Chapter 8

Planned change

Many forces are driving change in contemporary healthcare, including rising health-care costs, declining
reimbursement, workforce shortages, increasing technology, the dynamic nature of knowledge, and a
growing elderly population. Contemporary healthcare agencies then must continually institute change
to upgrade their structure, promote greater quality, and keep their workers. In fact, most healthcare
organizations fi nd themselves under-going continual change directed at organizational restructuring,
quality improvement, and employee retention.

In most cases, these changes are planned. Planned change, in contrast to accidental change or change
by drift, results from a well thought out and deliberate effort to make something happen. Planned
change is the deliberate application of knowledge and skills by a leader to bring about a change.
Successful leader–managers must be well grounded in change theories and be able to apply such
theories appropriately.

Today, most healthcare organizations find themselves undergoing continual change directed at
organizational restructuring, quality improvement, and employee retention.

Still, change is not easy. Regardless of the type of change, all major change brings feelings of
achievement and pride as well as loss and stress. Indeed, Sutton (2009, p. 45) suggests that “the
importance of predictability in people’s lives is hard to overstate and that this has been demonstrated in
numerous studies.” The leader must use developmental, political, and rela-tional expertise then to
ensure that needed change is not sabotaged.

What often differentiates a successful change effort from an unsuccessful one is the ability of the
change agent—a person skilled in the theory and implementation of planned change—to deal
appropriately with these very real human emotions and to connect and balance all aspects of the
organization that will be affected by that change. In organizational planned change, the manager is
often the change agent.

In some large organizations today, however, multidisciplinary teams of individuals, repre-senting all key
stakeholders in the organization, are assigned the responsibility for managing the change process. In
such organizations, this team manages the communication between the people leading the change
effort and those who are expected to implement the new strategies. In addition, this team manages the
organizational context in which change occurs and the emotional connections essential for any
transformation.

It becomes clear that initiating and coordinating change requires well-developed leadership and
management skills. It also requires vision and expert planning skills because a vision is not the same as a
plan. The failure to reassess goals proactively and to initiate these changes results in misdirected and
poorly used fi scal and human resources. Leader–managers must be visionary in identifying where
change is needed in the organization. And they must be fl exible in adapting to change that they directly
initiated as well as change that has indirectly affected them. Display 8.1 delineates selected leadership
roles and management functions necessary for leader–managers acting either in the change agent role
or as a coordinator of the planned change team.

THE DEVELOPMENT OF CHANGE THEORY: KURT LEWIN

Most of the current research on change builds on the classic change theories developed by Kurt Lewin in
the mid-20th century. Lewin (1951) identifi ed three phases through which the change agent must
proceed before a planned change becomes part of the system: unfreezing, movement, and refreezing.

Display 8.1

Leadership Roles and Management Functions in Planned Change

LEADERSHIP ROLES

1. Is visionary in identifying areas of needed change in the organization and the healthcare system

2. Demonstrates risk taking in assuming the role of change agent

3. Demonstrates fl exibility in goal setting in a rapidly changing healthcare system

4. Anticipates, recognizes, and creatively problem solves resistance to change

5. Serves as a role model to followers during planned change by viewing change as a challenge and
opportunity for growth

6. Role models high-level interpersonal communication skills in providing support for followers
undergoing rapid or diffi cult change

7. Demonstrates creativity in identifying alternatives to problems

8. Demonstrates sensitivity to timing in proposing planned change

9. Takes steps to prevent aging in the organization and to keep current with the new realities of nursing
practice

MANAGEMENT FUNCTIONS

1. Forecasts unit needs with an understanding of the organization and unit’s legal, political, economic,
social, and legislative climate

2. Recognizes the need for planned change and identifi es the options and resources available to
implement that change

3. Appropriately assesses and responds to the driving and restraining forces when planning for change

4. Identifi es and implements appropriate strategies to minimize or overcome resistance to change

5. Seeks subordinates’ input in planned change and provides them with adequate information during
the change process to give them some feeling of control
6. Supports and reinforces the individual efforts of subordinates during the change process

7. Identifi es and uses appropriate change strategies to modify the behavior of subordinates as needed

8. Periodically assesses the unit/department for signs of organizational aging and plans renewal
strategies

Unfreezing occurs when the change agent convinces members of the group to change or when guilt,
anxiety, or concern can be elicited. Thus, people become discontented and aware of a need to change.
For effective change to occur, the change agent needs to have made a thorough and accurate
assessment of the extent of and interest in change, the nature and depth of motivation, and the
environment in which the change will occur.

Because human beings have little control over many changes in their lives, the change agent must
remember that people need a balance between stability and change in the workplace. Change for
change’s sake subjects employees to unnecessary stress and manipulation.

Change should be implemented only for good reasons.

The second phase of planned change is movement. In movement, the change agent identifies, plans,
and implements appropriate strategies, ensuring that driving forces exceed restraining forces. Because
change is such a complex process, it requires a great deal of planning and intricate timing. Recognizing,
addressing, and overcoming resistance may be a lengthy process and whenever possible, change should
be implemented gradually. Any change of human behavior, or the perceptions, attitudes, and values
underlying that behavior, takes time. Lewin suggested that this is because change, “even at the
psychological level, is a journey rather than a simple step. This journey may not be that simple and the
person may need to go through several stages of misunderstanding before they get to the other side”
(Warrilow, 2009, para 5).

The last phase is refreezing. During the refreezing phase, the change agent assists in stabilizing the
system change so that it becomes integrated into the status quo. If refreezing is incomplete, the change
will be ineffective and the prechange behaviors will be resumed. For refreezing to occur, the change
agent must be supportive and reinforce the individual adaptive efforts of those affected by the change.
Because change needs at least 3 to 6 months before it will be accepted as part of the system, the change
agent must be sure that he or she will remain involved until the change is completed.

Change agents must be patient and open to new opportunities during refreezing, as complex change
takes time and several different attempts may be needed before desired outcomes are achieved.

It is important to remember though, that refreezing does not eliminate the possibility of further
improvements to the change. Indeed, measuring the impact of change should always be a part of
refreezing. Display 8.2 illustrates the change agent’s responsibilities during the various stages of planned
change.
LEWIN’S DRIVING AND RESTRAINING FORCES

Lewin also theorized that people maintain a state of status quo or equilibrium by the simultaneous
occurrence of both driving forces (facilitators) and restraining forces (barriers) operating within any fi
eld. Driving forces advance a system toward change; restraining forces impede change.

The forces that push the system toward change are driving forces, whereas the forces that pull the
system away from change are called restraining forces.

Lewin’s model suggested that people like feeling safe, comfortable, and in control of their environment
and that they derive a strong sense of identity from their environment, including work (Warrilow, 2009,
para 3). Sutton (2009) agrees, suggesting that people do not embark on careers to feel powerless, since
the whole point of work is to achieve outcomes and have an impact. For change to occur then, the
balance of driving and restraining forces must be altered. The driving forces must be increased or the
restraining forces decreased.

Driving forces may include a desire to please one’s boss, to eliminate a problem that is undermining
productivity, to get a pay raise, or to receive recognition. Restraining forces include conformity to
norms, an unwillingness to take risks, and a fear of the unknown. In Figure 8.1, the person wishing to
return to school must reduce the restraining forces or increase the driving forces to alter the present
state of equilibrium. There will be no change or action until this occurs. Therefore, creating an
imbalance within the system by increasing the driving forces or decreasing the restraining forces is one
of the tasks required of a change agent.

Numerous factors affect successful implementation of planned change. Many good ideas are never
realized because of poor timing or a lack of power on the part of the change agent. For example, both
organizations and individuals tend to reject outsiders as change agents because they are perceived as
having inadequate knowledge or expertise about the current status, and their motives often are not
trusted. Therefore, there is more widespread resistance if the change agent is an insider. The outside
change agent, however, tends to be more objective in his or her assessment, whereas the inside change
agent is often infl uenced by a personal bias regarding how the organization functions.

Likewise, some greatly needed changes are never implemented because the change agent lacks
sensitivity to timing. If the organization or the people within that organization have recently undergone
a great deal of change or stress, any other change should wait until group resistance decreases.

Display 8.2

Stages of Change and Responsibilities of the Change Agent

STAGE 1—UNFREEZING

1. Gather data.

2. Accurately diagnose the problem.

3. Decide if change is needed.

 4. Make others aware of the need for change; often involves deliberate tactics to raise the group’s
discontent level; do not proceed to Stage 2 until the status quo has been disrupted and the need for
change is perceived by the others.

STAGE 2—MOVEMENT

1. Develop a plan.

2. Set goals and objectives.

3. Identify areas of support and resistance.

4. Include everyone who will be affected by the change in its planning.

5. Set target dates.

6. Develop appropriate strategies.

7. Implement the change.

8. Be available to support others and offer encouragement through the change.

9. Use strategies for overcoming resistance to change.

10. Evaluate the change.

11. Modify the change, if necessary.

STAGE 3—REFREEZING

Support others so that the change remains.