1. PLANNING FOR CHANGE Change occurs over time, often fluctuating between
intervals of change then a time of settling and stability. Change management
entails thoughtful planning and sensitive implementation, and above all,
consultation with, and involvement of, the people affected by the changes. If you
force change on people normally problems arise. Change must be realistic,
achievable and measurable. These aspects are especially relevant to managing
personal change.
Definition
Planning: ―Planning refers to thinking ahead of time and formulation of
preliminary thoughts‖ .
Planned change: ―Planned change entails planning and application of strategic
actions designed to promote movement towards a desired goal‖ .
o ―Planned change is a change that results from a well thought out and deliberates
effort to make something happen. It is the deliberate application of knowledge and
skills by a leader to bring about a change‖ . Tappen, 1995
Change agent: ―A change agent is one who generates ides, introduces the
innovation, and works to bring about the desired change‖ .
Change agent A change agent is someone who deliberately tries to bring about a
change or innovation, often associated with facilitating change in an organization
or institution. To some degree, change always involves the exercise of power,
politics, and interpersonal influence. It is critical to understand the existing power
structure when change is being contemplated. A change agent must understand the
social, organizational, and political identities and interests of those involved; must
focus on what really matters; assess the agenda of all involved parties; and plan for
action. The change agent should have the following qualities;
 The ability to combine ideas

2.  The ability to energize others
 Skills in human relations
 Integrative thinking
 Flexibility modify ideas
 Persistent, confident and has realistic thinking
 Trustworthy
 Ability to articulate a vision, and
 Ability to handle resistance
Assumptions regarding change
 Change represents loss. Even if the change is positive, there is a loss of stability.
The leader of change must be sensitive to the loss experienced by others.
 The more consistent the change goal is with the individual‘s personal values and
beliefs, the more likely the change is to be accepted. Likewise the more difficult
the goal is from the individual‘s personal values; the more likely it is to be
rejected.
 Those who actively participate in change process feel accountable for the
outcome.
 Timing is important in change. With ea successive change in a series of
ch
changes, individual‘s psychological adjustment to the change occurs more slowly.
And for this reason the leader of change must avoid initiating too many changes at
once.
The key principles driving the elements of the Change Management are: 1.
Targeted Commitment Levels 2. Executive Ownership 3. Visible, sustained

3. sponsorship 4. Deployment/Implementation Support and Monitoring 5. Employee
Support 6. Post Deployment Preparation Strategies for planned change In
general, three categories of change models exist: empirical-rationale, power-
coercive, and normative-educative model. (Bennis, Benne and Chin [1969], The
planning of change)
Rationale- empirical: This strategy emphasizes reason and knowledge.
People are considered rational beings and will adopta change if it is justified and in
their self- interest. Here the change agent‘s role is 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 is
useful when little resistance to change is expected. It is assumed that once if the
knowledge and rationales are given, people will internalize the need for change and
value the result.
Normative- re-educative: This is based on the assumption that group norms
are used to socialize individuals. The success of this approach often requires a
change in attitude, values, and/ or relationships. This strategy is most used when
the change is based on culture and relationships within the organization. The power
of the change agent, both positional and informal, becomes integral to the change
process.
Power- coercive: This approach is based on power, authority, and control.
Desired change is brought about by political or economic power. It requires that
the change agent have the positional power to mandate the change. The outcome of
change is often based either on follower‘s desire to please the leader or fear of the
consequences for not complying with the change. This strategy is effective for
legislated changes, but other changes using this strategy are often short- lived.

4. Barriers to change and strategies to overcome It is important to identify all
potential barriers to change, to examine them contextually with those affected by
proposed change, and to develop strategies collectively to reduce or remove the
barriers. Change requires movement, which as physics indicates, is a kinetic
activity that that requires energy to overcome resistance.

6. Types of changes Hohn (1998) identified four different types of change: Change
by exception, Incremental Change, Pendulum Change and Paradigm Change.
 Change by Exception: This occurs when someone makes an exception to an
existing belief system. For instance, if a client believes that all nurses are bossy,
but then experiences nursing care from a much modulated nurse, they may change
their belief about that particular nurse, but not all nurses in general.
 Incremental Change: A change that happens so gradually, that an individual is
not aware of it.
 Pendulum Changes: Are changes that result in extreme exchanges of points of
view.
 Paradigm Change: Involves a fundamenta rethinking of premises and
l
assumptions, and involve a changing of beliefs, values and assumptions about how
the world works.
Change Theories in Nursing Change theories are used in nursing to bring about
planned change. Planned change involves, recognizing a problem and creating a
plan to address it. There are various change theories that can be applied to change
projects in nursing. Choosing the right change theory is important as all change
theories do not fit every change project. Some change theories used in nursing are
Lewin‘s, Lippitt‘s, and Havelock‘s theories of change. The characteristics of
change theories are
Problem identification
 Plan for innovation
 Strategies to reduce innovation
 Evaluation plan

7. Kurt Lewin‟ s change theory: The theoretical foundations of change theory are
robust: several theories now exist, many coming from the disciplines of sociology,
psychology, education, and organizational management. Kurt Lewin (1890 – 1947)
has been acknowledged as the ―father of social change theories‖ and presents a
simple yet powerful model to begin the study of change theory and processes.
He is also lauded as the originator of social psychology, action research, as well as
organizational development. "Unfreezing" involves finding a method of making it
possible for people to let go of an old pattern that was counterproductive in some
way.
In this stage, the need for change is recognized, the process of creating awareness
for change is begun and acceptance of the proposed change is developed "Moving
to a new level" involves a process of change--in thoughts, feelings, behavior, or all
three, that is in some way more liberating or more productive. The need for change
is accepted and implemented in this stage. "Refreezing" is establishing the change
as a new habit, so that it now becomes the "standard operating procedure." Without
some process of refreezing, it is easy to backslide into the old ways.The new
change is made permanent here.
Lewin also created a model called ―force field analysis‖ which offers direction
for diagnosing situations and managing change within organizations and
communities. According to Lewin‘s theories, human behavior is caused by forces –
beliefs, expectations, cultural norms, and the like – within the "life space" of an
individual or society. These forces can be positive, urging us toward a behavior, or
negative, propelling us away from a behavior. ―Driving Forces‖ - Driving forces
are those forces affecting a situation that are pushing in a particular direction; they
tend to initiate a change and keep it going. In terms of improving productivity in a
work group, pressure from a supervisor, incentive earnings, and competition may
be examples of driving forces. ―Restraining Forces‖ - Restraining forces are

8. forces acting to restrain or decrease the driving forces. Apathy, hostility, and poor
maintenance of equipment may be examples of restraining forces against increased
production. ―Equilibrium‖ - This equilibrium, or present level of productivity,
can be raised or lowered by changes in the relationship between the driving and the
restraining forces. Equilibrium is reached when the sum of the driving forces
equals the sum of the restraining forces.
Lippitt‟ s phases of change theory: Lippitt‟ s theory is based on bringing in an
external change agent to put a plan in place to effect change. There are seven
stages in this theory. The first three stages correspond to Lewin's unfreezing stage,
the next two to his moving stage and the final two to his freezing change. In this
theory, there is a lot of focus on the change agent. The third stage assesses the
change agent‘s stamina, commitment to change and power to make change happen.
The fifth stage describes what the change agent‘s role will be so that it is
understood by all the parties involved and everyone will know what to expect from
him. At the last stage, the change agent separates himself from the change project.
By this time, the change has become permanent. The seven phases shift the change
process to include the role of a change agent through the evolution of the change.
• Phase 1:Diagnose the problem
• Phase 2:Assess the motivation and capacity for change
• Phase 3:Assess the resources and motivation of the change agent(commitment the
change, power, and stamina)
• Phase 4:Define progressive stages of change
• Phase 5: Ensure the role and responsibility of the change agent is clear and
understood (communicator, facilitator, and subject matter expert.

9. • Phase 6:Maintain the change through communication, feedback, and group
coordination
• Phase 7:Gradually remove the change agent from the relationship, as the change
becomes part of an organizational culture.
Havelock's change model: Havelock's change theory has six stages and is a
modification of the Lewin's theory of change. The six stages are building a
relationship, diagnosing the problem, gathering resources, choosing the solution,
gaining acceptance and self renewal. In this theory, there is a lot of information
gathering in the initial stages of change during which staff nurses may realize the
need for change and be willing to accept any changes that are implemented. The
first three stages are described by Lewin's unfreezing stage the next two by his
moving stage and the last by the freezing stage.
John P Kotter's 'eight steps to successful change' John Kotter's highly regarded
books 'Leading Change' (1995) and the follow-up 'The Heart Of Change' (2002)
describes a helpful model for understanding and managing change. Each stage
acknowledges a key principle identified by Kotter relating to people's response and
approach to change, in which people see, feel and then change: Kotter's eight step
change model can be summarized as:
Increase urgency - inspire people to move, make objectives real and relevant.
Build the guiding team - get the right people in place with the right emotional
commitment, and the right mix of skills and levels.
Get the vision right - get the team to establish a simple vision and strategy
focus on emotional and creative aspects necessary to drive service and efficiency.

10. Communicate for buy-in - Involve as many people as possible, communicate
the essentials, simply, and to appeal and respond to people's needs. De-clutter
communications - make technology work for you rather than against.
Empower action - Remove obstacles, enable constructive feedback and lots of
support from leaders - reward and recognize progress and achievements.
Create short-term wins - Set aims that are easy to achieve - in bite-size chunks.
Manageable numbers of initiatives. Finish current stages before starting new ones.
Don't let up - Foster and encourage determination and persistence - ongoing
change - encourage ongoing progress reporting - highlight achieved and future
milestones.
Make change stick - Reinforce the value of successful change via recruitment,
promotion, and new change leaders. Weave change into culture.
General considerations for planning change
 Secure and maintain commitment to change
 Define and communicate desired end state
 Identify critical success factors
 Establish targets and prioritize activities
 Develop a theme
 Understand why the change is desired/ required
 General considerations for planning change
 Secure and maintain commitment to change
 Define and communicate desired end state
 Identify critical success factors
 Establish targets and prioritize activities

11.  Develop a theme
 Understand why the change is desired/ required
Nurse Leader (manager) as role model for Planned Change
Implement a comprehensive and coordinated change management program:
Discover, develop, detect.
‖
 Identify ―change agents and engage people at all levels in the organization.
 Ensure the message comes from the top, and executives and line managers are
―walking the talk.‖
 Make change visible with new tools and/or environment.
 Ensure clear, concise, and compelling communication.
 Integrate change goals with day-to-day activities, e.g., recruiting, performance
management, and budgeting.
 Address short-term performance while setting high expectations about long-term
performance.
 Help management avoid attempts to short circuit the change management
process.
 Foster change in people‘s attitudes first, then focus on change in processes, then
change in the formal structure.
 Manage both supporters and champions, as well opponents and possible
detractors.

12.  Accept that all people go through the same steps – some faster, some slower –
and it is not possible to skip steps.
 Build a safe environment that enables people to express feelings, acknowledge
fears, and use support systems.
 Acknowledge and celebrate successes regularly and publicly!
Mistakes by a leader manager
 Fail to provide visible support and reinforce th change with other managers.
e
 Do not take the time to understand how current business processes would be
affected by change.
 Delayed decision-making, which leads to low morale and slow project progress.
 Are not directly or actively involved with change project.
 Fail to anticipate the impact on employees.
 Underestimate the time and resources needed
 Abdicate ownership of the project to another manager.
 Fail to communicate both the business reasons for the change and the expected
outcome to employees and other managers
 Change the project direction mid-stream
 Do not set clear boundaries and objectives for the project
Organizational ageing The organization has to undergo progress through certain
developmental stages within the organizational structure termed organizational
ageing. The young organization is characterized by high energy, movement and
constant change and adaptation; while the aged organizations will have established
‗turf boundaries functioning in an orderly and predictable fashion, and are focused
on rules and regulations. In any type of ageing, organizations must find a balance

13. between chaos and stagnation. Some areas that undergo restructuring during an
organizational ageing are; • leadership changes • organizational restructuring •
outsourcing and offshoring • new technologies and tools • new competitors and
markets
INNOVATIONS IN NURSING
Introduction
Change is a natural social process of individuals, groups, organizations and
society. The source of change originates inside and outside health care
organizations. Change today is constant, inevitable, pervasive and unpredictable,
and varies in rate and intensity, which unavoidably influences individuals,
technology and systems at all levels of the organization.
Creativity and innovation Creativity is defined as ‗artistic or intellectual
inventiveness.‘
Innovation is defines as ‗introduction of something new. ‗These definitions
suggest that the terms are interchangeable. A person could say that creativity is the
mental work or action involved in bringing something new into existence, while
innovation is the result of that effort.
A constant flow of new ideas is needed to procure new products, services,
processes, procedures and strategies for dealing with the change occurring in every
sphere of endeavour:
technology social system, government and everyday living. Innovation is the key
to survival and growth of health care and nursing. Change, innovation and
creativity are comparison terms but can also be differentiated. Changes occur when
the system is disrupts; innovation uses changes to create new and different
approaches to resolve an issue and develop new products or procedures.

14. (Huber 1996). Systemic innovations according to (Drucker 1992) require
willingness to look on changes as an opportunity. Innovations do not create
change. Successful innovations are accomplished by exploiting the change not
forcing it.
Process of Innovation The process of the innovation may include several steps.
They are:
Assessment
It is the first step of process and it requires a look at both the strength and
problems. An administrator must focus on what is specific content requirement the
expected outcome. Specific content requirement changes often in the health care,
as new technologies and research bring new knowledge needs.
Defining objectives
It is the second step. The administrator should search for research or technique that
could address the identical needs. Asking the peers for the suggestion is also
helpful. This is the place where the creativity begins. It is important to look at
many different ways to address the learning objectives before selecting one.
Planning
Once a strategy has been selected the third step, planning is important. Understand
who the stakeholders are and what their investment is in the status quo or in change
can be helpful in planning the strategies to bring them on board. Many stake
holders do not like the changes and will resist the new approaches. Using the
change theory it can assist in demonstrating the needs and provide information that
can make resistors more amenable to change. It‘s important to take time to develop
a support for the strategy. In more complex strategies it may be important to bring
other administrators.

15. Gaining support for the innovation
Some strategies require little or resources to implement where as others require
significant physical and financial resources. If resources are needed then gaining
support for the accusation of those resources are essential. Grants can provide good
funding sources but require time and effort to secure and may be for a limited time.
Administrative support may be required but administrators may also be an
excellent resource to tap to discuss the potential funding or acquisitions of the
physical resource.
Preparing faculty members for the innovation
Rehearsal time may be required or additional education may be required. Planning
sufficient for those activities will increase everyone‘s comfort level with this
process. This is the time where everyone agrees how the strategy will be in run.
Use of perception, validate and clarification can be a valuable tool.
Implementing the evaluation
In this step it is hope that the things will be going well, but flexibility may be
required if problems arise. Sometimes unintended consequences, such as surfacing
of emotional issues can occur. Administrator should be alert to the need for the
follow up or referral if problem arise.
Evaluating the outcome
It is the final step of the process. It may be possible to measure short term
attainment goals. A strong evaluation process provides an opportunity to evaluate
the outcome of the change.

16. Sources of innovation Seven sources for innovative ideas have been identified by
(Drucker 1992)
Four sources are found internally within the institutions are:
Unexpected outcomes: Situation presents themselves that require different
methods to be adopted. Knowing what is happening in an institution allows an
individual to prepare for the impending changes.
Incongruous circumstances: Disruptions occur that require change to be made
discrepancies exists between the reality as it is and reality as it is assumed to be.
Innovations made on the process needs: Procedures and policies need to be
altered to respond to the new regulations, policies or law.
Changes in structure: Organizational changes require changes in method of the
operations.
Three sources are outside the institutions:
Change in the demographics: Alteration in the community statistics such as
age and income levels affect the organizational operations.
New information or knowledge: New technological knowledge requires
change in practice.
Change in perception, taste and meaning: Shifts in demographics,
technologies and social needs create different ways of looking at the situation.
Steps in Innovation adoption
Knowledge: Aware of new information and possible significance to practice.
Persuasion: Positive attitudes about importance and utility of new knowledge.
Decision: Trial use of new information to test relevance to practice.

17. Implementation: Change of care setting to facilitate use of the innovations.
Confirmation: Gathering of evidence to confirm appropriateness of using the
innovations.
Theories Planned change using linear approaches Theories for planned
change Six phases of planned change Havelock (1973) is credited with this
planned change model Key idea: Change can be planned, implemented and
evaluated in six sequential stages. The model is advocated for development of
effective change agents and use as a rational problem solving process. The six
stages are:-
1. Building a relationship
2. Diagnosing the problem
3. Acquiring relevant resources
4. Choosing the solution
5. Gaining acceptance
6. Stabilizing the innovation and generating self renewal
Application to practice: Useful for low level, low complexity change. Seven
phases of planned change Lippitt, Watson and westly (1958) are credited with
this planned change model Key idea: change can be planned, implemented and
evaluated in seven sequential phases. Ongoing sensitivity to forces in the change
process is essential. The seven phases are:
1. The client system become aware of the need for the change
2. The relationship is developed between the client system and change
3. The change problem is defined
4. The change goal are set and options for achievements are explored

18. 5. The plan for the change is implemented
6. The change is accepted and stabilized
7. The change entities redefine their relationship
Application to practice: Useful for low level, low complexity change. Innovation
– decision process Rogers (1995) is credited with formulating this process. Key
idea: Change for an individual occurs over five phases when choosing to accept or
reject an innovation/idea. Decision is to not accept the new idea may occur at any
five stages. The change agent can promote acceptance by giving information about
benefits and disadvantages and encouragement. The five stages are:
1. Knowledge
2. Persuasion
3. Decision
4. Implementation and
5. Confirmation
Application to practice: Useful for individual change.
Nonlinear change Chaos theory Organization can no longer rely on rules,
policies, and hierarchies to get work accomplished in flexible ways. According to
the chaos theory perspectives because of rapidly changing nature of human and
world factors health organizations cannot control long term outcomes. The
assertion of chaos theory are that ‗organization are potentially chaotic‘(thietat and
Forgues, 1995). In other words, ‗order emerges through fluctuations and chaos‘.
Organization will experience periods of stability interrupted with periods of intense
transformation. Response to change / Human side of change The human side of

19. the managing change refers to staff responses to change that either facilitate or
interfere with change process. Responses to all or part of the change process by
individuals and group may vary from full acceptance and willing participation to
open rejection. Responses may be categorized behaviourally or emotionally. Some
nurses may manifest their dissatisfaction visibly; others may quietly accommodate
the change. Some individuals consistently reject any new thinking or way of doing
things. The initial response to change may be, but not always, reluctance and
resistance. Resistance and reluctance are common when the change threaten the
personal security. Eg: -Changes in the structure of an agency can result in changes
of position for personnel. The change agent‘s recognition of the ideal and common
patterns of the individuals behaviour responses to change can facilitate an effective
change process (Rogers 1983). The responses and brief descriptions are as follows:
Innovators thrive on change, which may be disruptive to the unit stability.
Early adopters are respected by their peers and thus are sought out for advice
and information about innovations/changes.
Early majority prefer doing what has been done in the past but eventually will
accept the new ideas.
Late majority are openly negative and agree to change only after most others
have accepted the change.
Laggards prefer keeping tradition and openly express their resistance to new
ideas.
Rejecters oppose change actively.
General characteristics of effective change agents
 Isa respected member of the organization (insider) or community (outsider).
 Possesses excellent communication skills.

20.  Understands change process.
 Knows how group functions.
 Is trusted by others.
 Participates actively in change processes.
 Processes expert and legitimate power.
Principles characterizing effective change implementation
 The recipients of change feel they own the change.
 Administrators and other key personnel support the proposed change.
 The recipients of change ant cipate benefit from the change.
i
 The recipient of change participates in identifying the problem warranting a
change.
 The change holds interest for the change recipients and other participants.
 Agreements exist within the work group about the benefit of the change.
 The change agents and recipients of change perceive a compatibility of values.
 Trust and empathy exist among the participants of the change process .
 Revision of the change goal and process is negotiable.
 Thechange process is designed to provide regular feedback to its participants.
Challenges met by the change leaders Mc Daniels (1996) advocates that change
leaders in healthcare organizations meet the challenges of managing by applying
12 recomendations:
1. Dispense with controlling and planning.

21. 2. Operate on the margin between order and disorder.
3. Develop new organizations with the help of everyone.
4. Allow individual autonomy.
5. Encourage information sharing among staffs.
6. Promote staffs knowledge of others work.
7. Stimulate open learning through discussion generating ‗creative tension‘.
8. Considering the organization structure as dynamic.
9. Help staffs discover their goals.
10. Encourage cooperation not competition.
11. Approach work from smarter view, not harder.
12. Uncover values continuously to form organization wide visions.