NURS
236A
Module
7
Phyllis
M. Connolly, PhD, APRN-BC, CNS
Change
is inevitable
Purpose
The need for change within yourself as a leader will be explored. You will review and analyze a variety of change theories and models. Completion of this module will assist you in selecting an appropriate change theory/model for a specific nursing administration problem.
Learning Outcomes
After completing this module you
will be able to:
� Analyze and apply change theories
� Select a change theory to be used in your synthesis paper
� Apply strategies for change
� Explore multiple online resources related to change
Required Learning Activities
1. Read
a. AACN (January 2002). White Paper: Hallmarks of the Professional Nursing Practice Environment available at http://www.aacn.nche.edu/Publications/positions/hallmarks.htm
b. AACN (May, 2003) Draft AACN White Paper: The Role of the Clinical Nurse Leader, May 2003 is available at http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htm
c. Baulcomb, J. S. (2003). Management of change through force field analysis. Journal of Nursing Management, 11(4), 275 � 280.
d. Bennet, M. (2003). Implementing new clinical guidelines: The manager as agent of change. Nursing Management, 10(7), 20 � 23.
e. Fontaine, D., Gerardi, D. (2005). Healthier hospitals? Nursing Management, 36(10),� 34 � 44.
f. Larrabee, S. B. (1999). Benner�s novice to expert nursing theory applied to the implementation of laptops in the home care setting. Home Health Care Management & Practice, 11(5), 41 � 47.
g. Ritter-Teitel, J. (2002). The impact of restructuring on professional nursing practice. The Journal of Nursing Administration, 32(1), 31 � 41.
h. Valentine, N. (2001). Quality measures essential to the transformation of the Veterans Health Administration: Implications for nurses as co-creators of change. Journal of Nursing Care Quality, 15(4), 48 � 59.
i.
View http://atn7.sjsu.edu/webcontent/nurs236a010904/trainer.rm
���for a
discussion about change from one of the community nurse leaders, Joan P. Smith,
Director of Patient Care Services at
2. Post Responses by December
1,
Situation A: You are the nurse managers responsible for organizing and implementing the change to implement the AACN�s new nursing role: The �new nurse� the Clinical Nurse Leader (AACN) draft Role of the Clinical Nurse Leader, May 2003 is available at http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htm and the update at http://www.aacn.nche.edu/Publications/positions/cnssupport.htm . Briefly describe which change theory or theories and strategies that will facilitate the change. Support your approach from the assigned readings.
If your name begins with an �A�
through �M� you will respond in the Discussion Board to Situation A.� The first person whose name begins with �M�
will summarize the responses for the group include (N = )
and the name of each person. The person who is summarizing will present the
summary during class on December 7.
Situation B: You are the staff nurses on the unit where the new nursing role of Clinical Nurse Leader (AACN) will be implemented. Describe what is happening on the unit with the introduction of the change. Refer to assigned readings to label what processes are being used and the reactions of the staff nurses.� You are all BSN nurses. You will want to review the draft AACN White paper The Role of the Clinical Nurse Leader, May 2003� available at http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htm� and the Statement of Support for the CNS found at http://www.aacn.nche.edu/Publications/positions/cnssupport.htm
If your name begins with �N�
through �Z� you will respond in the Discussion Board to Situation B. The first
person whose name begins with an �R� will summarize the responses for the
group; include (N = ) and the name of each person. The
summarizer will present�
the summary during class on December 7.
Note: for both participants
in Situation A and B, review comments from both groups as you prepare your
responses. The Clinical Nurse Leader is in �Draft� form thus still demands
discussion.
�Mini-Lecture�
�When you change yourself you
change the world� (Wilson & Porter-O�Grady, 1999, p. 230)
Clearly, change is inevitable however,
how and what leaders do to prepare for change is as important as planning and
implementing change.
Determining where the nurse
administrator may need to change before requiring others to change is
accomplished through reflection and journaling as suggested by
|
1. Am I current? Do I
appreciate contemporary events, philosophy, religion economics, art and music,
literature, science, psychology and business development? |
|
2. Am I plugged in? Am I
connected to the main body of people and events shaping my profession and my
personal life? |
|
3. Do I see the dark side of good?
The dark side of joy is sadness. The dark side of achievement is� no time for family. |
|
4. Do I accept the fact that
anything carried to an extreme can become absurd? Values can lead to absurd
actions. |
|
5. Am I sure that I have not
become self righteous in my choices about my professional and personal
life?� Pride in the illusion that one
has achieved the right answer is disastrous for leaders. |
|
6. Do I recognize that I will
never become ideologically correct if�
I� am to grow as a leader? This
is a tough question for the rigid, the fearful, or the opinionated. |
|
7. Am I willing to grow with
those I lead to the cutting edge and in so doing evoke the censure of those
who do not wish to grow? Cutting edge people are pushing the boundaries of
the frontiers of knowledge and experience. |
|
8. Am I sensitive to the needs
and aspirations of all those who may be affected by what I say, think, or do?
Do you take the time to listen and reflect upon what you are hearing? |
|
9. How well do I accept that
compromise is the right answer? What is the right action for me may not fit
with the diversity of right actions of others involved in certain situations. |
|
10. Do I have a realistic view
of myself upon which greater leadership can be built? This is the most
difficult of perspectives to see oneself as one really is. |
The practice environment for nursing is frequently cited as the most demanding across all settings and therefore must change (AACN, 2002). This change is also identified as a major factor in patient safety and quality care as well as a strategy in counteracting the nursing shortage and increasing tenure. Go to the American Association of Colleges of Nursing (AACN) website for the AACN White Paper: Hallmarks of the Professional Nursing Practice Environment http://www.aacn.nche.edu/Publications/positions/hallmarks.htmfor the characteristics of the practice setting which supports professional nursing practice. The characteristics are believed to allow baccalaureate and higher degree nurses to practice at their fullest. AACN has identified the �Clinical Nurse Leader� also called the �New Nurse� as the nurse prepared to respond to the changes needed in the health care system across all settings. A draft White Paper: The Role of the Clinical Nurse Leader, May 2003 is available at http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htm and the Statement of Support for Clinical Nurse Specialist found at� http://www.aacn.nche.edu/Publications/positions/cnssupport.htm . One of the Power Point Presentations on the topic,� a View from Practice by Cathy Rick, Chief Nursing Officer, Department of Veterans Affairs during the Pre-Conference on the New Nursing, October 24 � 25, 2003,� is available with this module with the Power Points for this course.
There are a number of models and theories of change which you will find in the literature and several of the assigned articles provide examples of applications of change based on specific models (Baulcomb, 2003;� Larrabee, 1999). Many are very similar to the nursing process, all require energy. Larrabee (1999) utilized Benner�s novice to expert framework to guide the implementation of laptops for nurses working in home health. The work is an example of the performance expectations that need to be incorporated when instituting a new task at each of Benner�s stages (a) novice , (b) advanced beginner, (c) competent, (d) proficient, and (e) the expert. Keeping the perspective of the continuous learner the use of the Benner stages facilitates growth and development and can be applied to many introductions of innovations.
There are a number of theories and models of change which you can explore at the Communication Initiative web site http://www.comminit.com/change_theories.html. Each of the pages with the various models can be evaluated and you can submit your evaluation which will be helpful to the Project. A visual of the steps of change, the Diffusion Model, which you may find helpful is located at http://www.comminit.com/ctheories/sld-2937.html. Another interesting model is the Innovation Process in Organizations found at http://www.comminit.com/ctheories/sld-2938.html. Organizing stakeholders can be found at http://www.comminit.com/ctheories/sld-8722.html. Yet, another theory which you may be familiar with from NURS 204 and NURS 200 is Precede-Proceed used for implementing health promotion programs. To see several change theories/models compared go to http://www.comminit.com/ctheories/sld-2928.html. Finally, a visual of a planning model, the COAST Model can be seen at http://www.comminit.com/pmodels/sld-2781.html.
Below a table compares some of the more common models of Change.
|
Lewin�s
Force Field Model |
Havelock�s
Model, Six-Step |
Roger�s
Diffusion Model |
Lippitt�s
Seven Step |
|
Increase driving forces Decrease restraining forces |
1. Building a relationship 2. Diagnosing the problem |
1. Knowledge, awareness |
Based on the consultant model 1. Diagnose the problem |
|
1. Unfeezing Motivate participants, get them
ready for change Active participation &
generation of alternative solutions |
3. Acquiring resources 4. Choosing the solution 5. Gaining acceptance |
2. Persuasion |
2. assess motivation, emphasis
is on involvement of key members of target system Communication skills Rapport building Problem solving 3. Assess change agent�s
motivation & resources 4. Select progressive change
objects 5. Choose change agent role |
|
2. Moving Participants agree status quo
must go View problem with new
perspective Link with view of respected or
powerful leader who supports change Help scan environment to search
for relevant information |
|
3. Decision 4. Implementation |
|
|
3. Refreezing Reinforce new patterns of
behavior Institutionalize through formal
and informal mechanisms e.g. policies, communication channels |
6. Stabilization & self
renewal |
5. Confirmation , adoption |
6. Maintain change Terminate helping
relationships |
From a system�s perspective any change in one part results in
change in any other part of the system. It is extremely important to identify
the relationship between subsystems to anticipate possible unintended
reactions. For quick review of systems properties go
to http://ide.ed.psu.edu/change/theory/systems-characteristics-3.htm.
In general, all change models include the following steps:
1. Recognizing the need for change
2. Diagnosing the problem
3. Analyzing alternative solutions
4. Selecting the change, if needed
5. Planning the change
6. Implementing the change
7. Evaluating the change
8. Stabilizing the change.
How people respond to change is very important, Rodgers (1983) categorized the types of responses in the following ways:
� Innovators, love change and thrive
� Early adopters
� Early majority, prefer status quo, but change
� Late majority, resistive, accept after most others
� Laggards, dislike change and are openly antagonistic
� Rejectors, actively oppose, and may even sabotage.
Some have compared the responses to change to those responses labeled in the Kubler-Ross grief response: denial, anger, bargaining, depression and acceptance. However, caution should be taken in applying the grief model in organizational settings since this research was completed on folks in the process of dying.
Strategies for change vary and will depend on the amount of anticipated resistance, and the degree of power of the change agent (Sullivan & Decker, 2001). The chart below provides and overview of change strategies. Please note that the strategy of timing and Incrementalism are based on my own 43 years of nursing experience.
|
Strategy |
Definition |
|
Power-coercive |
Legitimate authority, economic
sanctions, or political clout e.g. Laws, policies, financial appropriations,
regulations, accrediting bodies |
|
Empirical-rational
model |
Assume that people are rational
and will follow self-interest if that self-interest is made clear e.g. new
technology will save person time & improve care. |
|
Normative-reeducative |
Based on the assumption that
people act in accordance with social norms & values, e.g. evidence-based
practice, quality circles, CQI results. |
|
Timing |
The opportunity for a change
frequently is enhanced because of timing, e.g. a change in organizational
structure; a new law, or a new administrator. A proposed change may not have
been possible earlier, however, at a future point in time it may be feasible. |
|
Incrementalism |
A smaller piece of a whole
change may be possible and builds toward the desired change. |
You will need to apply one of the theories/models of change in your synthesis paper and having completed this module you should have the knowledge and skills to complete the assignment.
Please go to URL http://atn5.sjsu.edu:8080/ramgen/presenter/nurs236a010904/trainer.smi���� for a discussion about change from one of
the community nurse leaders, Joan P. Smith, Director of Patient Care Services
at
References
AACN (January 2002). White Paper: Hallmarks of the Professional Nursing Practice
Environment� retrieved
AACN (May, 2003). Draft AACN White Paper: The Role of the Clinical Nurse
Leader, May 2003 retrieved January 1, 2004 from http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htm
AACN (2005). Position Statement: Statement of Support for Clinical Nurse Specialist, retrieved July 2, 2006 from�
����������� http://www.aacn.nche.edu/Publications/positions/cnssupport.htm
Baulcomb,
J. S. ( 2003). Management of change through force field analysis. Journal
of Nursing Management, 11(4), 275 � 280.
Bennet, M. (2003). Implementing new clinical guidelines: The manager as agent of
����������� change. Nursing Management, 10(7), 20 � 23.
Fontaine, D., Gerardi, D. (2005). Healthier hospitals? Nursing Management, 36(10), 34 � 44.
Larrabee, S. B. (1999). Benner�s novice to expert nursing theory applied to the
implementation of laptops in the home care setting. Home Health Care Management & Practice, 11(5), 41 � 47.
Nyberg, J. (1998).
). A caring approach in nursing administration. eBook ISBN
0585042446, Niwot, CO: University Press of Colorado. On
reserve in SJSU
library.
Nyberg, J. (1998). A caring approach in nursing administration. Niwot, CO: University
�������� �Press of
Ritter-Teitel, J. (2002). The impact of restructuring on professional nursing practice.
The Journal of Nursing Administration, 32(1), 31 � 41.
Rogers, E. (1983). Diffusion of innovations(3rded.). New York: Free Press.
Sullivan, E. &
Decker, P. (2001). Effective leadership and management in nursing (5th
����������� ed.). Upper Saddle
River, NJ: Prentice Hall.
Swansburg, R. C, & Swansburg, R. J. (1999).
Introductory management and leadership
����������� for
nurses (2nd�
ed.). Sudbury, MA: Jones and Bartlett Publishers.
Valentine, N. (2001). Quality measures essential to the transformation of the Veterans
Health Administration: Implications for nurses as co-creators of change. Journal of Nursing Care Quality, 15(4), 48 � 59.
Wilson Krueger, C.,
& Porter-O�Grady, T. (1999). Leading the revolution in health
care:
���� Advancing systems, igniting performance ( 2nd ed.). Gaithersburg, MD: Aspen.