To improve is to change; to be perfect is to change often. - -Winston Churchill
How do we facilitate change? Change is essential in order to adapt to a changing environment and continue with growth and prosperity. Change is inevitable. Change occurs in our personal lives, our workplaces, and yes, even in our professional organizations. Change should be embraced and considered necessary to survive in today's world of technical advancements and medical discoveries. Health care has never been as flux as it is today. So change is necessary, like it or not.
Nurses have always been exposed to change. Flexibility is necessary for our survival as a nurse and especially in our day-to-day patient encounters. Many of us just go with the flow so to speak and may have never considered the formal process of initiating change and sustaining that change. Even today, there are individuals who are reluctant to change and are very satisfied with the status quo. Status quo does not allow growth and development. Or others may have seen change initiatives that we less than successful. I want to briefly discuss models of change that have been proven to facilitate change and its success.
MODELS OF CHANGE
Even the American Society of Plastic Surgical Nurses (ASPSN) has recognized change that was necessary for our growth and prosperity. When considering change it is not uncommon to feel uneasy and intimidated by that challenge to change. We all get comfortable with the status quo and oftentimes we think why rock the boat. It is working or at least we think it is. Change is healthy and challenging so change must be encouraged and embraced. With the rising specialty of anesthetic nursing, the ASPSN recognized the need for change in order to promote patient safety and developed a certification examination to distinguish those aesthetic providers as experts in this specialty area. This change has been embraced by our members and even practicing providers outside our membership. Why do you think this was a change that was accepted and supported by our membership? I am not sure any formal change model was used to analyze and promote this change, but I thought it might be interesting to evaluate some change models for future reference. There are specific models of change that have been shown to be effective. I will briefly present some of these models that may assist with future changes in our organization and even in your professional lives.
LEWIN'S CHANGE MODEL
Lewin's, a social scientist, change model is based on the work of Lewin's Force Field Analysis (1947). From the 1950s until the early 1980s, theories concerning organizational change were dominated by Lewin's planned change approach. Lewin's change model provides a framework for identifying group behavior by recognizing the division in the field in which the behavior occurs (Burnes, 2004). Burnes (2004) further states that some forces within an organization desire change, the driving forces, whereas others strive to maintain the status quo or restraining force. Lewin proposed that change in behaviors will occur from changes in the forces or energies within the environment (Lewin, 1947). Lewin advised that if one could identify and understand these forces, one could understand why persons behave as they do (Burnes, 2004). Of note, Lewin's model does not replace organizational analysis methods such as strategic planning but offers an innovative and practical theoretical enhancement that can be advantageous in building a process for change (Medley & Akan, 2008).
Lewin's model brings together four complex integrated elements: (1) field theory, which seeks to map the totality of human behaviors taking place; (2) group dynamics, which seeks to understand the behavior of groups; (3) action research, which requires analyzing the situation and choosing the best change for the situation; and (4) the three-step planned change model, consisting of an unfreezing human behavior that is supported by a complex field of driving and restraining forces, moving to learn new behaviors and effectuating desired changes, and refreezing an equilibrium to ensure new behaviors or, more commonly known, as "unfreeze, change and refreeze" (Medley & Akan, 2008).
Unfreeze, the first step, is preparing the organization that change is necessary and that breaking the existing status quo will be necessary. One must develop a convincing argument as to why the change is necessary. This may be used when the evidence supports doing a nursing intervention as a new way improves patient safety and outcomes, supporting evidence-based practice. This step may be the most difficult when the old ways of doing things are challenged. This may evoke strong reactions in the individuals that the change impacts.
The second step is the change. In this stage individuals begin to resolve uncertainty and look for new ways of doing things. Individuals believe in the change and start to behave in ways that support the new change. This transition takes time as individuals take time to embrace change and understand how it will benefit them. Time and communication are keys to success for the change to occur.
Refreeze, the third step, is when the change is taking shape and individuals embrace the new change and the organization is ready to refreeze. The purpose of this step is to stabilize the new equilibrium resulting from the change by balancing both the driving and restraining forces. This step needs to take place after the change has been implemented in order for it to be sustained over time. If this step is omitted, it is likely that the change will be short-lived and individuals will revert to their old behaviors. New patterns and institutionalizing them through new policies and procedures can implement this third step. Lewin's model of change offers fundamental ideas for successful and planned organizational change and insight into the change process for all organizations (Medley & Akan, 2008).
LIPPITT'S PHASES OF CHANGE THEORY
Lippitt, Watson, and Wesley (1958) extended Lewin's three-step theory and created a seven-step theory that focuses more on the role and responsibility of the change agent than the evolution of the change itself. Information is continuously exchanged throughout this process (Kritsonis, 2005). The seven steps are (1) diagnose the problem; (2) assess the motivation and capacity for change; (3) assess the resources and motivation of the change agent, which includes their commitment to change, power, and stamina; (4) choose progressive change objects including developing plans of action and strategies; (5) the role of the change agent should be selected and clearly understood by all parties so that expectations are clear; (6) maintain the change including communication, feedback, and group coordination, which are essential for this step; and (7) gradually terminate from the helping relationship with gradual withdrawal of the change agent. This will only occur when the change becomes part of the organization (Kritsonis, 2005). ASPSN leadership must serve as a change agent and incorporate a culture of giving to the Plastic Surgical Nursing Foundation within our organization. This will only be successful when this change is part of ASPSN culture of giving.
KOTTER'S EIGHT-STEP CHANGE MODEL
Kotter, a professor at Harvard Business School and world-renowned change expert, first published his change model in 1995 and in greater detail in his book titled Leading Change (Kotter, 1996). Kotter's model has been criticized because he cited no references and it was solely based on personal experience and research. Appelbaum, Habashy, Malo, and Shafiz (2012) revisited Kotter's change model and found support for most of the steps but determined the model's popularity was due to its direct and usable format rather than from any scientific consensus on the results. They further found no evidence against Kotter's change model and concluded it remains a recommendable reference (Appelbaum et al., 2012).
The first step of Kotter's model is to create urgency. For change to happen it helps if everyone really wants the change and develops a sense of urgency. This urgency creates the motivation to get things moving. This requires honest communication and convincing dialogue about what is happening in health care, specifically plastic surgical nursing, to convince stakeholders change is necessary. People will not change if they cannot see the need for the change. The change must be understood otherwise the change agents will not have enough power and credibility to initiate the change. This will requires strong and honest leadership.
The second step of the model of change is to create a guiding coalition. No one person is capable of single handedly leading and managing the change process in an organization (Appelbaum et al., 2012). Be leery of such an individual. Putting together, a guiding coalition of people to lead a change initiative is critical. Have enough key players on board so that those left out cannot block progress. You need expertise so that all relevant points of view can be represented so that informed intelligent decisions can be made. The coalition should be credible and respected by others so that ideas and decisions will be taken seriously. Above all, the coalition should have enough proven leaders to be able to drive the change process (Appelbaum et al., 2012). This may be the Board of Directions or a Task Force of leaders and experts within our organization.
Step thee of Kotter's model is to develop a vision and strategy. The ASPSN revised our vision and strategic plan in 2015. According to Kotter the vision should be clear and concise. The importance of a clear and concise vision is more in implementation of that vision than the vision itself (Appelbaum et al., 2012). One would have to agree. The vision of the ASPSN is words and without implementation is meaningless. It is up to us to follow our strategic plan to execute that vision.
The fourth step to Kotter's model is to communicate the vision. Communication is crucial to any change and can reduce uncertainty. Complaints of inadequate communication can undermine any proposed change. Communication should be done frequently, powerfully, and embedded within everything you do using multiple avenues (i.e., internet, newsletter, journal, and face-to-face). It should be talked about with every opportunity, and the vision should be used daily in making decisions and solving problems. Leaders and change agents must "walk the talk" because what one does is more important than what one says. Demonstrate the behavior that is ideal for others.
Kotter's fifth step is to empower broad-based action to remove obstacles. An obstacle may be other members who are reluctant to change. It is important for the communication to be sufficient, but this alone may not be able to alleviate obstacles. Put together, the structure for change and continuously check for and evaluate for barriers. Identify people who are resisting change and help them see the need for the change. Empowering individuals involves addressing four major obstacles: structure, skills, systems, and supervisors or leaders (Appelbaum et al., 2012). The true leaders of the organization should be identified as well as stakeholders and ask for commitment from these key individuals. Work on team building within the coalition or group and foster support and commitment to the change. This will help alleviate obstacles.
The sixth step of Kotter's model is to create short-term wins. Seeing the changes happening and the work being done toward achieving the change toward achieving the longer-term goals is critical (Kotter, 1995). Nothing motivates more than success and setting short-term achievable goals maintains motivation. Meeting short-term goals demonstrates that the change effort is paying off.
The seventh step to Kotter's model is to build on the change. Consolidate these short-term gains and produce more change. Real change runs deep, and these short-term goals are only the beginning of what needs to be accomplished to reach that long-term change. Each success allows for an analysis of what went right and what needs improving. Change is continuous and keeps ideas fresh (Kotter, 1995).
Kotter's eight and last step is to anchor the changes into the culture. For the change to occur and be successful, it must become part of the core of our organization. The culture determines what gets done so the values behind our vision must show in our day-to-day operations. Leaders must continue to support that change as well as new immerging leaders. Communicate the progress at each and every opportunity and commend those who have contributed to the change.
There are limitations to Kotter's model. Some argue the approach is too rigid as Kotter argues that the eight steps should be followed in sequence and that extended overlapping steps are requisite of one another (Kotter, 1995). Others argue that certain steps may not be necessary (Appelbaum et al., 2012). Appelbaum et al. (2012) found evidence to support most of the steps are relevant and useful today, and importance of maintaining the eight steps in sequence remains under investigation.
SOCIAL COGNITIVE THEORY
Social cognitive theory is another model to facilitate change. In social cognitive theory human behavior is regulated and motivated by ongoing self-influence and individuals can learn by direct experiences, human dialogue and interaction, and observation (Bandura, 1991). This theory proposes that behavior change is affected by the environmental influences, personal factors, and attributes of the behavior itself (Bandura, 1991,1996). This theory is probably the most familiar especially to nurses as perceived personal benefit will promote healthy behaviors such as in managing hypertension or diabetes. With the social cognitive theory the individual must possess self-efficacy (Kritsonis, 2005). In other words, the individual must believe in their capability to perform the behavior and perceive that there is an incentive to do so. Behaviors are a result of consequences and individuals react to how they perceive the consequences of their behavior. Social learning will occur if the individual's positive expectations of the behavior outweigh the negative expectations. Consequences or outcomes may be classified as having immediate or long-term benefits. Self-efficacy is believed to be the most important characteristic that determines an individual's behavioral change. Self-efficacy can be increased by providing clear instructions; provide the opportunity for skill development or training, and model the desired behavior. The change is more apt to occur if the change relates to something they care about.
SUMMARY
The models presented are by no means exhaustive but are meant to stimulate the understanding of change and the processes that make change effective. Certain themes became evident in all models discussed here. The first theme is that change has to be seen as beneficial to all stakeholders. The second theme is that there has to be open and frequent communication between all stakeholders. The third theme involves new behaviors or change must become the culture of the organization in order to be sustained. And lastly, strong leaders are necessary to lead the change efforts. No one model will fit each organization or every situation. Leaders, as the change agents, must walk the talk and live by example. Change is inevitable. Embrace it and grow with it.
Respectfully submitted,
Marcia Spear, DNP, ACNP-BC, CWS, CPSN, CANS
President, ASPSN
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