MOTHER THERESA POST GRADUATE &

RESEARCH INSTITUTE OF HEALTH

SCIENCES, PUDUCHERRY

SEMINAR ON
UNIT - III

PLANNING FOR CHANGE

SUBMITTED TO SUBMITTED BY

Dr.J. Rukumani, PhD, Ms.P. Josmin Selvakumari,

Principal, College of Nursing, Msc nursing 2nd Year

MTPG & RIHS, MTPG & RIHS.

SUBMITTED ON

17/08/2011
SL
CONTENTS PAGE NO
NO

1. Introduction 1

2. Terminologies 2

3. PLANNING FOR CHANGE

3.1 Definitions

- Change

- Planned change

- Change agent

3.2 Principles of change

3.3 Levels of change

3.3.1 knowledge

3.3.2 Attitude

3.3.3 Individual behavior

3.3.4 Group behavior

3.4 Planned change

- Factors that predict organizational change success

3.5 The Planned change process

3.5.1 unfreezing

3.5.2 moving

3.5.3 refreezing

3.6 Similarities of change, nursing process & problem solving

3.7Models of organizational change

3.7.1 Lewin’s classical model

 3.7.2 Hersey and colleagues frameworks

- First order change

- Second order change

3.7.3 Lippitt’s Phases of Change

3.7.4 Havelock’s Model

3.7.5 Rogers diffusion of innovation

3.7.6 Chaos theory

3.8 Change strategies

3.8.1 Rational empirical strategy

3.8.2 Normative reeducative strategy

3.8.3 Power-coercive strategy

3.9 Emotional stages of change

- Lose focus
- Minimize the impact
- The pit
- Let go of the past
- Test the limits
- Search for meaning
- Integration

3.10 Driving and restraining forces

3.11 Four manifestations of Resistance to change

3.12 Areas of major change in health care and nursing

- Organizational structures
- Nursing labor force
- Reimbursement
- Information systems
 3.13 Planned change as a collaborative process

3.14 Barriers to change

3.15 The leader-manager as a role model during planned change

3.16 Leadership roles and management functions in planned change

4. Changes in nursing education

Conclusion
5.

Bibliography
6.
 PLANNING FOR CHANGE

1. INTRODUCTION:

“Nothing is permanent but change” - Heraclitus

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. Meeting the health-care needs of
the world requires that the nurse be proactive and creative in guiding change.

Change is a pervasive element of society, of today’s health care environment, and

of life. Many words are used to describe change, including constant, inevitable,
pervasive, universal and powerful. 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.
Learning how to manage change was listed as one of the major components
necessary when developing future nurse leaders.

Regardless of the type of change, all major change brings feelings of

achievement, 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. Planned change is the deliberate
application of knowledge and skills by a leader to bring about a change. This type of
planning requires the leadership skills of problem solving and decision making and
interpersonal and communication skills.

2. TERMINOLOGIES:

2.1 Strategy: "Strategy is the direction and scope of an organisation over

the long-term: which achieves advantage for the organisation
through its configuration of resources within a challenging
environment, to meet the needs of markets and to fulfill
stakeholder expectations".

2.2 Unfreezing: the process of getting accustomed to a new organisation and its
procedures

2.3 Moving: moving involves a process of change–in thoughts, feelings,

behavior, or all three that is in some way more liberating or
more productive than doing things the old way.

Moving is where the individual or community has to

acknowledge and embrace change in their thoughts,
behaviors, and feelings.

2.4 Refreezing: establishing the change as a new habit, so that it now becomes
the ‘standard operating procedure’”

2.5 Resistance: behavior which is intended to protect an individual from the

effects of real or imagined change.

Resistance to change is the action taken by individuals and

groups when they perceive that a change that is occurring as a
threat to them.
 3. PLANNING FOR CHANGE

3.1 Definitions

CHANGE: Change is defined as an alteration to make something different. This

activity of alteration can be either haphazard or planned, obvious or
subtle, radical or incremental, left to change or occurring by drift.
- Diane L. Huber

Change is inevitable, but growth is intentional. - Glenda Cloud

Change is the law of life. And those who look only to the past or the
present are certain to miss the future. - John F.Kennedy

PLANNED
CHANGE: Planned change is defined as a process of intentional intervention to
create something new. In general it is a process by which new ideas
or programs are created and developed, diffused through
communication and intervention, and result in consequences of
adoption or rejection.

CHANGE
AGENT: Change agent is the outside helper used to plan and implement the
change process. The term has come to mean a person who functions
as a change facilitator.

A change agent is one who generates ideas, introduces the

innovation and works to bring about the desired change.

3.2 Principles of change:

 A change in one part affects other parts and other systems.

 People affected by the change should participate in making the change.
 People should be informed of the reasons for the change.
 Concrete and specific feedback about the process of change will enhance its
acceptance.
 People need assistance in dealing with the effects of the change.
 A change must be reinforced or the system will revert to its old practices.
 Conflict may occur at any step during the change process.
 The more compatible the new ideas are with one’s values and needs, the more
easily a change will be adopted.
 The more trust one has in the initiator of change, the more likely one is to
support the change.
 One’s past experience with change can profoundly affect one’s willingness to
support a new idea.

When leaders or managers are planning to manage change, there are five key
principles that need to be kept in mind:

1. Different people react differently to change

2. Everyone has fundamental needs that have to be met
3. Change often involves a loss, and people go through the "loss curve"
4. Expectations need to be managed realistically
5. Fears have to be dealt with

Here are some tips to apply the above principles when managing change:

Give people information - be open and honest about the facts, but don't give
overoptimistic speculation. I.e. meet their OPENNESS needs, but in a way that
does not set UNREALISTIC EXPECTATIONS.

For large groups, produce a communication strategy that ensures information is

disseminated efficiently and comprehensively to everyone (don't let the grapevine
take over). E.g.: tell everyone at the same time. However, follow this up with
individual interviews to produce a personal strategy for dealing with the change.
This helps to recognise and deal appropriately with the INDIVIDUAL
REACTION to change.
 Give people choices to make, and be honest about the possible consequences of
those choices. i.e. meet their CONTROL and INCLUSION needs

Give people time, to express their views, and support their decision making,
providing coaching, counselling or information as appropriate, to help them
through the LOSS CURVE

Where the change involves a loss, identifies what will or might replace that loss -
loss is easier to cope with if there is something to replace it. This will help
assuage potential FEARS.

Where it is possible to do so, give individuals opportunity to express their

concerns and provide reassurances - also to help assuage potential FEARS.

Keep observing good management practice, such as making time for informal
discussion and feedback (even though the pressure might seem that it is
reasonable to let such things slip - during difficult change such practices are even
more important).

3.3 Levels of change

Hersey and colleagues (2001) viewed change from four levels:

1) Knowledge
2) Attitudes
3) Individual behavior
4) Group or organizational behavior

These levels of change can be graphed from high to low according to the
difficulty and the time involved in making a change. The lowest difficulty and
shortest time to make a change occurs with knowledge changes. Attitudes are more
difficult to change because of being emotionally charged.

Individual behavior is the next most difficult and time- intensive change. Group
behavior and performance changes are the most difficult and take the longest time.
Participative change uses personal power and is used when new knowledge is made
available to a group. Directive change uses position power and when change is
imposed.

Nurse use teaching as an intervention to change knowledge as a part of working

with clients and managing other people. Changing individual behaviors takes more
time and is more difficult.

For example, in working with clients with diabetes, teaching them health principles
is easier and takes less time than does effecting a change in their behaviors (e.g., in
selecting foods based on size, quantity and balance of nutrients). It is even more
difficult to change group behaviors among staff. This may be partially a function of
dealing with two entities simultaneously because the group does not change unless
individuals change first.

Group behavoir
Individual 4 Behavior
3
Attitudes
2
Knowledge
1

e r
ow
lp
na
erso
P

Participative change cycle

For example, if a group is having communication difficulties and conflict, a change

in knowledge can be attempted by an explanation of the destructive behavior.
Sensitivity training could be used to change attitudes. The group may understand
perfectly, but getting them to actually change their behavoir takes more time and is
 more difficult. Changing individual and group behavior is not impossible, but it
involves time and a large investment of effort, persuasion, and surveillance.

3.4 Planned change

The amount of change and the rapidity of change disrupt and disorganize people.
Because of the rapidity of change in areas such as computer software, it is easy to
slip into the perception that history is what occurred 2 years ago and ancient history
refers to 5 years ago.
Obsolescence occurs before people have had a chance to adapt to the last round
of changes. The inevitable result is stress on individuals as they try to cope. These
dynamic affect nurses in their roles as care providers and care managers and
profoundly influence the profession of nursing through employment and
compensation fluctuations. One method to enhance nurses’ productivity and
decrease stress from turbulence in the environment is to strategically use planned
change.

The use of planned change is a nursing management intervention strategy. The

nurse uses diagnosis and intervention in clinical practice: the nurse assess, diagnoses,
develops a plan for the client’s care needs and selects an intervention that is matched
to that assessment and diagnosis.

Managers also assess, diagnose and plan interventions to meet organizational

needs and goals. They look at resource allocation and deployment of people in using
planned change as a management intervention. Planning and managing the change
process may focus on any or all of the following situational elements: organizational
structure, people, or resources.

- Factors that predict organizational change success

1. Mandate / project launch

 2. Leader goals, involvement, and support
3. Supporters and opponents
4. Middle manager goals, involvement and support.
5. Tension for change
6. Staff needs assessment, involvement and support
7. Exploration of problem and understanding customer needs.
8. Change agent prestige and commitment
9. Source of ideas
10. Funding
11. Relative advantages
12. Radicalness of design
13. Flexibility of design
14. Evidence of effectiveness
15. Complexity of implementation plan
16. Work environment
17. Staff change required.
18. Monitoring feedback.

3.5 The Planned Change Process

The basic concepts of the change process were outlined by Lewin. A successful
change involves three elements:
(1) unfreezing
(2) moving, and
(3) refreezing

Lewin’s theory of change used ideas of equilibrium within systems.

unfreezing

refreezing moving
 Elements of a successful change

Unfreezing

Unfreezing the existing equilibrium involves motivating others for change. The
change agent must loosen, or “unfreeze,” the forces that are maintaining the status
quo. This involves increasing the perceived need for change and creating discontent
with the system as it exists. If individuals do not see a need for change, they are not
likely to be motivated or ready for change and may even hinder change. Assessment
of readiness for change is critical in this phase.

Moving
During the moving phase, the change agent identifies plans, and
implements strategies to bring about the change. The change agent must do all
that is possible to reduce restraining forces and strengthen driving forces. It is
critical that the change agent continue to work to build trust and enlist as many
others as possible. The more ownership there is in the change, the more likely the
change will be adopted. Timing is also important during this phase.
 People need time to assimilate change; therefore, the change agent must allow
enough time for people to redefine how they view this change cognitively.
Refreezing
During the refreezing phase, the change agent reinforces new patterns of
behavior brought about by the change. Institutionalizing the change by creating
new policies and procedures helps to refreeze the system at a new level of
equilibrium. Refreezing has occurred when the new way of doing things becomes
the new status quo.

3.6 Similarities of change, nursing process and problem solving:

Change Nursing process Problem solving

Unfreezing Assessing Problem identification
Moving Planning and implementing Problem analysis and seeking alternatives
Refreezing Evaluation Implementation and evaluation

3.7 Models / theories of organizational change:

3.7.1 Lewin’s classical model

Kurt Lewin’s identified three phases of change: unfreezing, moving, and refreezing.

3.7.2 Hersey’s framework

Hersey and colleagues (2001) discussed two frameworks within which change
occurs:
(1) first order change
(2) second order change
First order change occurs in a stable system. For an organization, this is adaptation
and incremental change based on monitoring the environment and making
purposeful adjustments. At the industry level, this is evolution as a response to
external forces such as markets.
An example in nursing is when a new evidence-based protocol is developed and put
into use in clinical practice. This is adaptation and adjustment.
 Second-order change is discontinuous and radical and occurs when fundamental
properties or states of systems are changed. At the organization level, second-order
change is described as metamorphosis. The entire organization is transformed,
reconfigured, or moved along its life cycle. At the industry level, second order
change occurs when an entire industry is revolutionized or experiences quantum
change such as emergence, transformation, or decline. An example in health care is
the widespread implementation of computerized physician order entry (CPOE)
technology in response to the Institute of medicine’s recommendations for patient
safety reforms.

3.7.3 Lippitt’s Phases of Change

Lippitt’s Phases of Change Theory (1958) is built on the Lewin’s model.

He extended the model to include seven steps in the change process. Lippitt’s
model focuses more on the role of the change agent than on the evolution of the
change process. Communication skills, team building, and problem solving are
central to this theory. The participation of key personnel, those most affected by the
change, and those most critical in promoting the change is essential to the success of
the change effort (Noone, 1987). The seven steps of Lippitt’s phases of change are:

Step 1: Diagnosis of the Problem

The person or organization must believe there is a problem that requires change.
The change agent helps others see the need for change and involves 174 Skills for
Being an Effective Leader key people in data collecting and problem solving. The
ideal situation exists when both the organization and the change agent recognize and
accept the need for change.
Step 2: Assessment of the Motivation and Capacity for Change
Determine if people are ready for change. Assess the financial and human
resources. Are they sufficient for change? Analyze the structure and function of the
organization. Will it support the change, or does there need to be organizational
 redesign? This process is essentially defining the restraining and driving forces for
change within the organization.
Step 3: Assessment of the Change Agent’s Motivation and Resources
This step is crucial to achieving change. The change agent (either an individual or
a team) must count the personal cost of change. The change agent must be willing to
make the commitment necessary to bring about the planned change. He or she must
have the energy, time, and necessary power base to be successful. The change agent
may take on the role of leader, expert consultant, facilitator, or cheerleader, but
whatever role is assumed, the change agent must be willing to see the change
through.
Step 4: Selection of Progressive Change Objectives
The change is clearly defined in this step. Establish the change objectives.
Develop a plan of action; include specific strategies for meeting the objectives.
Decide how to evaluate the change plan and final result.
Step 5: Implement the Plan
It is critical to remain flexible during implementation. If resistance is higher than
anticipated, slow down. Give others a chance to catch up. On the other hand, if all is
going well and the momentum is good, keeps the plan moving ahead.
Step 6: Maintenance of the Change
During this phase the change is integrated into the organization. It is becoming
the new norm. In this phase, the role of the change agent is to provide support,
positive feedback and, if necessary, make modifications to the change.
Step 7: Termination of the Helping Relationship
The change agent gradually withdraws from the role and resumes the role of member
of the organization (Lippitt, Watson, & Wesley, 1958).

3.7.4 Havelock’s Model

Havelock’s Six Step Change Model (1973) is another variation of Lewin’s change
theory. The emphasis of this model is on the planning stage of change. Havelock’s
model asserts that with sufficient, careful, and thorough planning, change agents
can overcome resistance to change. Using this model, essential to the success of
 change is inclusion. It is imperative that the change agent encourage participation
at all levels. This follows the assumption that the more people are part of the plan,
the more they feel responsible for the outcome, and the more likely they will work
to make the plan succeed.
The planning stage of Havelock’s model includes:
(1) Building a relationship;
(2) diagnosing the problem; and
(3) Acquiring resources.
(4) Choosing the solution
(5) Gaining acceptance.
(6) Stabilization and renewal (Havelock, 1973).

3.7.5 ROGERS’ DIFFUSION OF INNOVATION

Everett Rogers (1983) developed a diffusion theory, as opposed to a planned

change theory. It is included with change theories because it describes how an
individual or organization passes from “first knowledge of an innovation” to
confirmation of the decision to adopt or reject an innovation or change. Rogers
defined diffusion as “the process by which innovation is communicated through
certain channels over time among the members of a social system”. Rogers’
framework emphasizes the reversible nature of change. Initial rejection of change
does not mean the change will never occur. Likewise, the adoption of change does
not ensure its continuation.
Rogers’ five-step innovation/decision-making process is:

Step 1: Knowledge
The decision-making unit (individual, team, or organization) is introduced to the
innovation (change) and begins to understand it.
Step 2: Persuasion
The change agent works to develop a favorable attitude toward the innovation
(change).
Step 3: Decision
 A decision is made to adopt or reject the innovation.
Step 4: Implementation/Trial
The innovation is put in place. Reinvention or alterations may occur.
Step 5: Confirmation
The individual or decision-making unit seeks reinforcement that the decision made
was correct. It is at this point that a decision previously made may be reversed.

3.7.6 CHAOS THEORY

Because of the rapidly changing nature of health care and health care
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 longterm behavior of that system.

Organizations are open systems operating in a complex environment that change

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”

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 thinking
promotes both organizational and individual learning. Organizations that use the
learning approach to deal with constant change are often referred to as learning
organizations.
Continue learning as a concept of organizational philosophy promotes
adaptation to change within the organization.
3.8 CHANGE STRATEGIES:

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, and power-coercive.

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, and 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.

3.8.1 Rational-Empirical Strategy

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.

3.8.2 Normative-Re-Educative Strategy

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 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 (rational-empirical) and administrative directives
were needed to bring about this change: it took a change in cultural values that
redefined the practice norms.

3.8.3 Power-Coercive Strategy

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.

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.

3.9 Emotional stages of change:

Manion (1995) who identified the following seven stages people go through
during personal transitions:
1. Lose focus: confusion and disorientation abound.
2. Minimize the impact: deny or pretend .the change is not significant.
3. The pit: feelings of anger, discouragement, resentment, and resistance arise.
4. Let go the past: energy returns as the end of the change process is seen.
 5. Test the limits: more optimism is gained, and the individual tries out new
skills or seeks new experiences.
6. Search for meaning: the individual reflects on the change process and
recognizes what was learned.
7. Integration: the transition is completed, and the change is integrated into daily
life.
Both Perlman and Takacs (1990) and Manion’s (1995) stages resemble the
general grief model. However, manion’s model is more customized to change.
Stage 5 through 7 mirror the process of coping that occurs as attitudes reconfigure
and individuals work to produce positive outcomes.

Emotional stages of change

1. Equilibrium: there is sense of balance and inner peace before change occurs.
2. Denial: energy is drained by denial of the reality of a change.
3. Anger: Energy is used to ward off the change.
4. Bargaining: Energy is used in an attempt to eliminate the change.
5. Chaos: Energy is diffused, with a loss of identity and direction.
6. Depression: no energy is left to produce results.
7. Resignation: Energy is expended to accept change passively.
8. Openness: Renewed energy is available.
9. Readiness: there is willingness to use energy to explore new events.
10.Re-emergence: Energy is rechanneled, producing empowerment.

3.10 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.
 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, unwillingness to take risks, and a
fear of the unknown.

Force Field Diagram

Change issue
Driving forces restraining forces

weak
weak

moderate

Strong force
Equilibrium

No change Change
change
No change

Fear of loss
of employment
Fear of Fear of
Loss of status loss of confidence

Why change
is resisted
Demands time Demands energy
 Therefore creating 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.

3.11 Four manifestations of resistance to change:

Resistance to change should be expected as integral to the whole process of

change. Resistance occurs because people are afraid of being disorganized or of
having their routines interrupted. Some may have a vested interest in the status
quo. Change may diminish the status of some people, or their network of
interpersonal relationships may be disrupted.
Resistance may be rooted in anxiety or fear. For example, some individuals fear
expenditure of the energy needed to cope with change. Some fear a loss of status,
power, control, money, or employment.
Asprec (1975) identified the following four ways in which resistance to change
may be manifested.
1. Active resistance through frustration and aggression.
2. Organized passive resistance or resisting change collectively.
3. Indifference by ignoring or attempting to divert attention elsewhere.
4. Acceptance on the surface or by not openly opposing a change.

Active resistance through frustration and aggression

Acceptance on the surface Organized passive resistance or resisting change collectively

change

Indifference by ignoring or attempting to divert attention elsewhere

 Four manifestations of resistance to change

3.12 Areas of major change in health care and nursing

Because of constant change, nurses and health care systems have had to
learn and adapt. To view the scope of change surrounding nursing in perspective,
four areas of major change can be identified.
They are
 organizational structures,
 nursing labour force,
 reimbursement, and
 information systems.

 First, organizational structures have been changing and reconfiguring in

response to the environment and financial pressures. For example, population-
based care, case management, patient centered care and patient safety initiates
are elements reflecting change in regard to client care systems redesign.

 Changes also are occurring in health care as integrated networks form and care
increasingly is moved into community settings. Changing organizational
structures are occurring in the midst of a nurse shortage. The complexion of the
nurse workforce is changing; and recruitment and retention, education, and staff
deployment alternatives are being explored.

 Another area of important change in health care is reimbursement. For example,

reimbursement (payment) for physicians has been changing, driven by the
federal government’s relative value unit’s determinations.
 Reimbursement for nurse practitioners currently is allowed under Medicare/
Medicaid. However, managed care, with its capitated reimbursement structure,
 has changed payment to all forms of health care providers. Payment reforms are
likely to continue and change. The cost areas are physician payment, already
being ratcheted down, pharmaceutical costs, and equipment and technology
costs.

Organizational structures

Nursing labour force

Change
Reimbursement

Information systems

Areas of change in health care and nursing

 Present and future changes will bring an increasing use of information systems.
A massive increase in computerization is urgent in a managed care environment.
For example, there is a national practitioner’s data bank that was created from
quality concerns. Any physician or nurse who has been party to a lawsuit must
have this information reported. Large national databases of all licensed nurses
also are being compiled.

 Powerful computers and sophisticated software programs undergo updates and

generational changes within a few years or less, creating challenges of
compatibility, archival retrieval, maintaining currency, and staff training.

3.13 Planned change as a collaborative process:

  Research by Knox and Irving (1997) found that communication was the most
important factor for subordinate managers in ensuring a successful change effort.
The importance of being perceived as legitimate and informed participant 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.
 The easiest way for the manager to ensure that subordinates share this perception
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 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.

3.14 Barriers to change:

Nurse leaders must also consider multiple factors and anticipate potential problems
when instituting changes.
Many factors can serve as barriers to change, including
decreased resources lack of support,
resistance,
poor communication mechanisms, or
pressure to get the day-to-day work done.

The more barriers there are to the change, the more effort will be needed to deal with
those barriers and, consequently, the less energy will be available to institute the
actual change.
3.15 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 managers’ behavior is the single most important factor in how people in the
organization accept change.
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 members make the needed change
requirements in their work. For a change to become part of an organization staff
must internalize it.
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.

3.16 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 healthcare system.
4. Anticipates, recognizes, and creativity 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 followers 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 units legal,
political, economic, social and legislative climate.
2. Recognizes the need for planned change and identifies the options and resources
available to implement that change.
3. Appropriately assess 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
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. Identifies 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.

4. CHANGES IN NURSING EDUCATION

Today nursing education is poised for bringing about sweeping changes.

The driving forces for these changes are numerous and difficult to isolate. These
include increasing multiculturalism of society; more financial resources in
education and health care; expanding technology and the need for life-long
learning," and the increasing public demand for accountability of educational
outcomes.

As the twenty first century approaches, rapidly changing environment and health
care reformats are having a dramatic effect on the new roles of the nursing
faculty.

Changes in health care demand that the nursing faculties critically evaluate
the competencies of their own as well as evaluate the curricula design. There is
an increasing emphasis on the teaching role of nursing faculty with
accompanying expectations that the outcomes of the educational process will be
regularly assessed at the institutional level as well as at the programme level.

The new information technologies (IT) in the 21st century affect currently most
spheres of life, including education at all levels. In the last few years dozens of
conferences were devoted to examining various aspects of the new technologies
impact, and hundreds of scholarly articles and books were published on IT
related themes. Unquestionably, the lT bears a tremendous potential to change
and reshape conventional study environments.

Further, changes during the last ten years in nursing education include a
revolution in teaching strategies. The faculty are now integrating the use of
technology into their teaching and promoting the active involvement of learners
in the teaching – learning process. IT has assumed increasing importance in
education.

Virtual Nursing training methodology is a major innovation which has

taken place at the end of last century and at the beginning of the present century.
The nursing profession is recognizing and implementing the significant trends
 that are being fostered by technological advances. Nursing education has
responded very well to the requirements of information age.

Numerous training technologies and innovations have been developed and

are being implemented all over the world. The internet offers challenging
educational opportunities for continuing education to an international audience. It
is high time to introspect and bring about necessary changes in the approach to
the profession to remain elevant. The use of information technology does not
mean merely the use of computers in learning; it is much more than that. It may
be a necessary and first step. Nurses have much to gain by participating in the
engineering of nursing information system that expedite information management
and processing. It has been found in earlier works that an effectively designed and
managed computerized information system can augment and improve nursing
education and nursing management system.

Good educational software is a synergism between the unique features of a

computer and a learning design that integrates these features into a meaningful
learning package. Jymehyshyn (1983) described that computer technological
ingenuity far outreaches the ability of educators to integrate into lesson and used
as continuing education for them.

Nursing is a dynamic process which always changes with the advancement

of medical technology. This needs unceasing Continuing Nursing Education for
nurse educators. Nurse educators need to develop specific teaching competency
and clinical skills to demonstrate new technological changes in medical science
while dealing with the students. Nurse educators need a periodical reinforcement
with a media that would be easily accessible, time saving and economically
viable.

5. Conclusion

Change is inevitable, the market changes, customer demands change and

the technology to support the business change, however change is not always
 within the control of the organization (Vroom, 1993). Research shows that it is
important to proactively manage and control and seek out change in order to
succeed and gain a competitive edge. Management need to communicate the need
for change and highlight the crisis situation that may develop by avoiding the
change. Effective communication should be used to promote or market the new
proposed changes while at the same time, demonstrate the inadequacies of the
older system. Users resist change because they fear the unknown but effective
communication from the start of the change project can help reduce this fear. It
was noted that communication efforts must be both verbal and active.
Management must be seen to give active support to the change process for it to
gain the full support of the workforce. In reality the change not only has to be
managed but also has to be marketed. Once the change has been implemented, the
change management process must constantly review the change and reinforce it.

BIBLIOGRAPHY
  Diane.L.Huber, "Leadership and nursing care management”, 3rd edition,

Elsevier’s publishers, Pg.no: 805 - 823.

 Bessie.L.Marquis & carol, "Management decision making for nurses", 1987,

Lippincott William and Wilkins, Pg.no:74-85.

 Sheila.C.Grossman, “The New leadership challenge”, 3rd edition, Jaypee

publishers, page no: 122-128.

 Clark.C, "Creative nursing leadership and management”, first edition, 2010,

Jones & Barlett publishers.

 Russell.C.Swansburg, “Introduction to management & leadership for nurse

managers”, 3rd edition, Jones & Barlett publishers, page no: 68, 269.

 Patrica Kelly, "Essentials of Nursing Leadership and Management", 2nd

edition, 2010, Delmar publishers.

 Howard.S.Rowland, "Nursing administration Handbook", fourth edition,

1997, aspen publishers

JOURNALS:

1. Knox. S., “ Journal of Nursing Administration”, Nurse manager perceptions of

health care executive behaviors during organizational change, volume 27,
issue11, 1997, pg.no:33-39.

2. Perlman. D., & Takacs, G.J., “Nursing management”, the ten stages of change,
volume 21, issue 4, 1990, Pg.no: 33-38

3. Baulcomb, J. (2003). Management of change through force field analysis.

Journal of Nursing Management, 11, 275–280.

WEBSITES:
 http://www.cliffsnotes.com/study_guide/Steps-in-Planned

Change.topicArticleId-8944,articleId-8888.html

 www.change-management-coach.com/kurt_lewin.html

 http://www.karis.biz/storage/crew_cv/types%20of%20change.pdf

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