approach to change, in which people see, feel and then change: Kotter's eight step change model can be summarized as: Increase urgency - inspire people to move, make objectives real and relevant. Build the guiding team - get the right people in place with the right emotional commitment, and the right mix of skills and levels. Get the vision right - get the team to establish a simple vision and strategy focus on emotional and creative aspects necessary to drive service and efficiency.

Communicate for buy-in - Involve as many people as possible, communicate the essentials, simply, and to appeal and respond to people's needs. De-clutter communications - make technology work for you rather than against. Empower action - Remove obstacles, enable constructive feedback and lots of support from leaders - reward and recognize progress and achievements.

Create short-term wins - Set aims that are easy to achieve - in bite-size chunks. Manageable numbers of initiatives. Finish current stages before starting new ones. Don't let up - Foster and encourage determination and persistence - ongoing change - encourage ongoing progress reporting - highlight achieved and future milestones. Make change stick - Reinforce the value of successful change via recruitment, promotion, and new change leaders. Weave change into culture. General considerations for planning change


Nurse Leader (manager) as role model for Planned Change Implement a comprehensive and coordinated change management program: Discover, develop, detect.

walking the talk.

-to-day activities, e.g., recruiting, performance management, and budgeting. short-term performance while setting high expectations about long-term performance.


change in the formal structure.


some faster, some slower and it is not possible to skip steps.

fears, and use support systems.

Mistakes by a leader manager e change with other managers.

affected by change. -making, which leads to low morale and slow project progress. hange project.

outcome to employees and other managers -stream

Organizational ageing The organization has to undergo progress through certain developmental stages within the organizational structure termed organizational ageing. The young organization is characterized by high energy, movement and constant change and adaptation; while the aged organizations will have established turf boundaries functioning in an orderly and predictable fashion, and are focused on rules and regulations. In any type of ageing, organizations must find a balance

between chaos and stagnation. Some areas that undergo restructuring during an organizational ageing are; leadership changes organizational restructuring outsourcing and offshoring new technologies and tools new competitors and markets

INNOVATIONS IN NURSING Introduction Change is a natural social process of individuals, groups, organizations and society. The source of change originates inside and outside health care organizations. Change today is constant, inevitable, pervasive and unpredictable, and varies in rate and intensity, which unavoidably influences individuals, technology and systems at all levels of the organization. Creativity and innovation Creativity is defined as artistic or intellectual inventiveness. Innovation is defines as introduction of something new. These definitions suggest that the terms are interchangeable. A person could say that creativity is the mental work or action involved in bringing something new into existence, while innovation is the result of that effort. A constant flow of new ideas is needed to procure new products, services, processes, procedures and strategies for dealing with the change occurring in every sphere of endeavour: technology social system, government and everyday living. Innovation is the key to survival and growth of health care and nursing. Change, innovation and creativity are comparison terms but can also be differentiated. Changes occur when the system is disrupts; innovation uses changes to create new and different approaches to resolve an issue and develop new products or procedures.

(Huber 1996). Systemic innovations according to (Drucker 1992) require willingness to look on changes as an opportunity. Innovations do not create change. Successful innovations are accomplished by exploiting the change not forcing it.

Process of Innovation The process of the innovation may include several steps. They are: Assessment It is the first step of process and it requires a look at both the strength and problems. An administrator must focus on what is specific content requirement the expected outcome. Specific content requirement changes often in the health care, as new technologies and research bring new knowledge needs. Defining objectives It is the second step. The administrator should search for research or technique that could address the identical needs. Asking the peers for the suggestion is also helpful. This is the place where the creativity begins. It is important to look at many different ways to address the learning objectives before selecting one.

Planning Once a strategy has been selected the third step, planning is important. Understand who the stakeholders are and what their investment is in the status quo or in change can be helpful in planning the strategies to bring them on board. Many stake holders do not like the changes and will resist the new approaches. Using the change theory it can assist in demonstrating the needs and provide information that can make resistors more amenable to change. Its important to take time to develop a support for the strategy. In more complex strategies it may be important to bring other administrators.

Gaining support for the innovation Some strategies require little or resources to implement where as others require significant physical and financial resources. If resources are needed then gaining support for the accusation of those resources are essential. Grants can provide good funding sources but require time and effort to secure and may be for a limited time. Administrative support may be required but administrators may also be an excellent resource to tap to discuss the potential funding or acquisitions of the physical resource. Preparing faculty members for the innovation

Rehearsal time may be required or additional education may be required. Planning sufficient for those activities will increase everyones comfort level with this process. This is the time where everyone agrees how the strategy will be in run. Use of perception, validate and clarification can be a valuable tool. Implementing the evaluation

In this step it is hope that the things will be going well, but flexibility may be required if problems arise. Sometimes unintended consequences, such as surfacing of emotional issues can occur. Administrator should be alert to the need for the follow up or referral if problem arise. Evaluating the outcome

It is the final step of the process. It may be possible to measure short term attainment goals. A strong evaluation process provides an opportunity to evaluate the outcome of the change.

Sources of innovation Seven sources for innovative ideas have been identified by (Drucker 1992) Four sources are found internally within the institutions are: Unexpected outcomes: Situation presents themselves that require different methods to be adopted. Knowing what is happening in an institution allows an individual to prepare for the impending changes. Incongruous circumstances: Disruptions occur that require change to be made discrepancies exists between the reality as it is and reality as it is assumed to be. Innovations made on the process needs: Procedures and policies need to be altered to respond to the new regulations, policies or law. Changes in structure: Organizational changes require changes in method of the operations.

Three sources are outside the institutions: Change in the demographics: Alteration in the community statistics such as age and income levels affect the organizational operations. New information or knowledge: New technological knowledge requires change in practice. Change in perception, taste and meaning: Shifts in demographics, technologies and social needs create different ways of looking at the situation.

Steps in Innovation adoption Knowledge: Aware of new information and possible significance to practice. Persuasion: Positive attitudes about importance and utility of new knowledge. Decision: Trial use of new information to test relevance to practice.

Implementation: Change of care setting to facilitate use of the innovations. Confirmation: Gathering of evidence to confirm appropriateness of using the innovations.

Theories Planned change using linear approaches Theories for planned change Six phases of planned change Havelock (1973) is credited with this planned change model Key idea: Change can be planned, implemented and evaluated in six sequential stages. The model is advocated for development of effective change agents and use as a rational problem solving process. The six stages are:1. Building a relationship 2. Diagnosing the problem

3. Acquiring relevant resources 4. Choosing the solution 5. Gaining acceptance 6. Stabilizing the innovation and generating self renewal Application to practice: Useful for low level, low complexity change. Seven phases of planned change Lippitt, Watson and westly (1958) are credited with this planned change model Key idea: change can be planned, implemented and evaluated in seven sequential phases. Ongoing sensitivity to forces in the change process is essential. The seven phases are: 1. The client system become aware of the need for the change 2. The relationship is developed between the client system and change 3. The change problem is defined 4. The change goal are set and options for achievements are explored

5. The plan for the change is implemented 6. The change is accepted and stabilized 7. The change entities redefine their relationship

Application to practice: Useful for low level, low complexity change. Innovation decision process Rogers (1995) is credited with formulating this process. Key idea: Change for an individual occurs over five phases when choosing to accept or reject an innovation/idea. Decision is to not accept the new idea may occur at any five stages. The change agent can promote acceptance by giving information about benefits and disadvantages and encouragement. The five stages are: 1. Knowledge 2. Persuasion 3. Decision 4. Implementation and 5. Confirmation

Application to practice: Useful for individual change. Nonlinear change Chaos theory Organization can no longer rely on rules, policies, and hierarchies to get work accomplished in flexible ways. According to the chaos theory perspectives because of rapidly changing nature of human and world factors health organizations cannot control long term outcomes. The assertion of chaos theory are that organization are potentially chaotic(thietat and Forgues, 1995). In other words, order emerges through fluctuations and chaos. Organization will experience periods of stability interrupted with periods of intense transformation. Response to change / Human side of change The human side of

the managing change refers to staff responses to change that either facilitate or interfere with change process. Responses to all or part of the change process by individuals and group may vary from full acceptance and willing participation to open rejection. Responses may be categorized behaviourally or emotionally. Some nurses may manifest their dissatisfaction visibly; others may quietly accommodate the change. Some individuals consistently reject any new thinking or way of doing things. The initial response to change may be, but not always, reluctance and resistance. Resistance and reluctance are common when the change threaten the personal security. Eg: -Changes in the structure of an agency can result in changes of position for personnel. The change agents recognition of the ideal and common patterns of the individuals behaviour responses to change can facilitate an effective change process (Rogers 1983). The responses and brief descriptions are as follows: Innovators thrive on change, which may be disruptive to the unit stability. Early adopters are respected by their peers and thus are sought out for advice and information about innovations/changes. Early majority prefer doing what has been done in the past but eventually will accept the new ideas. Late majority are openly negative and agree to change only after most others have accepted the change. Laggards prefer keeping tradition and openly express their resistance to new ideas. Rejecters oppose change actively.

General characteristics of effective change agents a respected member of the organization (insider) or community (outsider).

Principles characterizing effective change implementation

icipate benefit from the change.


fit of the change.

change process is designed to provide regular feedback to its participants.

Challenges met by the change leaders Mc Daniels (1996) advocates that change leaders in healthcare organizations meet the challenges of managing by applying 12 recomendations: 1. Dispense with controlling and planning.

2. Operate on the margin between order and disorder. 3. Develop new organizations with the help of everyone. 4. Allow individual autonomy. 5. Encourage information sharing among staffs. 6. Promote staffs knowledge of others work. 7. Stimulate open learning through discussion generating creative tension. 8. Considering the organization structure as dynamic. 9. Help staffs discover their goals. 10. Encourage cooperation not competition. 11. Approach work from smarter view, not harder. 12. Uncover values continuously to form organization wide visions.