CHAPTER

8
Planned Change

Most importantly, leaders must be able to

translate the demand for change into a clear and
understandable plan for those who must manage
the change and incorporate it into their lives
and work.
—Tim Porter-O’Grady

170
 CHAPTER 8 ■ Planned Change 171

Most organizations today find themselves undertaking a number of projects as

part of change efforts directed at organizational restructuring, quality improve-
ment, and employee empowerment. Many things drive change in contemporary
health care, among them are increasing technology, information availability, and
growing populations.
In the nursing profession the need for change has never been greater. Bednash
(2003) maintains that change is needed in both the practice of nursing and in the
systems that nurses use to deliver care. A fundamental difference in management
and leadership is that managers maintain the status quo and leaders embrace
change (Trent, 2003). Learning how to manage change was listed as one of the
major components necessary when developing future nurse leaders (Scobie and
Russell, 2003). The integrated leader–manager is well grounded in change theories
and applies such theory appropriately.
Regardless of the type of change, all major change brings feelings of achieve-
ment, loss, pride, and stress. What differentiates a successful change effort from an
unsuccessful one is often the ability of a 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.
It becomes clear, then, that initiating and coordinating change requires well-
developed leadership and management skills. Dye (2000) goes so far as to say that one
of the most fundamental values that differentiate effective leaders from average leaders
is the desire to “make a difference.” This value encourages effective leaders (change
agents) to become high achievers, to seek out and address flaws and to implement pos-
itive change to improve the organizations in part and society as a whole.
Being an effective change agent requires expert planning skills. This includes
planning for changing needs. The failure to reassess goals proactively and initiate
these changes results in misdirected and poorly used fiscal and human resources.
Not only must leader–managers be visionary in identifying where change is needed
in the organization, but they also must be flexible in adapting to change they have
directly initiated or by which they have been indirectly affected.
Planned change, in contrast to accidental change or change by drift, is change that Planned change occurs
results from a well thought-out and deliberate effort to make something happen. because of an intended
Planned change is the deliberate application of knowledge and skills by a leader to effort by a change
bring about a change. This type of planning requires the leadership skills of problem agent to deliberately
solving and decision making and interpersonal and communication skills. move the system.
Planned change occurs because of an intended effort by a change agent to deliber-
ately move the system. A change agent is the person responsible for moving others who
are affected by the change through its stages. Changes are implemented slowly after
consultation with others. In planned change, the manager is often the change agent. In
some large organizations today, multidisciplinary teams of individuals, representing 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
can occur and the emotional connections essential for any transformation.
172 UNIT 3 ■ Roles and Functions in Planning

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 health-
care system.
2. Demonstrates risk taking in assuming the role of change agent.
3. Demonstrates flexibility 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 subordinates 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 fol-
lowers undergoing rapid or difficult 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 nursing current with the
new realities of nursing practice.

Management Functions
1. Forecasts unit needs with an understanding of the organization’s and unit’s legal, polit-
ical, economic, social, and legislative climate.
2. Recognizes the need for planned change and identifies the options and resources avail-
able to implement that change.
3. Appropriately assesses the driving and restraining forces when planning for change.
4. Identifies and implements appropriate strategies to minimize or overcome resistance to
change.
5. Seeks subordinates’ input in planned change and provides them with adequate infor-
mation 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. Identifies and uses appropriate change strategies to modify the behavior of subordi-
nates as needed.
8. Periodically assesses the unit/department for signs of organizational aging and plans
renewal strategies.

Display 8.1 delineates selected leadership roles and management functions nec-
essary for leader–managers acting either in the change agent role or as a coordinator
of the team.

THE DEVELOPMENT OF CHANGE THEORY

Most of the current research on change builds on the classic change theories devel-
oped by Kurt Lewin in the mid-20th century. Lewin (1951) identified three phases
through which the change agent must proceed before a planned change becomes
part of the system: unfreezing, movement, and refreezing.
 CHAPTER 8 ■ Planned Change 173

In the unfreezing stage, the change agent unfreezes forces that maintain the status
quo. Thus, people become discontented and aware of a need to change. Unfreezing
is necessary because before any change can occur, people must believe the change is
needed. Unfreezing occurs when the change agent convinces members of the group
to change or when guilt, anxiety, or concern can be elicited. 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. Change should be implemented only
for good reasons. Because human beings have little control over many changes in
their lives, the change agent must remember that people need a balance between sta-
bility and change in the workplace. Change for change’s sake subjects employees to
unnecessary stress and manipulation.

Learning Exercise 8.1

Unnecessary Change
Try to remember a situation in your own life that involved unnecessary
change. Why do you think the change was unnecessary? What types of
turmoil did it cause? Were there things a change agent could have done
that would have increased unfreezing in this situation?

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. Whenever possible, change should be
implemented gradually. Because change is such a complex process, it requires a
great deal of planning and intricate timing. Recognizing, addressing, and over-
coming resistance may be a lengthy process. Any change of human behavior, or
the perceptions, attitudes, and values underlying that behavior, takes time.
Therefore, any change must allow enough time for those involved to be fully
assimilated in that change.
The last phase is refreezing. During the refreezing phase, the change agent
assists in stabilizing the system change so it becomes integrated into the status quo.
If refreezing is incomplete, the change will be ineffective and the pre-change
behaviors will be resumed. For refreezing to occur, the change agent must be sup-
portive and reinforce the individual adaptive efforts of those affected by the change.
Because change needs at least three to six months before it will be accepted as part
of the system, change should never be attempted unless the change agent can make
a commitment to be available until the change is complete.
It is important to realize that refreezing does not eliminate the possibility of further
improvements to the change. Display 8.2 illustrates the change agent’s responsibilities
during the various stages.
174 UNIT 3 ■ Roles and Functions in Planning

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 the change remains

Lippitt, Watson, and Westley (1958) built on Lewin’s theories in identifying

seven phases of planned change:

1. The patient must feel a need for change. Unfreezing occurs.

2. A helping relationship begins between the change agent and his or her
patients. Movement begins.
3. The problem is identified and clarified. Data are collected.
4. Alternatives for change are examined. Resources are assessed.
5. Active modification or change occurs. Movement is complete.
6. Refreezing occurs as the change is stabilized.
7. The helping relationship ends, or a different type of continuing relationship
is formed.

Murphy (1999), in a more contemporary model, suggests that there are four
predictable stages that people pass through when exposed to any change: resist-
ance, confusion, exploration, and commitment. There are predictable behaviors
associated with each of these stages, and the most effective managers study these
behaviors and are able to respond appropriately to get their team back on track
toward the goals.
 CHAPTER 8 ■ Planned Change 175

Display 8.3 Ten Emotional Phases of the Change Process

1. Equilibrium: Characterized by high energy and emotional and intellectual balance.
Personal and professional goals are synchronized.
2. Denial: Individual denies reality of the change. Negative changes occur in physical,
cognitive, and emotional functioning.
3. Anger: Energy is manifested by rage, envy, and resentment.
4. Bargaining: In an attempt to eliminate the change, energy is expended by bargaining.
5. Chaos: Characterized by diffused energy, feelings of powerlessness, insecurity, and
loss of identity.
6. Depression: Defense mechanisms are no longer operable. No energy left to produce
results. Self-pity apparent.
7. Resignation: Change accepted passively but without enthusiasm.
8. Openness: Some renewal of energy in implementing new roles or assignments that
have resulted from the change.
9. Readiness: Willful expenditure of energy to explore new event. Physical, cognitive, and
emotional reunification occurs.
10. Reemergence: Person again feels empowered and begins initiating projects and ideas.
Adapted from Perlman, D., & Takacs, G. J. (1990). The ten stages of change. Nursing Management, 21(4), 33–38.

Perlman and Takacs (1990), building on Lewin’s work, identified 10 such

behaviors or emotional phases in the change process (Display 8.3). The phases of
equilibrium, denial, anger, and bargaining reflect Lewin’s unfreezing phase; chaos,
depression, and resignation, the movement phase; and openness, readiness, and
reemergence, the refreezing phase. Regardless of the number of phases or their
names, it is critical that the manager recognizes that organizations must consciously
and constructively deal with the human emotions associated with all phases of
planned change.
Quinn, Spreitzer, and Brown (2000) state that any real adaptive change can be
achieved only by mobilizing people to make painful adjustments in their attitudes,
work habits, and lives. They must “surrender their present selves and put themselves
in jeopardy of becoming part of an emergent system. This process usually requires
the surrender of personal control, the toleration of uncertainty, and the development
of a new culture at the collective level and a new self at the individual level” (p. 147).

DRIVING AND RESTRAINING FORCES

Lewin also theorized that people maintain a state of status quo or equilibrium by
the simultaneous occurrence of both driving and restraining forces operating within
any field. The forces that push the system toward the change are driving forces,
whereas the forces that pull the system away from the change are called restraining
forces. Lewin’s model maintained that for change to occur, the balance of driving
and restraining forces must be altered. The driving forces must be increased or the
restraining forces decreased.
176 UNIT 3 ■ Roles and Functions in Planning

Figure 8.1 Driving and restraining forces.

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, cre-
ating an imbalance within the system by increasing the driving forces or decreasing
the restraining forces is one of the tasks required for a change agent.

A
Learning Exercise 8.2

Making Change Possible

Identify a change that you would like to make in your personal life (such
as losing weight, exercising daily, or stopping smoking). List the restrain-
ing forces keeping you from making this change. List the driving forces
that make you want to change. Determine how you might be able to
change the status quo and make the change possible.

Numerous factors affect successful implementation of planned change. Many

Many good ideas are good ideas are never realized because of poor timing or a lack of power on the part
never realized because of the change agent. For example, both organizations and individuals tend to reject
of poor timing or a lack outsiders as change agents because they are perceived as having inadequate knowl-
of power on the part of edge or expertise about the current status, and their motives often are not trusted.
the change agent. Therefore, there is less 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 influenced by a personal bias regarding
how the organization functions.
 CHAPTER 8 ■ Planned Change 177

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.

CHANGE STRATEGIES
Three commonly used strategies for effecting change in others were described by
Bennis, Benne, and Chinn (1969). The appropriate strategy for any situation
depends on the power of the change agent and the amount of resistance expected
from the subordinates. One of these strategies is to give current research as evidence
to support the change. This group of strategies is often referred to as rational–
empirical strategies. The change agent using this set of strategies assumes that resist-
ance to change comes from ignorance or superstition (Quinn, Spreitzer, & Brown,
2000) and that humans are rational beings who will change when given factual
information documenting the need for change. This type of strategy is used when
there is little anticipated resistance to the change or when the change is perceived as
reasonable.
Because peer pressure is often used to effect change, another group of strategies
that uses group process is called normative–re-educative strategies. These strategies
use group norms to socialize and influence people so change will occur. The
change agent assumes humans are social animals, more easily influenced by others
than by facts. This strategy does not require the change agent to have a legitimate
power base. Instead, the change agent gains power by skill in interpersonal rela-
tionships. He or she focuses on noncognitive determinants of behavior, such as
people’s roles and relationships, perceptual orientations, attitudes, and feelings, to
increase acceptance of change.
The third group of strategies, power–coercive strategies, are based on the appli-
cation of power by legitimate authority, economic sanctions, or political clout of
the change agent. These strategies include influencing the enactment of new laws
and using group power for strikes or sit-ins. Using authority inherent in an indi-
vidual position to effect change is another example of a power–coercive strategy.
These strategies assume that people often are set in their ways and will change
only when rewarded for the change or are forced by some other power–coercive
method. Resistance is handled by authority measures; the individual must accept
it or leave.
Often the change agent uses strategies from each of these three groups. An
example would be the change agent who wants someone to stop smoking. The
change agent might present the person with the latest research on cancer and
smoking (the rational–empirical approach); at the same time, the change agent
might have friends and family educate the person socially (normative–re-educative
approach). The change agent also might refuse to ride in the car if the person
smokes while driving (power–coercive approach). By selecting from each set of
strategies, the manager increases the chance of successful change.
178 UNIT 3 ■ Roles and Functions in Planning

Learning Exercise 8.3

Using Change Strategies to Increase Sam’s Compliance

You are a staff nurse in a home health agency. One of your patients, Sam
Little, is a 38-year-old man with Type 1 diabetes. He has developed some
loss of vision and had to have two toes amputated as consequences of his
disease process. Sam’s compliance with four times a day Accu-checks and
sliding-scale insulin administration has never been particularly good, but he
has been worse than usual lately. However, he does seem willing to follow
a prescribed diabetic diet and has kept his weight to a desired level.
Sam’s wife called you at the agency yesterday and asked you to work
with her in developing a plan to increase Sam’s compliance with his
blood sugar monitoring and insulin administration. She said that Sam,
while believing it “probably won’t help,” has agreed to meet with you
to discuss such a plan.
Assignment: What change strategy or combination thereof
(rational–empirical, normative–reeducative, power–coercive) do you
believe has the greatest likelihood of increasing Sam’s compliance? How
could you use this strategy? Who would be involved in this change effort?
What efforts might you undertake to increase the unfreezing so Sam is
more willing to actively participate in such a planned change effort?

RESISTANCE: THE EXPECTED RESPONSE TO CHANGE

Resistance is recognized Because change disrupts the homeostasis or balance of the group, resistance should
as a natural and always be expected. The level of resistance generally depends on the type of change
expected response proposed. Technological changes encounter less resistance than changes that are
to change. perceived as social or that are contrary to established customs or norms. For exam-
ple, nursing staff are more willing to accept a change in the type of intravenous
pump to be used than a change regarding who is able to administer certain types of
IV therapy. Nursing leaders also must recognize that subordinates’ values, educa-
tional levels, cultural and social backgrounds, and experiences with change (positive
or negative) will have a tremendous impact on their degree of resistance. It also is
much easier to change a person’s behavior than it is to change an entire group’s
behavior. Likewise, it is easier to change knowledge levels than attitudes.
In an effort to eliminate resistance to change in the workplace, managers histor-
ically used an autocratic leadership style with specific guidelines for work, an exces-
sive number of rules, and a coercive approach to discipline. The resistance, which
occurred anyway, was both covert (such as delaying tactics or passive–aggressive
behavior) and overt (openly refusing to follow a direct command), and resulted in
wasted managerial energy and time and a high level of frustration.
Today, resistance is recognized as a natural and expected response to change.
Instead of wasting time and energy trying to eliminate opposition, contemporary
managers immerse themselves in identifying and implementing strategies to minimize
or manage this resistance to change. One such strategy is to encourage subordinates to
 CHAPTER 8 ■ Planned Change 179

Display 8.4 Common Responders and Responses to Change

• Innovators: enthusiastic and thrive on change
• Early adopters: open and receptive to new ideas
• Early majority: adopt new ideas before the average person
• Late majority: skeptical of innovation and change
• Laggards: dedicated to tradition and the last to adopt a change
• Rejecters: openly oppose innovation and encourage others to also oppose change
Source: Bushy, A., & Kamphuis, J. (1993). Response to innovation: Behavioral patterns. Nursing Management,
24(3), 62–64.

speak openly so options can be identified to overcome objections. Likewise, workers

are encouraged to talk about their perceptions of the forces driving the planned change
so the manager can accurately assess change support and resources.
Bushy and Kamphuis (1993) identified six behavioral patterns commonly seen
in response to change: innovators, early adopters, early majority, late majority, lag-
gards, and rejecters (see Display 8.4). Innovators are enthusiastic, energetic people
who thrive on change and are almost obsessed with adventure. Described by some
as disruptive radicals, they are able to effect change, often amidst controversy with-
in the organization. Early adopters are open and receptive to new ideas but are less
obsessed with seeking out changes than innovators. Early majority individuals
adhere to the adage, “Be not the last to lay the old aside, nor the first by which the
new is tried.” Early majority individuals prefer the status quo but adopt new ideas
shortly before the average person. Late majority individuals are followers, skeptical
of innovation, and frequently express their negative views. Only after a majority of
the organization accepts an innovation will the late majority favor it. Laggards, the
last to adopt an innovation, are dedicated to tradition. They interact primarily with
other traditionalists and are highly suspicious of innovations and innovators. Rejec-
tors openly oppose innovation and actively encourage others to do so. Although
covert in nature, their activities may completely immobilize the change process, the
change agent, or the system, even to the extent of sabotaging an innovation.
Similarly, Pesut (2000) classifies individuals as either crusaders or tradition bear-
ers in response to their propensity to seek change. Crusaders are change agents who

Learning Exercise 8.4

What Is Your Attitude Toward Change?

Which behavioral pattern do you most commonly assume in response to
change: innovator, early adopter, early majority, late majority, laggard, or
rejecter? Is this behavioral pattern similar to your friends’ and family’s?
Has your behavior always fit this pattern, or has the pattern changed
throughout your life? If so, what life events have altered how you view
and respond to change?
180 UNIT 3 ■ Roles and Functions in Planning

see problems in the present and want to make things better for the future. Tradition
bearers are the preservers of what is best from the past and the present.
Perhaps the greatest factor contributing to the resistance encountered with
change is a lack of trust between the employee and the manager or the employee and
the organization. Workers want security and predictability. That’s why trust erodes
when the ground rules change, as the assumed “contract” between the worker and
the organization is altered. Subordinates’ confidence in the change agent’s ability to
manage change depends on whether they believe they have sufficient resources to
cope with it. In addition, the leader–manager must remember that subordinates in
an organization will generally focus more on how a specific change will affect their
personal lives and status than on how it will affect the organization.
Heifetz and Laurie (2001) maintain that most followers want comfort, routine
stability, and good problem solving. Change creates chaos and order is disturbed.
Leaders must recognize this and continue to “push the walls” even as they meet
resistance. Porter-O’Grady (2003) feels that this is the time of great challenge for
the leader. The skills necessary to move reticent groups cannot be understated. The
leader must use developmental, political, and relational expertise to ensure that
needed change is not sabotaged.

PLANNED CHANGE AS A COLLABORATIVE PROCESS

Often times, the change process begins with a few people who meet to discuss their
dissatisfaction with the status quo, and an inadequate effort is made to talk with
anyone else in the organization. This approach virtually guarantees that the change
effort will fail. People abhor “information vacuums,” and when there is no ongoing
conversation about the change process, gossip usually fills the void. These rumors
are generally much more negative than anything that is actually happening.
Whenever possible, all those who may be affected by a change should be
involved in planning for that change. Ayers (2002) suggests that the empirical pic-
ture that is emerging is that communication and organizational change processes
are inextricably linked. When change agents fail to communicate with the rest of
the organization, they prevent people from understanding the principles that guided
the change, what has been learned from prior experience, and why compromises
have been made. Research by Knox and Irving (1997) found that communication
about the goals and progression of organizational change by healthcare executives
was the most important factor for subordinate managers in ensuring a successful
change effort. The importance of being perceived as a legitimate and informed par-
ticipant in the change process was critical to their role success.
Likewise, subordinates affected by the change should thoroughly understand the
change and how it affects them as individuals. Good, open communication throughout
the process can reduce resistance. Leaders must ensure that group members share per-
ceptions about what change is to be undertaken, who is to be involved and in what role,
and how the change will directly and indirectly affect each person in the organization.
The easiest way for the manager to ensure that subordinates share this percep-
tion is to involve them in the change process. When information and decision
making are shared, subordinates feel that they have played a valuable role in the
 CHAPTER 8 ■ Planned Change 181

change. Change agents and the elements of the system—the people or groups
within it—must openly develop goals and strategies together. All must have the
opportunity to define their interest in the change, their expectation of its outcome,
and their ideas on strategies for achieving change.
It is not always easy to attain grassroots involvement in planning efforts. Even
when managers communicate that change is needed and that subordinate feedback
is wanted, the message often goes unheeded. Some people in the organization may
need to hear a message repeatedly before they hear, understand, and believe the
message. If the message is one they do not want to hear, it may take even longer for
them to come to terms with the anticipated change.

THE LEADER–MANAGER AS A ROLE MODEL DURING

PLANNED CHANGE
Leader–managers must act as role models to subordinates during the change process.
The leader–manager must attempt to view change positively and to impart this view
to subordinates. It is critical that managers not view change as a threat. Instead, it
should be viewed as a challenge and the chance or opportunity to do something new
and innovative. Porter-O’Grady (2003) suggests that these dramatically changing
times in the practice of nursing have given leaders a more demanding role in health
care, and that the manager’s behavior is the single most important factor in how peo-
ple in the organization accept change. Presently, the need for change is so important in
healthcare organizations and in the nursing profession that Porter-O’Grady says lead-
ers should accelerate disruptive change as a vehicle for making sure change occurs.
The leader has two responsibilities in facilitating change in nursing practice.
First, leader–managers must be actively engaged in change in their own work and
role model this behavior to staff. Secondly, leaders must be able to assist staff mem-
bers make the needed change requirements in their work. For a change to become
part of the organization, staff must internalize it. One way to assist staff with inter-
nalization is to show a relationship between the process of change and outcome,
when this can be measured then the evidence to support the change is convincing
(Porter-O’Grady, 2003).
Managers must believe that they can make a difference. This feeling of control is
probably the most important trait for thriving in a changing environment. Friends,
family, and colleagues should be used as a support network for managers during
change. Likewise, managers should learn to recognize their own stress signals during
change and take appropriate steps when the stress level becomes too high.

ORGANIZATIONAL AGING: CHANGE AS A MEANS OF RENEWAL

Organizations progress through developmental stages, just as people do—birth,
youth, maturity, and aging. As organizations age, structure increases to provide
greater control and coordination. The young organization is characterized by high
energy, movement, and virtually constant change and adaptation. Aged organiza-
tions have established “turf boundaries,” function in an orderly and predictable
182 UNIT 3 ■ Roles and Functions in Planning

fashion, and are focused on rules and regulations. Change is limited. Other charac-
teristics of aged organizations include hierarchical structures and bureaucratic
processes that are resistant to change (Ayers, 2002).
It is clear that organizations must find a critical balance between stagnation and
chaos, between birth and death. In the process of maturing, workers within the organ-
ization can become prisoners of procedures, forget their original purposes, and allow
means to become the ends. Gardner (1990) argues that organizations must be ever
renewing. The ever-renewing organization is infant-like—curious and open to new
experience and change. Gardner says that the only way to conserve an organization is
to keep it changing. Without change, the organization may stagnate and die.
The other term Gardner uses to describe the aged organization is organizational
dry rot. Gardner states that organizational dry rot can be prevented by having effec-
tive programs for the recruitment and development of young talent; providing a hos-
pitable organizational environment that fosters individuality; building in provisions
for self-criticism by providing an atmosphere in which uncomfortable questions can
be raised; and being forward-thinking. The organization needs to keep foremost
what it is going to do, not what it has done.

ORGANIZATIONAL CHANGE ASSOCIATED

WITH NONLINEAR DYNAMICS
Most organizations frequently experience stability followed by intense transforma-
tion. Some later organizational theorists feel that Lewin’s refreezing to establish equi-
librium should not be the focus of contemporary organizational change. Ayers (2002)
maintains that when change was predictable and rare in the industrial age, Lewin’s
theory worked well for organizations. However, during the information age of the
21st century, change is unforeseeable and ever present. In the past, organizations have
looked at change and organizational dynamics as linear, both occurring in steps and
sequential, but some theorists maintain that the world is so unpredictable that the
dynamics are nonlinear and do not occur in any order (Wagner and Huber, 2003).

Chaos Theory
Because of the rapidly changing nature of health care and healthcare organizations,
long-term outcomes are unpredictable, resulting in the potential for chaos (Thi-
etart & Forgues, 1995). The basic tenets of chaos theory are that organizations can
no longer rely on rules, policies, and hierarchies, or afford to be inflexible; and that
small changes in the initial conditions of a system can drastically affect the long-
term behavior of that system (Wagner & Huber, 2003). Organizations are open
systems operating in a complex environment that changes rapidly and much of the
change is unpredictable. “The richness of the interactions among parts and
between the system and its environment allows the system as a whole to undergo
spontaneous self-organization” (McDaniel, 1998, p. 356).
System thinking refers to the need for both individuals and organizations to
understand how each is an open system with constant input from both visible and
invisible interactions. Senge (1990) maintains that the dialogue necessary in system
 CHAPTER 8 ■ Planned Change 183

thinking promotes both organizational and individual learning. Organizations that

use this learning approach to deal with constant change are often referred to as
learning organizations (Senge). Continuous learning as a concept of organizational
philosophy promotes adaptation to change within the organization.

Complex Adaptive Systems Change Theory

Highly unstable environmental conditions require today’s organizations to deal with
change in a manner that allows for constant fluidity and continuous renewal (Ayers,
2003). A contemporary approach to changing organizations, which is quite different
from traditional change, is Olson and Eoyang’s (2001) theory of complex adaptive
systems (CAS). The authors say that the self-organizing nature of human interac-
tions in a complex organization leads to surprising effects. Rather than focusing on
the macro level of the organization system, complexity theory suggests that most
powerful change processes occur at the micro level where relationships, interactions,
and simple rules shape emerging patterns. Olson and Eoyang summarize the main
features of the CAS approach to change as follows:
• Change should be achieved through connections between change agents,
instead of from the top-down.
• There should be an adaptation during the change to uncertainty instead of
trying to predict stages of development.
• Goals, plans, and structures should be allowed to emerge instead of depend-
ing on clear, detailed plans and goals.
• Value differences should be amplified instead of focusing on consensus.
• Self-similarity should be created instead of differences between levels of change.
• Success should be regarded as a matter of fit with the organizational envi-
ronment instead of focusing on one-dimensional success measurement.

IS THE NURSING PROFESSION IN NEED OF RENEWAL?

This is a time of changing nursing practice, a change that often creates crisis when
nurses try to defend existing models of practice instead of embracing change.

A
Learning Exercise 8.5

Young or Old Organization?

Reflect on the organization in which you work or the nursing school you
attend. Do you believe this organization has more characteristics of a
young or aged organization and do you believe that nonlinear dynamics
is at work in the organization? Diagram on a continuum from birth to
death where you feel this organization would fall. What efforts has this
organization taken to be ever renewing? What further efforts could be
made? Do you agree or disagree that most organizations change unpre-
dictably? Can you support your conclusions with examples?
184 UNIT 3 ■ Roles and Functions in Planning

Porter-O’Grady (2003) posits that the profession must examine and adapt to the
changing context of nursing practice. The traditional realities are:
• institutional based care
• process oriented
• procedurally driven
• based on mechanical and manual intervention
• provider driven
• treatment based
• late-stage intervention
• based on vertical clinical relationships
According to Porter-O’Grady the emerging realities of nursing practice for this
century will be the following:
• mobility based or multisettings
• outcome driven
• best-practice oriented
• technology and minimal-invasive intervention
• user driven
• health based
• early intervention
• based on horizontal clinical relationships
Perhaps there is no greater need for the leader, at this point in the changing pro-
fession, than to be the catalyst for change. Many people attracted to the profession
now find that their values and traditional expectations no longer fit as they once
did. It is the leader’s role to help the staff turn around and confront the opportuni-
ties and challenges of the realties of emerging nursing practice: to create enthusi-
asm and passion for renewing the profession; to embrace the change of locus of
control, which now belongs to the healthcare consumer; and to engage a new social
context for nursing practice.

INTEGRATING LEADERSHIP ROLES AND MANAGEMENT

FUNCTIONS IN PLANNED CHANGE
It should be clear that leadership and management skills are necessary for successful
planned change to occur. The manager must understand the planning process and
planning standards and be able to apply both to the work situation. The manager,
then, is the mechanic who implements the planned change.
The leader, however, is the inventor or creator. Leaders today are forced to plan
in a chaotic healthcare system that is changing at a frenetic pace. Out of this chaos,
leaders must identify trends and changes that may affect their organizations and
units and proactively prepare for these changes. Thus, the leader must retain a big-
picture focus while dealing with each part of the system. In the inventor or creator
role, the leader displays such traits as flexibility, confidence, tenacity, and the ability
to articulate vision through insights and versatile thinking.
 CHAPTER 8 ■ Planned Change 185

Both leadership and management skills are necessary in planned change. The
change agent fulfills a management function when identifying situations where
change is necessary and appropriate and when assessing the driving and restraining
forces affecting the plan for change. The leader is the role model in planned
change; he or she is open and receptive to change and views change as a challenge
and an opportunity for growth. Perhaps the most critical element in successful
planned change is the change agent’s leadership skills—interpersonal communication,
group management, and problem-solving skills.

❊ Key Concepts
• Change should not be viewed as a threat but as a challenge or the chance to
do something new and innovative.
• Change should be implemented only for good reason.
• Because change disrupts the homeostasis or balance of the group, resistance
should be expected as a natural part of the change process.
• The level of resistance to change generally depends on the type of change
proposed. Technological changes encounter less resistance than changes
that are perceived as social or that are contrary to established customs
or norms.
• Perhaps the greatest factor contributing to the resistance encountered with
change is a lack of trust between the employee and the manager or the
employee and the organization.
• It is much easier to change a person’s behavior than it is to change an
entire group’s behavior. It also is easier to change knowledge levels
than attitudes.
• Change should be planned and thus implemented gradually, not sporadically
or suddenly.
• Those who may be affected by a change should be involved in planning for
it. Likewise, workers should thoroughly understand the change and its
effect on them.
• The feeling of control is critical to thriving in a changing environment.
• Friends, family, and colleagues should be used as a network of support
during change.
• The change agent has the leadership skills of problem solving and decision
making and has good interpersonal skills.
• In contrast to planned change, change by drift is unplanned or accidental.
• Historically, many of the changes that have occurred in nursing or have
affected the profession are the results of change by drift.
• People maintain status quo or equilibrium when both driving and restraining
forces operating within any field simultaneously occur. For change to happen,
this balance of driving and restraining forces must be altered.
• Organizations are preserved by change and constant renewal. Without
change, the organization may stagnate and die.
• Some modern theorists believe that change is unpredictable, occurs at
random, and small changes can effect the entire organization.
186 UNIT 3 ■ Roles and Functions in Planning

More Learning Exercises and Applications

Learning Exercise 8.6

Implementing Planned Change in a Family Planning Clinic

You are an Hispanic RN who has recently received a two-year grant to
establish a family planning clinic in an impoverished, primarily Hispanic
area of a large city. The project will be evaluated at the end of the grant
to determine whether continued funding is warranted. As project direc-
tor, you have the funding to choose and hire three healthcare workers.
You will essentially be able to manage the clinic as you see fit.
The average age of your patients will be 14 years, and many come from
single-parent homes. In addition, the population with which you will be
working has high unemployment, high crime and truancy levels, and great
suspicion and mistrust of authority figures. You are aware that many
restraining forces exist that will challenge you, but you feel strongly com-
mitted to the cause. You believe that the exorbitantly high teenage preg-
nancy rate and maternal and infant morbidity can be reduced.
Assignment:
1. Identify the restraining and driving forces in this situation.
2. Identify realistic short- and long-term goals for implementing such a
change. What can realistically be accomplished in two years?
3. How might the project director use hiring authority to increase the
driving forces in this situation?
4. Is refreezing of the planned change possible so that changes will con-
tinue if the grant is not funded again in 2 years?

Learning Exercise 8.7

Retain the Status Quo or Implement Change?

Assume that morale and productivity are low on the unit where you are
the new manager. In an effort to identify the root of the problem, you
have been meeting informally with staff to discuss their perceptions of
unit functioning and to identify sources of unrest on the unit. You believe
that one of the greatest factors leading to unrest is the limited advance-
ment opportunity for your staff nurses. You have a fixed charge nurse on
each shift. This is how the unit has been managed for as long as everyone
can remember. You would like to rotate the charge nurse position but are
unsure of your staff’s feelings about the change.
Assignment: Using the phases of change identified by Lewin, identify the
actions you could take in unfreezing, movement, and refreezing. What are
the greatest barriers to this change? What are the strongest driving forces?
 CHAPTER 8 ■ Planned Change 187

Learning Exercise 8.8

How Would You Handle This Response to Change?

You are the unit manager of a cardiovascular surgical unit. The work sta-
tion on the unit is small, dated, and disorganized. The unit clerks have
complained for some time that the chart racks on the counter above their
desk are difficult to reach, that staff frequently impinge on their work
space to discuss patients or to chart, that the call-light system is antiquated,
and that supplies and forms need to be relocated. You ask all eight of
your shift unit clerks to make a “wish list” of how they would like the
work station to be redesigned for optimum efficiency and effectiveness.
Construction is completed several months later. You are pleased that
the new work station incorporates what each unit clerk included in his or
her top three priorities for change. There is a new revolving chart rack in
the center of the work station, with enhanced accessibility to both staff
and unit clerks. A new state-of-the-art call-light system has been installed.
A small, quiet room has been created for nurses to chart and conference,
and new cubbyholes and filing drawers now put forms within arm’s reach
of the charge nurse and unit clerk.
Almost immediately, you begin to be barraged with complaints about
the changes. Several of the unit clerks find the new call-light system’s
computerized response system overwhelming and complain that patient
lights are now going unanswered. Others complain that with the chart
rack out of their immediate work area, charts can no longer be monitored
and are being removed from the unit by physicians or left in the charting
room by nurses. One unit clerk has filed a complaint that she was injured
by a staff member who carelessly and rapidly turned the chart rack. She
refuses to work again until the old chart racks are returned. The regular
day-shift unit clerk complains that all the forms are filed backward for
left-handed people and that after 20 years, she should have the right to
put them the way she likes it. Several of the nurses are complaining that
the work station is “now the domain of the unit clerk” and that access to
the telephones and desk supplies is limited by the unit clerks. There have
been some rumblings that several staff members believe that you favored
the requests of some employees over others.
Today, when you make rounds at change of shift, you find the day-shift
unit clerk and charge nurse involved in a heated conversation with the
evening-shift unit clerk and charge nurse. Each evening, the charge nurse
and unit clerk reorganize the work station in the manner that they
believe is most effective, and each morning, the charge nurse and unit
clerk put things back the way they had been the prior day. Both believe
that the other shift is undermining their efforts to “fix” the work station
organization and that their method of organization is the best. Both
groups of workers turn to you and demand that you “make the other
shift stop sabotaging our efforts to change things for the better.”
Assignment: Despite your intent to include subordinate input into this
planned change, resistance is high and worker morale is plummeting. Is
the level of resistance a normal and anticipated response to planned
change? If so, would you intervene in this conflict? How? Was it possible
to have reduced the likelihood of such a high degree of resistance?
188 UNIT 3 ■ Roles and Functions in Planning

Learning Exercise 8.9

Old and New Roles of Nursing Practice

Examine the old and new realities of nursing practice as identified
on p.184.
Assignment: In a small group discuss the old and new roles of nursing
practice. In your observations, based on your nursing school clinical
experiences, theory based classes, and watching other nurses in their
roles, what type of nursing practice do you see being practiced? Give
specific examples. Are the practice models in evidence provider driven or
user driven? Is the nursing practice process oriented or outcome driven?
As an organization do you believe nursing would be classified as a) an
aging organization, b) in constant motion and ever renewing, or c) a
closed system that does not respond well to change?

Web Links
Orlikowski, W. J., & Hofman, D. An Improvisational Model of Change
Management
http://ccs.mit.edu/papers/CCSWP191/CCSWP191.html
The Case of Groupware Technologies: Massachusetts Institute of Technology, Sloan
School of Management. Examines a dynamic and variable “improvisational” approach
to technological change in which the major steps of change are defined in advance and the
organization then strives to implement these changes in a specified period of time.

Kurt Lewin
http://muskingum.edu/%7Epsychology/psycweb/history/lewin.htm
Biography, overview of planned change theory, timeline of his theoretical developments,
and bibliography.

Kurt Lewin Institute homepage

http://www.psy.vu.nl/kli
Describes the institute’s mission, training program, and current research.

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