Directing change

.
Presenter : Mr. Mahesh Kumar sharma
MSc Nursing
CON, AIIMS

Few quotations
 Only I can change my life. No one can do it for me.
 –Carol Burnett
 We all have big changes in our lives that are more or
less a second chance.
 Harrison Ford (1942 ),
 Things do not change; we change.
 Henry David Thoreau (1817 - 1862), Walden (1970)

Introduction
 Change is unavoidable, part of life. Few changes are
under our control.
 Some things we can intentionally change…our
behaviors, thoughts, feelings…habits.
 Successful, self-changing individuals follow a powerful
and, perhaps most important, controllable and
predictable course.

Introduction
 The key of successful change is to use the right strategy
for the right time.
 There are no magic pills, pins or plans.
 We can learn new skills, draw upon your inner
strength, enhance our self-sufficiency, and avoid
becoming dependent on others for solutions; thus
building our self-confidence for the future.
-changing for good (book)

CHANGE
 Definition of change: Implies making an essential difference, often
amounting to a loss of original identity or a substitution of one
thing for another.
Examples:
New email system
 Transition from paper to electronic
Requisitions
 Introduction of a new technology
 Distribution of workers in newly built
hospital building

Specific forces that are acting as
stimulants for change
 Nature of the workforce-
eg More cultural diversity
Increase in professionals
 Technology-
eg More computers and automation
 Economic shock-
eg Interest rate fluctuations
Foreign currency fluctuations

Specific forces that are acting
as stimulants for change
 Competition-
eg- Growth of new global competitors
 Social trends-
eg- Increase in college attendance
Delayed marriages by young people
 World politics eg: Collapse of Soviet Union
Iraq’s invasion of Kuwait

FORMS OF CHANGE
 Planned Change:
 To improve the ability of the organization to adapt to changes in its
environment.
 To change the behaviour of its employees.
 Unplanned Change:
 Changes in government regulations
 Changes in the economy.

Directing change
 Thoughtful planning
 Sensitive implementation of change in consultation
 And with the involvement of the people affected by
the changes.

Organizational change
It is any alteration in
People (attitudes, expectations, perception, behaviour).
Structure(work specialization, departmentalization ,chain of
command, span of control, centralization , formalization, job
redesign, actual structure design).

Organizational change Contd..
Technology (work processes, methods & equipment)

What provokes
Organizational Change?
Achievement of a goal.
Counteracting some major outside driving force.
eg.- substantial cuts in funding.
Evolving to a different level in their life cycle
eg. from traditional government to an e-
government.
Appointment of a new chief executive when his /her
new and unique personality and views, changes the
entire organization.

CHANGE MANAGEMENT
 Change management is not:
 Managing the “technical” side of change
 Just communication plans
 It is the process, tools and techniques to
manage the people-side of change to achieve
the required outcome.

Trans-theoretical model [TTM]
of behaviour change
This model explains the stages of individual behaviour change.
It is based on analysis and use of different theories of
psychotherapy; hence the name “trans-theoretical” model.

Trans-theoretical model [TTM] of
behaviour change

TMBC and quitting tobacco
 A tobacco user in this stage…
 Precontemplation
Gives no thought to quitting use, and has no intention
to quit in the near future (i.e., within next 6 months)
 Contemplation
Has begun to examine their tobacco use and desire to
quit; Is weighing the pros and cons of quitting tobacco

TMBC and quitting tobacco
 Preparation
Has made a commitment to quit (usually within next
30 days), and has begun developing a plan for quitting
 Action
Has put their plan for quitting tobacco into action (< 6
months)
 Maintenance
Has successfully sustained abstinence for at least 6
months

THE ROLE OF CHANGE AGENTS
 Change Agent -The individual or group who
undertakes the task of introducing and managing a
change in an organization.
 Change agents are of two types:
Internal Change Agents: are appointed to oversee the
change process, and they are from within the organization.
External Change Agents: are external , such as outside
consultants. They bring an outsider's objective view to the
organization.

Internal change agents
Advantages
 They know the organization's past history, its
political system, and its culture.
 Careful about managing change because they must
live with the results of their change efforts.
 Disadvantages
 May easily be accused of favouritism.
 As very close to the organization, devoid of an
objective view of what needs to be done.

External change agents
Advantages
 May be preferred by employees because of their
impartiality.
 If employees perceive the change agents as being
trustworthy, possessing important expertise, they are
easily accepted and can function well.
 Disadvantages
 Face certain problems, because of limited knowledge
about the organization's history.
 May be viewed with suspicion by the organization
members.

Theories on change
 Lewin’s theory
 Roger’s theory
 Reddin’s theory
 Havlock’s theory
 Spradley’s theory

KURT LEWIN ‘S THEORY OF
CHANGE
 UNFREEZING
 CHANGING
 REFREEZNG

STAGES OF ORGANIZATINAL
CHANGE
 UNFREEZING: Old ideas and practices has to be kept
aside, so that new ones can be learned.
 CHANGING : New ideas and practices are learned
helping an employee think, reason and perform in new
ways; it’s a time of confusion, disorientation, overload
and despair.
 REFREEZING : What has been learned is integrated
into actual practice or routine behaviour.

STAGES OF ORGANIZATINAL CHANGE contd..
 As the Organization works its way through these
stages, there can be a negative impact on Productivity.
This is referred to as the Productivity Dip.

APPLICATION OF LEWIN’S THEORY IN
NURSING
 Unfreezing: The nurse manager is motivated by the need
to create the change and affected nurses are made aware
of this need.
The need for change in nursing is assessed from
 Quality monitoring and benchmarking
 Patient complaints, or consumer consultation
 Reporting of adverse events
 Staff speaking up about obstacles, errors, or opportunities for
improvement.
Unfreezing reduces resistance and helps readiness for
change.

APPLICATION OF LEWIN’S
THEORY IN NURSING contd….
 Moving stage- Implementing the solutions identified as
most appropriate, for a planned change.
 Requires destabilising the equilibrium between the
forces ‘driving’ and ‘restraining’ the group.
 Restraining force -Lack of knowledge and skills acts
 Driving force-Training for staff to develop new skills required
in changed practice.

APPLICATION OF LEWIN’S THEORY IN NURSING
contd..
FREEZING: The new way of doing things is reinforced,
aligned with other organizational procedures and
routines, and thus, institutionalised .

Research study
Implementation of a nursing professional practice model of care in a
pediatric hospital.
 Mullen JE, Asher LM. Pediatr Nurs. 2007 Nov-Dec;33(6):499-504
 METHODOLOGY
 A children's hospital was selected to implement
professional practice model to optimize outcomes for
patients, families, nursing staff, and the organisation.
periodic education, into nursing procedures, and
assisting nurses in using the model at the bedside were
used to implement the model and sustain the
culture change
 RESULT:
 The model of care was successfully implemented in both
the inpatient and outpatient areas.

ROGER’S THEORY
 Everette Rogers modified Lewin's change theory and
created a five-stage theory of his own.
 The five stages are awareness, interest, evaluation,
implementation and adoption.
 This theory is applied to long-term change projects.
 It is successful when nurses who ignored the proposed
change earlier adopt it because of what they hear from
nurses who adopted it initially

REDDIN’S THEORY
 He has developed a planned change model that can be
used by nurses. Maximum information is important to
the success of change. At least announcements should
be made by management.
1. That a change will be made
2. What the decision is and why it was made
3. How the decision will be implemented
4. How the implementation is progressing

REDDIN’S THEORY CONTD….
 7 Techniques by which change can be
accomplished
1. Diagnosis
2. Mutual setting of objectives
3. Group Emphasis
4. Maximum information
5. Discussion of implementation
6. Use of ceremony and ritual
7. Resistance Interpretation

HAVLOC THEORY
 Havelock's theory of change is a linear model that generally
resembles Lewin's model, with an emphasis on planning and an
understanding of the possibility that people and systems may be
resistant to change.
 The 6 Aspects of Havelock's Theory of Change.
 Relationship. It states that relationship with the system in
need of change needs to be established. This could be regarded
as a stage of "pre-contemplation" where things are going along
as usual.
 Diagnosis. Once the agent of change is comfortable with the
system as it is, the person or entity being evaluated needing
change is evaluated to see if there is any awareness of a need for
change.
 Acquire resources for change. At this change, the need for
change is understood and the process of developing solutions
begins by gathering as much information as possible that is
relevant to the situation that requires change.

HAVLOC THEORY contd….
 Selecting a pathway. It is when a pathway of change is
selected from available options and then implemented.
 Establish and accept change. Once the change has been
put in place, it must be established and accepted.
 Maintenance and separation. Now that the change is
successful, the change agent should monitor the affected
system to make sure that it is successfully maintained

Spradley’s model of change
Based on Lewin’s theory the model has been developed;
8 step
model of change
The following are the steps :
1. RECOGNISE THE SYMPTOMS-There is evidence that
something needs change.
2. DIAGNOSE THE PROBLEM-Gather and analyse the
data to discuss the cause.
 Communicate with the staff.
 Read appropriate materials

Spradley’s model of change-contd
3.ANALYSE THE ALTERING SOLUTIONS-
 by brain storming, creative thinking
 assess the risks and benefits
 set a time ,plan resources and look for obstacles.
4.SELECT THE CHANGE:
Choose the option that is likely to succeed and
affordable.

5.PLAN THE CHANGE: It includes
 Specific measurable objectives and actions.
 A time table
 Plan the resources
 Budget
 An evaluation method such as programme evaluation
review technique(PERT).
 A plan for resistance management.

6.IMPLEMENT THE CHANGE-
 Plot the strategy
 Prepare involve, train, assist and support those who will be
affected by the change.
7.EVALUATE THE CHANGE-
 Analyse the achievement of objectives and audit.
8. STABILIZE THE CHANGE
 Refreeze. Monitor until stable.

RESEARCH STUDY
Making the transition to nursing bedside shift
reports.
Wakefield DS, Ragan R, Brandt J, Tregnago M. Jt Comm J Qual Pat 2012
BACKGROUND:
For hospitalized patients, nurse shift reports between
the off going and oncoming nurses, must include all
critical information about a patient's plan of care, and
that information must be well communicated.
METHOD:
Study compared bed side shift report with the routine
shift report and the difference and feasibility was
evaluated by examining baseline patient satisfaction
scores, reviewing the existing shift report processes, and
identifying potential barriers and facilitators in moving

RESEARCH STUDY CONTD..
RESULTS:
 For the first six months following implementation of
bedside shift reports, there were significant increase in
patient satisfaction scores from the 20th to > 90th
percentile when compared with similar nursing units in
peer institutions.
CONCLUSIONS:
 Although the transition to bedside shift reports met
with some resistance, the transition was made smoother by
extensive planning, training, and gradual implementation.
On the basis of this pilot study, the decision was made to
adopt bedside shift reports in all inpatient nursing units in
five hospitals.

ORGANIZATIONAL CHANGE
MANAGEMENT
 Two approaches to organization change:
 Organizational development(OD): Formal top -down
approach.
 Grass root approach: An unofficial and informal
bottom-up change.

Managing Organizational Change
 Change management requires a system of ‘doers’
Middle managers
and supervisors
Middle managers
and supervisors
Change
management
resource/team
Change
management
resource/team
Executives and
senior managers
Executives and
senior managers
Project
team
Project
team
Project
support
functions
Project
support
functions
Each ‘gear’ plays
a specific role
based on how
they are related
to change

Executives and senior managers
-role
1. Participate actively and visibly throughout the
project.
2. Communicate directly with employees.
Not just signing checks and project charters!

Middle managers and supervisors
-Why are they important?
 They are close to the people who adopt the change.
 They play a role in all types of change in the
organization.
 They need to be trained to be successful.

Middle managers and supervisors
-roles
Role 1 – Communicator
Role 2 – Advocate
Role 3 – Coach
Role 4 – Liaison
Role 5 – Resistance manager

Project team
Why are they important
Drive the technical side of change
 Design solutions
 Develop solutions
 Deliver solutions

Project team-role
1. Design the actual change.
2. Manage the ‘technical side’ of the change.
• schedule, resources, work breakdown structure, budget
etc.
3. Engage with change management team/resource.
4. Integrate change management plans into project
plan.

Project support functions
 Bring specific experience, knowledge, tools
and expertise to the project.
 Sometimes act as the change management
resource.
 Key pieces of the ‘technical’ and ‘people’ side.
 Eg: human resource department ,
communication , training etc.

How to accomplish organisational
change?
Get senior management agreement (i.e. conflicting goals can
kill the project!)
Identify a leader who can articulate the reasons for and
advantages of the change.
Translate the vision for change into a realistic plan and then
carry out the plan.
Involve people from every area of the organization.

Widely communicate the potential
need for change.
• Communicate what you're doing about it.
• Communicate what was done and how it worked out with the
help of examples.
• Communicate that Senior Management backs this strategy
unanimously.

Get as much feedback about
practical aspects from employees
• Include what they think the problems are and what should be
done to resolve them.
• If possible, work with a team of employees to see how to
manage the change.

Don't get wrapped up in doing
change for the sake of change
 Know why you are making the change
 What goals do you hope to accomplish?
 Communicate the goals.

Plan the change
 Plan how to reach the goals,
 What is required to reach the goals,
 How long might it take to accomplish the goals.
 Plan how will you know that , you have reached your
goals or not?
 Focus on the coordination of the
 departments/programmes from organization.

Delegate decisions to employees
as much as possible
• This includes granting them the authority and responsibility to
get the job done.
• As much as possible, let them decide how to do the project.

Managing organizational change
 Don't try to control change-but rather expect it,
understand it and manage it.
 Include closure in the plan- Acknowledge and celebrate
your accomplishments.
 Read some resources about organizational change-
including new trends ,forms and structures regarding
change management.
 Consider using a consultant- Ensure the consultant is
highly experienced in organization wide change.

Managing change-
role of manager
 Facilitate and enable change.
 Manage the change in a way that employees can cope
with it.
 Understand the situation from an objective
standpoint.
 Help people by make them to understand reasons,
aims, and ways of changing by responding positively,
according to employee’s own situations and
capabilities.
 Increasingly, the manager's role is to interpret,
communicate and enable - not to instruct and impose.

Strategies for advancing evidence-based
practice in clinical settings.
J N Y State Nurses Assoc. 2004
Levin RF, Melnyk BM.
BACKGROUND:
 Evidence-based practice (EBP) is a problem-solving
approach that incorporates the best available scientific
evidence, clinicians' expertise, and patients' preferences
and values.
METHODOLOGY:
 Researchers developed the ARCC (Advancing Research
and Clinical practice through close Collaboration) model
for the purpose of implementing EBP. A pilot study was
conducted to test the ARCC model at 2 acute-care sites.

Contd..
RESULT:
 This pilot study shows what all are necessary for the
successful implementation of EBP in the acute-care
setting. These essentials include identifying EBP leaders,
redefining nurse’s roles to include EBP activities,
allocating time and money to the EBP process, and
creating an organizational culture that fosters EBP.

Reasons for failure of change
management
 Research indicates that two-thirds of all organizational
changes fail. Some causes for failure are:
 A lack of commitment from the top.
 Change overload.
 Lack of incentives tied to the change initiative.
 A lack of training.

KEY POINTS IN DIRECTING CHANGE
 To move from good intentions to good results, there is a need
to realize that ,we (the “changers”) may be “living” in the
future state, while everyone else (“the changees”) is living in
the present.
 Effective change management MUST be focused on
individuals change.
 Individual change is a process.
 Need the right people involved and engaged in the right ways.
 Begin with end in mind.

Resistance to change
• Efforts by employees to block the intended change is referred
to as Resistance to Change.
• Any employee behavior designed to discredit, delay or
prevent the implementation of a work change is
known as resistance to change.

Unified social response to change
 Absenteeism
 Strike
 Demand
 Indifference
 Harder work
 Sabotage

How prevalent is Resistance to
Change?
 It is generally acknowledged that in an average
organization, when the intention for change is
announced:
 15% of the workforce is eager to accept it.
 15% of the workforce is dead set against it.
 70% is sitting on the fence, waiting to see
what happens.

Resistance to change
 Resistance to change can be categorized into two
sources:
1. Individual resistance
2. Organizational resistance.

Individual resistance to change:
Efforts by which an employee block the intended
change.
• Individual sources of resistance to change reside in
basic human characteristics such as perceptions,
personalities , needs etc.

Reasons for individual resistance
to change
1.Economic Reasons
 Fear of technological unemployment.
 Fear of increased work hours and less pay.
 Fear of demotion and thus reduced wages.
 Fear of speed-up and reduced incentive wages.

to change-contd
2.Fear of the Unknown: Change often bring substantial
uncertainty and ambiguity into what was once a
comfortable situation for them.
3.Fear of Loss: When a change is impending, employees
may fear losing their jobs, particularly when an advanced
technology is introduced .
4.Feeling Of Insecurity: change threatens their feeling of
safety.

to change-contd
5.Peer Pressure :Whenever change is unwilling to the
peers, they force the individual who want to accept
change to resist change.
6.Social Displacement: Introduction of change often
results in disturbance of the existing social relationships
ie. breaking up of work groups.

Reasons for Organizational
Resistance
1.Resource Constraints: Financial, material and human
resources may not be available to the organization to
make the needed changes.
2.Structural Inertia: In an organization where jobs are
narrowly defined, lines of authority are clearly spelled
out, change would be difficult.

Reasons for Organizational
Resistance-contd
3.Sunk Costs: Some organizations invest a huge amount
of capital as fixed assets. If an organization wishes to
introduce a change ,then difficulty arises because of
these sunk costs.
4. Threat to expertise: Change in organizational pattern
may threaten the expertise of specialized groups.
Therefore specialist usually resists change.

Management Of Resistance To
Change
Education and Communication:
 Communication about impending change
 The details of the change should be clear to the
employees- how, why, what….
 Make clear the rationale behind the change.

Change contd
Participation:
 It is difficult for individuals to resist a change decision
in which they are participating.
 Prior to making a change, those opposed can be
brought into the decision process.
 When employees are allowed to participate, they are
likely to assist the change.

Change contd
Empathy and Support:
 Provide empathy and support to employees
who have trouble in dealing with the change.
 Active listening is an excellent tool for
identifying the reasons behind resistance and
for uncovering fears.
 Negotiation:
 To exchange something of value for the
lessening of the resistance.
 Negotiation is a tactic when resistance comes
from a powerful source.

Change-contd
Manipulation:
 Manipulation refers to twisting and distorting facts to
make them appear more attractive, withholding
undesirable information and creating false rumours to
get employees to accept a change.

Change contd..
Coercion:
 Coercion is the application of direct threats or force on
the resisters.
 They essentially force people to accept a change by
explicitly or implicitly threatening them with the loss
of their jobs, promotion possibilities and transferring
them.
 Coercion is mostly applied where speed is essential in
implementing change and the change initiator
possesses considerable power.

Examples showing bad
‘management of change’
 The following employee excuses demonstrate that
change is being managed badly and that employees are
increasingly demotivated:
“it’s
not my
job”
“anyway
the boss
doesn’t
care”
”I’m
keeping
my head
down
this
time”
FAILURE

Repetitive Change Syndrome
 It is often caused by series of organizational initiatives
that are started ,but not completed, results in the
blurring up of the programmes.
 Although resistance to change can initiate changes, it
can also slow the pace of change and ultimately cause
it to fail.

Summary Change
 Organizational change
 Forms of change
 Trans theoretical model on behavioural change.
 Change agents
 Theories on change
 Individual change management
 Organizational change management
 Resistance to change

CONCLUSION
 Change must be continually managed to yield
sustained results.
 A consistent process of measuring the results of the
change initiative combined with a rewards program
that reinforces the desired behaviour is the backbone
of an effective change program.

“Everyone thinks of changing the
world, but no one thinks of
changing himself.”
Leo Tolstoy

 Change is the law of the universe. What you think of as death, is
indeed life. In one instance you can be a millionaire, and in the other
instance you can be steeped in poverty. Yours and mine, big and small -
erase these ideas from your mind. Then everything is yours and you
belong to everyone.”

References
 http://www.businessballs.com/changemanagement.ht
m
 Colin A. Carnall. “Managing change”4th edition, New
fetter lane, London,2007.pgs:7-48
 Managing change.pdf for Govt office for the South
West
 Stephen P. Robbins, Mary Coulter. “Organization and
management”pg:360-364
 Principles_ of management_ notes_ pdf

Directing change

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Editor's Notes