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Reading, Reflection, and application in Reality. By Shelley Jones. A professional development activity proudly brought to you by Nursing Review

Change management is a fundamental element in quality and improvement processes. It is also at the heart of leadership. Those implementing change need first to disrupt the status quo, secondly, to move everyone and everything involved to a new way of doing things, and finally, to ensure that the new practice and processes cannot change back to the former state. Change leaders are advised to do everything possible to predict and manage resistance to the proposed change. Ironically, suppressing resistance – rather than actively encouraging concerns and critiques to surface – compromises not only acceptance of the change process but also its robustness and sustainability. In this learning activity, we’ll revisit Lewin’s classic theory of planned change in the light of new thinking about resistance and readiness.

LEARNING OBJECTIVES

Reading and reflecting on this article will enable you to:

• Outline elements and stages in planned organisational change.
• Identify ways that resistance to change can be understood positively.
• Think about your own role and competence in relation to change management.

WHAT DRIVES ORGANISATIONAL CHANGE?

Organisations change to anticipate, adapt, or respond to change in their environments or to find ways to better fulfill their mission.

Revolutionary change (also referred to as strategic, radical, fundamental, ‘big-bang’, transformational change) involves sharp and simultaneous shifts across many organisational dimensions – structure, strategy, ideology, power relations, cultural systems of meaning, and control mechanisms. It is often thought to be driven by external political or market forces or other threats to the organisation’s viability, but internally, pressure to change and the capacity to take action is also necessary.

Evolutionary, incremental or convergent change fine-tunes an organisation without abandoning its basic structures and systems, nor the framework of shared interpretations and understandings held by organisation members.

Whether organisational change is considered revolutionary or evolutionary depends on the pace and scale of adjustment and upheaval: revolutionary change affects all parts of the organisation and happens relatively quickly; evolutionary change may happen differently in different parts of the organisation and happens relatively slowly and gradually. New technologies may be the driver or enabler in either scenario (1,2,3,4,5).

Change and stability in the health system

Articles on organisational change in health services often open with statements about the inevitability, increasing pace, and necessity of change – perhaps making change-weary readers feel even more weary. But what doesn’t change? The need for health services and health professionals’ willingness to provide them are two things that endure (6). Health care systems such New Zealand’s, or the National Health Service in the United Kingdom, have been subjected to large scale ‘redisorganisations’ (7) bringing about significant (and enduring) changes in health service structures, funding, and accountability. Yet, through all this, it can be argued that health professionals have retained significant control at a micro or clinical level (4,8).

The clinical level presents both the most potential to make real improvements in care, and, because any change must be negotiated within and between teams (which in turn, are part of interrelated systems), the most difficulty (9). Lewin’s work on planned change, tested in difficult social change projects, is relevant and helpful because it is based on the group – defined not on the basis of similarity or dissimilarity of individuals but their interdependence (10).

Goals for health service change

Change without a clearly identified causative reason can be viewed as ‘change for change’s sake’. But aims for innovation and improvement in health care identified in the United States11 present clear, compelling, and enduring goals for all health systems (12). By the acronym S-T-E-E-E-P, they are:

Safety – reducing treatment related injuries and harm to patients

Timeliness – reducing waits and delays throughout the health system

Effectiveness – increasing the reliability of care through an evidence base

Efficiency – reducing the total cost of care

Equity – reducing disparities in health outcomes

Patient centredness – giving patients and carers far more voice, control, and competence in self-management (11,12).

 

Change competencies

These goals certainly represent a challenge when contrasted with the need to competently manage change. This need is highlighted by reports that estimate:

• up to 70% of change initiatives do not succeed (13)
• the rate of quality improvement implementation in healthcare is less than 50% (14)
• translation of research findings into routine clinical practice may be delayed up to two decades (15).

Effective change implementation and building sustained change capability are emerging as general leadership requisites, but these are especially needed in complex organisations such as health services (5,13). Whether those involved in innovation or improvement processes see themselves as change managers, change leaders, or change agents, they need to be able to:

Create the case for change by effectively engaging others in recognising the business need for change.

Create structural change by ensuring that the change is based on depth of understanding of the issues and supported with a consistent set of tools and processes.

Engage others in the whole change process and building commitment.

Implement and sustain changes by developing effective plans and ensuring good monitoring and review practices are developed.

Facilitate and develop capability by ensuring that people are challenged to find their own answers and that they are supported in doing this (13).

 

Managing change: Resistance and readiness

Resistance

… no business survives over the long term if it can’t reinvent itself. But, human nature being what it is, fundamental change is often resisted mightily by the people it most affects: those in the trenches of the business. Thus, leading change is both absolutely essential and incredibly difficult (19).

Resistance to change has been described as any conduct that has the effect of maintaining the status quo in the face of pressure to alter it, and is often linked with negative attitudes and undermining behaviour (20). Even small scale incremental change designed to make a real difference in quality and safety of care for patients – at the front line – can find the would-be change agent feeling apprehensive about being taken out by ‘friendly fire’.

However, defensive or adversarial approaches designed to pre-empt resistance can provoke objections that weren’t there in the first place (20).

The idea that little or no resistance is the sign of a successful change project is being challenged in arguments for the utility of resistance. Most compelling is the idea that resistance contributes to robustness in the change process:

proposals that are not properly thought through, inappropriate, or just ‘plain wrong’ are questioned

more alternatives are generated and evaluated, from more perspectives, allowing the possibility of synthesizing different opinions and expertise (20).

Moreover, resistance to change can be seen as a legitimate and human response (20) that is

• preferable to acquiescence or apathy – which also threaten the likelihood of the change being implemented;
• often about the uncertainties and potential outcomes of a proposed change (rather than the change itself), especially as they impact on the individual or disrupt notions of equity within a team or between roles (1,2);
• to be expected if change feels imposed or there is a noticeable discrepancy between espoused values and what actually happens (2,6).

 

Readiness

[Good leaders] help people see and articulate what [is] wrong… make them intrinsically unhappy with the current state of affairs without demeaning their accomplishments or dishonouring their past in any way (21).

Accompanying a rethinking of resistance is new thinking on how to prepare for change more positively. This is an important consideration when change projects in health services are often prompted by some sort of failure or negative – perhaps audit results are not as they should be or a patient has been harmed in an adverse event. (An alternative approach to change, based on understanding what we do well, is appreciative inquiry (22,23,24)).

Armenakis and his colleagues (1) recommend that change managers communicate a consistent change message to convey the nature and meaning of the change, helping shape staff perceptions and responses. Their three stage change model (readiness – adoption – institutionalisation) incorporates social learning theory, which proposes that most behaviour is learned through observation and modelling (25).

According to Armenakis et al an effective change message has five elements:

• Discrepancy ‘We know we need to change’
• Appropriateness ‘We have agreed this is the right change to make’
• Efficacy ‘We can cope with change and we have the capability to change successfully’
• Principal support ‘Those the change affects are behind it, and it has the support it needs’
• Personal valence ‘It is in my best interest to change’ (1)

For this message to be credible, it must be congruent with experience – the staff feel they have been involved and consulted, they have the skills, and they can see what it will mean for their practice.

What is your position?

If leadership is a social influence process, in which connectedness between the leader and the individual is the most powerful component (26), where in the organisation should commitment, capability, and competencies for leading change be positioned?

Executive level leadership – ‘from the top’ – is critical in strategic or fundamental change which involves the culture or identity of the organisation. However, there are arguments that – especially in large and complex health service organisations – ‘distant’ executive leaders (while actively supporting innovation and improvement) cannot do what ‘close’ or ‘nearby’ first-line and middle managers are well positioned to do, which is having the ongoing conversations that facilitate understanding and learning at the clinical level (12,13,26). Those with change agent roles (for example, leading an improvement project) may not have the positional power of line management, but their expertise and ability to work with people gives them credibility (27).

These roles (your role perhaps) integrate organisational strategy with operations and bridge management and professional cultures (8). Critically, it is at the team level that leaders can build a supportive social climate that buffers the agitating and distracting effects of any uncertainty for the wider organisation (28). They can help staff make sense of a change process by telling the change message consistently. One study found managers simultaneously using ‘progressive narratives’ about the ‘what’, ‘how’, and ‘why’ of change, along with ‘stability narratives’, which preserved existing messages about the organisation’s purpose (29). Being close to the work, they have an immediate and continuous influence over the mundane but critical business of changing habits and routines (30).

In ‘nearby’ leadership roles it is possible to see what practical steps should be taken to support the skill development required, and to make it happen. An example is a study of a challenging technology adoption (cardiac surgery) where the successful teams had carefully selected their members, ran practice sessions (which created psychological safety and helped develop a shared mental model of the new procedure), and reviewed their learning to create further improvement (3).

Leadership near the front line is well placed to recognise the pressures on individuals to work harder and deliver continuous improvements in performance (13), and therefore, to advocate for autonomy, realistic expectations and resources for specific change efforts, and building change capability within the team (28).

Following Lewin’s belief that learning is the process that enables individuals to understand and restructure their perceptions of the world around them10, change leaders can reframe change itself as a process of managed learning (3,16), and learning as an enabler of change that empowers and transforms individuals and teams in their work (31).

Looking at it this way, is the managing of meaning in change a role you can take?

LEWIN’S PLANNED CHANGE THEORY

Kurt Lewin (1890-1947), recognised by his contemporaries as an innovative and influential social scientist, is mainly remembered today for just one part of his Planned Change theory – the 3 Step Model (10).

His deep commitment to democratic values caused him first to flee Nazi Germany for America and then informed a programme of research encompassing diverse aspects of social conflict, including problems experienced by minority and disadvantaged groups.

The result of Lewin’s theory development and humanitarian research was an approach to Planned Change. It integrates four elements designed to be taken as a whole:

• Field Theory and Group Dynamics, which explain how groups are formed, motivated, and maintained, and
• two methods to change group behaviour, Action Research and the 3 Step Model.

Critics of the 3 Step Model as outdated or simplistic have been referred to this larger conceptual framework as providing answers to their points (10), and it’s worth highlighting that the model focuses on changing group perceptions and behaviour (because individuals conform to group pressures) rather than concentrating on individual behaviour.

Schein uses Lewin’s own famous dictum, ‘There is nothing so practical as a good theory’, to commend the 3 Step Model as a framework for understanding human change as a profound psychological process involving painful unlearning and difficult relearning (16).

Transition through stages of change described in the 3 Step Model is evident in many models of change.

 

3 Step Model for a planned change process

Unfreezing: Motivation to change comes from accepting that the current situation is not satisfactory, a desire or sense of obligation to address what is not right, and critically, so that people don’t take defensive positions or deny the existence of a problem, a safe psychological environment (16). Information or insights that challenge the validity of the status quo may come from quality monitoring and benchmarking, patient complaints, or consumer consultation, investigation of adverse events or near misses, or staff speaking up about obstacles, errors, or opportunities for improvement (17). Unfreezing reduces resistance and helps readiness for change.

Moving: Implementing the solutions identified as most appropriate (in a participative and collaborative action research process) also requires destabilising the equilibrium between the forces ‘driving’ and ‘restraining’ the group. For example, lack of knowledge and skills acts as a restraining force, but implementing training for staff to develop new skills required in changed practice becomes a driving force. Simply increasing the expectation of changed performance, without decreasing the difficulty of making the changes, means ‘higher aggressiveness, higher emotionality, and lower constructiveness’ (18).

Refreezing: Without new norms, policies, and practices to act as forces holding group attitudes and behaviour in a new equilibrium – and congruent with what the group values – performance may drift back to return to its earlier state. The new way of doing things must be reinforced, aligned with other organisational procedures and routines, and thus, institutionalised (2,10). For instance, making the new behaviour count helps it to stick: ‘What gets measured gets done, what gets rewarded gets done repeatedly’.

QUESTIONS THIS ARTICLE MIGHT PROMPT YOU TO ASK YOURSELF

• How might Lewin’s 3 Step Model be useful in the next change process I am involved with?
• Do I resist change processes at work? What are my reasons?
• Is there a change process I know of that went well? What helped people be ready?

 

Recommended reading and resources

Articles

• WADDELL D & SOHAL AS (1998) Resistance: A constructive tool for change management. Management Decision 36(8):543–548.
• EDMONDSON AC, BOHMER RM & PISANO GP (2001) Disrupted routines: Team learning and new technology implementation in hospitals. Administrative Science Quarterly 46(4):685-716.

 

Web resources

Published in Harvard Business Review in 1995, Kotter’s classic short article, Leading Change: Why Transformation Efforts Fail is available here http://cerc.stanford.edu/leading_change.PDF

At the United States based Institute for Healthcare Improvement, sign in (free) to the online IHI knowledge centre to access the ‘Changes for Improvement’ resource page www.ihi.org/knowledge/Pages/Changes/default.aspx where you can download a white paper: REINERTSEN JL, BISOGNANO M, PUGH MD (2008) Seven Leadership Leverage Points for Organisation-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008.

On this webpage you will find a useful set of short articles by Helen Bevan, Chief of Service Transformation at the NHS Institute for Innovation and Improvement: bit.ly/xMzPr5

It’s worth exploring short courses in massive open online courses (MOOCs). For instance, at the Stanford led www.coursera.org/ relevant topics include leading strategic innovation in organisations, healthcare innovation and entrepreneurship, and organisational analysis.

About the author:

Shelley Jones RN BA MPhil has been working in nursing professional development for 30 years.

Acknowledgements:

Thank you to peer reviewers Sam Denny and Faith Roberts for their helpful critique.

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