Lecturer – Olena Bidovanets
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Change is nothing new. In fact, it is often
said that change is the only constant.
Change, particularly in the health-care
environment, is complex and is
occurring at an unprecedented rate.
Change is driven by many factors: the
increasing cost of health-care delivery,
the nursing shortage, the rapid
advancements in technology and
information management, and new
expectations by the public to have a
more active role in health-care decisions.
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Meeting the health-care needs of the
world requires that the nurse be
proactive and creative in guiding
change. The ability to create and
manage meaningful change is an
essential skill for nurses in the 21st
century.
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Change fosters growth and innovation;
progress cannot occur without change. If
nurses are to be leaders of change, it is
imperative that they understand the
changes occurring in the health-care
arena, use political clout to have a hand
in the changes, and master the change
process. This chapter will introduce
readers to the principles of planned
change, barriers commonly encountered
when introducing change, strategies for
overcoming barriers, and the role of the
nurse as the change agent.

Change is an integral part of any
organization, and the process can be
uncomfortable and disturbing to those
who are affected. An awareness of the
elements common to the change
process is important.

Change means to be different, to cause
to be different, or to alter. Change may
be personal or organizational and can
occur suddenly or incrementally. Change
may be planned or unplanned.
Unplanned change, or reactive change,
usually occurs suddenly and in response
to some event or set of circumstances.
For example, an unanticipated rise in
patient census may precipitate the need
for a change in patient assignments.
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Decisions are made—and change
follows—as a reaction to an event.
Planned change, however, entails
planning and application of strategic
actions designed to promote
movement toward a desired goal.
Planned change is deliberate and
proactive. For example, changing
staffing patterns from extensive use
of unlicensed assistive personnel to an
all-professional staff requires time
and planning.

Specific strategies need to be
developed and implemented before
such a sweeping change is adopted.
Generally, planned change is more
likely to occur incrementally, over
time. Planned change responds to
anticipated events in the environment
or community.

Change may be initiated in response
to internal or external forces. Internal
forces stem from within the
organization. Internal forces include
organizational values and beliefs,
culture, and past experiences with
change.

External forces come from outside the
organization. These can be social
influences, economic factors, or
legislation.

Assumption 1 Change of any kind
represents loss. Even if the change is
positive, there is a loss of stability.
This loss of the familiar may produce
anxiety and even grief in many
individuals. The leader of change must
be sensitive to the loss experienced by
others.
Assumption 2
 The more consistent the change goal
is with the individual’s personal values
and beliefs, the more likely the change
is to be accepted. Likewise, the more
different the goal is from the
individual’s personal values, the more
likely it is to be rejected. The change
agent needs to know and respect the
values and beliefs of those most
affected by the change.

Assumption 3
 Those who actively participate in the
change feel accountable for the
outcome. The more people who are
involved in the process, the more the
group will feel responsible for the
outcome.

Assumption 4
 With each successive change in a
series of changes, individuals’
psychological adjustment to the
change occurs more slowly. It is for
this reason that the leader of change
must avoid initiating too many
changes at once. Timing is important.

Assumption 5
 Power is important to the change
process. Organizations with many
layers of hierarchy between the
initiator of change and the ultimate
decision makers may have difficulty
with implementing change. The
shorter the distance the change
proposal must travel from the initiator
to the decision maker, the greater the
likelihood that the change will be
accepted. Conversely, the greater the
distance, the more likely resistance


Assessing readiness for change is
generally the first step in any change
project. Until participants are ready for
change, little can be done to bring
about change. According to Terry
(1993), readiness for change is
assessed by answering the following
questions:
1. What is the ultimate purpose of the
action/ change?
 2. Why might I lead or be involved in
this change?
 3. What is at stake if I lead or
participate in this change action?
 4. What structures are in place either
to foster success or hinder the
change?
 5. Are the necessary resources
available to achieve this change
action?
 6. What is the stakeholders’ level of
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
Those wishing to bring about change
must develop strategies to foster
change. Bennis, Benne, and Chin
(1969), in their classic text, The
Planning of Change, identified three
strategies to promote change:
rational-empirical,
 normative-re-educative,
 power-coercive.
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Decisions about which strategies to
employ depend, to a great extent, on
three factors:
 the type of change planned,
 the power of the change agent,
 the amount of resistance expected.
These strategies may be used
independently or together. More often
than not, some combination of
strategies is indicated: the larger the
change and the more resistance
expected, the more strategies the
change agent must employ.
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This strategy assumes that people are
rational beings and will adopt a
change if it is justified and in their
self-interest. When using this
strategy, the change agent’s role
includes 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
emphasizes reason and knowledge. It
presents those affected by the change
with the knowledge and rationale they
need to accept and implement the
change.

This strategy is most useful when little
resistance to a change is expected.
The power of the change agent is
typically not a factor in changes
amenable to this strategy. This
strategy assumes that once given the
knowledge and the rationales, people
will internalize the need for the
change and value the result.
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A second strategy takes into account
social and cultural implications of
change and is based on the
assumption that group norms are
used to socialize individuals. This
strategy requires “winning over” those
affected by the change. Success is
often relationship-based; relationship,
not information, is the key to this
strategy.

The success of this approach often
requires a change in attitude, values,
and/or relationships. Sufficient time is
essential to the successful use of the
normative-re-educative strategy. This
strategy is most frequently used when
the change is based in the culture and
relationships within the organization.

The power of the change agent, both
positional and informal, becomes
integral to the change process. For
example, one of the most powerful
changes in recent history occurred
when the norm changed regarding
when to wear surgical gloves for
preventing the spread of infection.
More than knowledge (rationalempirical) and administrative
directives were needed to bring about
this change: it took a change in
cultural values that redefined the
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This strategy is based on power,
authority, and control. Political or
economic power is often used to bring
about desired change. The change
agent “orders” change, and those with
less power comply. This strategy
requires that the change agent have
the positional power to mandate the
change.
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Change effected by this strategy is
often based either on the followers’
desire to please the leader or fear of
the consequences for not complying
with the change. This strategy is very
effective for legislated changes, but
other changes accomplished using
this strategy are usually short-lived if
people have not embraced the need
for the change through some other
mechanism
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All changes have the potential for
both gain and loss. It is important to
identify all the potential barriers to
change, to examine them
contextually with those affected by the
proposed change, and to develop
strategies collectively to reduce or
remove the barriers. Barriers most
common to change within the healthcare environment are discussed below,
along with some strategies to
Change requires movement, which, as
physics indicates, is a kinetic activity
that requires energy to overcome
resistance. Also, as in physics, an object
at rest (and that includes an
organization) prefers to remain at rest.
Movement over barriers requires an
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A number of theories exist to explain
the change process. These theories
provide a framework within which to
guide change efforts. They are useful
for planning both personal change
and organizational change. Tiffany et
al. (1994) surveyed 176
nurseauthored journal articles dealing
with planned change. This study
identified the type and frequency of
planned change theories found in the
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Lewin’s Change Theory was most
commonly used as a framework for
change. Several other change theories
were also frequently referenced. A
brief description of Lewin’s theory,
along with Lippitt’s Phases of Change,
Havelock’s Six Step Change Model,
and Rogers’ Diffusion of Innovations
Theory, follows.
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These models of change are a mere
sampling of change models. They
provide a strong basis for
understanding change theory. Before
exploring the change theories,
consider this brief discussion of
change agents, an element in any
change theory.
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A change agent is the individual or
group that seeks to lead change. The
change agent may be from inside or
outside the organization. Change
agents may have formal lines of
authority or may be informal leaders.
In either case, the change agent is
responsible for moving those affected
by the change through the process
and implementing the change.

Effective change agents are masters of
change. They do three things
correctly: they sense the right moment
to initiate the plan, they find
supporters for their ideas, and they
have vision (Bruning, 1993).

The successful change agent earns the
respect and trust of the target system
(individuals, groups, or organizations)
by communicating openly and
honestly, offering assistance, and
demonstrating ability. A change
agent’s success depends on
communication and consultation style,
interpersonal skills, and expert power.
Ongoing communication is integral to
the role of the change agent
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Change is an inevitable part of life;
learning to lead change effectively is a
skill that can be cultivated and
mastered with practice. If you have
been given the responsibility of
leading an organizational change,
there are several practical steps you
can take to increase your chance for
success.
1. Begin by articulating the change
vision clearly and concisely.
 2. Select the change project team
carefully.
 3. Identify the formal and informal
leaders who can help you implement
the change successfully.
 4. Stay alert to political forces, both
for and against the change.
 5. Develop communication skills. Keep
communication lines open.
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6. Practice problem-solving skills.
 7. Develop conflict resolution skills.
 8. Learn to trust yourself and your
project team. Functioning effectively
as a change agent requires the nurse
to have an understanding of the
theoretical frameworks of change. A
discussion of several classic, as well
as emerging, theories of change
follows.
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