Change needs to be planned properly, objectives and timetables set, and resistance dealt with sensitively if you are to get people on board to implement change
National initiatives have outlined the importance of involving frontline staff in service improvement, and the ability to influence and manage change has been identified as an essential skill for delivering new models of care. Nurses often have to take the lead in managing change in clinical practice. The second in a three-part series is designed to help nurses at all levels develop the knowledge and skills to function as change agents within their organisations. This article focuses on planning the change and dealing with resistance.
Citation: Kerridge J (2012) Leading change: 2 - planning. Nursing Times [online]; 108: 5, 23-25.
Author: Joanna Kerridge is practice educator at Sue Ryder Nettlebed Hospice and associate lecturer at the University of West London.
- This article has been double-blind peer reviewed
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Nurses are often required to take the lead in managing change in clinical practice to improve care. The NHS Leadership Framework (National Leadership Council, 2011) emphasises the importance of the role of frontline staff in service improvement, and identifies the ability to influence and manage change as an essential skill. It also acknowledges the potential for all staff to contribute to service improvement, irrespective of discipline, role or function, and advocates developing the skills of the entire workforce to create a climate of continuous service improvement.
The first article in this series suggested ways of highlighting the change required by identifying exactly what is wrong and finding a way to put it right. This article continues by discussing how to plan the proposed change and deal with resistance.
Planning is a key component of any change management strategy. Anderson (2010) suggests that developing a plan demonstrates commitment and enables others to see how you intend to manage the change.
At this point you need to ask members of your stakeholder group to sign up for project working groups. Active involvement develops a sense of ownership and inclusivity (Anderson, 2010; Maurer, 2010). If you can approach potential partners at a workshop, where they have already identified the problems and solutions themselves, you may get a more positive response.
Try to get a variety of stakeholders in each working group, as it will be useful to have different perspectives. One of the most insightful views may come from a patient or volunteer who does not understand healthcare culture.
If you have not been able to organise a workshop, you can still get people involved after establishing their interest through a questionnaire or one-to-one discussion. Some will respond to an individual approach more positively as you will be seeking their specific expertise, but it can be time consuming.
Now you have found a potential solution or a number of potential solutions to your problem, and identified the people who are going to help you, you need to identify what you are going to do. What changes are you going to make? It is important to be clear about this, as you may need to explain this on many occasions in order to get everyone on board.
You will need to identify an aim or goal for each project, and be clear how you intend to achieve it by developing objectives. Each goal may have a number of objectives - the most common method of setting these is by using the SMART tool (Ambler, 2006). Unfortunately, this is seldom used correctly, but it can be invaluable if you understand what is required in each stage (Table 1).
Returning to the example used in part 1 on discharging patients in a timely fashion, the objectives would be:
- To design a discharge form;
- To implement the use of this form.
Are these objectives SMART? Designing a discharge form is a specific objective; it states what we want to happen, and is measurable as there will be an end product. In part 1, root cause analysis showed it must be designed following discussions with colleagues - this will make it achievable and realistic. And, to make it timely, you will need to ensure there is a deadline.
A SMART objective: To design a discharge form with input from the rest of the multidisciplinary team by the end of the month.
When it comes to the second objective, simply saying you will implement the use of the form is too vague.
A SMART objective: To use the discharge form for all admissions to the ward after the first of next month.
A change management or action plan should show all the planned change activities against the project milestones (Anderson, 2010). It should identify the roles and responsibilities of those who will play a part in making the change happen.
Action plans will help you to keep on track and achieve your goal; they may save time in the long run by ensuring that everything has been taken into account.
After identifying the goal and objectives, the next questions are:
- What do we need to achieve them?
- Who is going to do it?
- By when?
- How are we going to measure progress?
- What are the risks or potential problems?
This involves making a list of all the tasks required in order to deliver each objective, and if, necessary, all the actions required for each task. The more you break down each objective, the more manageable and achievable it will become. Again, you will increase motivation to contribute to the project if members of the working group develop their own action plan.
You also need to identify key milestones and when they must be completed, both to motivate staff and to show progress. Identifying risks and adding them to your action list may enable you to minimise or even eliminate them.
The action plan should be reviewed by the project leader and working group on a regular basis to ensure the project is not stalling or falling too far behind. It will also allow any new risks to be identified and dealt with.
One of the first actions in the plan should always be to research what other people or organisations have done to address similar issues. This may save you a huge amount of time and prevent costly mistakes. Learn from what others have done, but remember that you will be working in a different environment and with different people so circumstances will be different and their results - good or bad - may not be replicated.
Understanding the challenges
It would be wonderful if everyone were as committed to this change as you are but this is not likely to be the case. Once
you have defined your objectives, you will need to identify the various forces for and against the change so you can develop strategies to deal with them. Lewin’s force field analysis (1951) may be a useful tool in helping you understand this (Fig 1).
Lewin’s theory proposes that:
- There are forces driving change and forces restraining it;
- Where there is equilibrium or a status quo between the two sets of forces, there will be no change;
- For change to occur, the driving force must exceed the restraining force.
Lewin suggests that there are three steps to making a change happen. These are as follows:
- Unfreezing - altering the strength of the forces that maintain the current status quo;
- Moving - implementing the change;
- Refreezing - stabilising and consolidating after the changes have been made.
First, the status quo must be upset. Unfreezing can begin by adding conditions favourable to the change and strengthening supporting forces, or by removing conditions unfavourable to the change and reducing the impact of opposing or restraining forces.
In the example given in Fig 1, which relates to discharging patients in a timely fashion, the driving or supporting forces are clinicians, patients and relatives who want change. These could be bolstered by, for example, introducing compelling evidence of the need to reduce the length of hospital stay, perhaps by demonstrating the financial burden on the ward and suggesting better ways of spending the money.
The opposing or restraining forces could be clinicians opposed to change, limited resources or a lack of influence over external processes or clinicians. Presenting clinicians with evidence of the potential benefits to them and their patients may persuade them to come on board, or at least withdraw active opposition. Inviting key external groups, such as district nurses, to become actively involved in the project may increase your influence over external processes or clinicians.
Lewin (1951) recommended working to reduce the resisting forces instead of increasing the driving forces. He believed that simply increasing the driving forces would result in an escalation in the resisting forces against the change. It may therefore be more productive to persuade people to come around to your point of view than to force change upon them.
The key is to spot restraining forces early, and to identify their source and the factors involved. The most common are human, financial and technical. How you deal with them will depend on the form they take. For example, if there is a lack of financial resources, you may be able to overcome this through negotiation, fundraising or sponsorship; you would need to develop a different strategy to influence clinicians opposed to change.
The importance of persuasion and/or negotiation should not be underestimated but relying on these without understanding why you are facing opposition could significantly reduce your chance of success.
Dealing with resistance
The human element of resistance has been identified as one of the main factors preventing organisational change (Maurer, 2010; NHS Institute for Innovation and Improvement, 2008), and how you react to this may well be the key to the success or failure of the project.
People naturally resist things that they perceive to be against their own or their organisation’s best interests. Viewing resistance as a normal rational response to implementing change can reassure others that you are responding appropriately to their concerns.
Maurer (2010) suggests that support and resistance are two sides of a single coin and identifies three types or levels of resistance.
Level 1 - people either understand you or do not
This type of resistance may stem from a lack of information, a lack of understanding of the information or disagreement with the information given.
To deal with this, you need a response that involves rational explanation and logical argument. You need to give more information or clearer information, in a way that can be understood by those who need it.
It may involve a written report, newsletter, email or memo with detailed facts and figures that show why you want to change, what you are trying to achieve, and how you will do it. You may need to present this information in a visual form using graphs or tables but simple formats are easier to understand.
Presenting the information in person with question-and-answer sessions is often most effective. This direct engagement also enables you to see things from other people’s perspectives and understand how the change will affect them. Be willing to be influenced by valid objections and let people know what conclusions you draw and why.
Some people may be reluctant resistors but have fundamental objections based on their personal circumstances or beliefs, which can be difficult to overcome.
Any solution is likely to be a compromise on both sides - the key is to keep things amicable and avoid antagonism.
Level 2 - people are either excited by or afraid of change
This is an emotional response, often unconscious and uncontrollable, and stems from fear. Individuals may fear that they will lose their jobs or lose control; or they may be worried that they will not be able to do what is expected of them.
People perceive the situation as dangerous to them and prepare for fight or flight. You may be unintentionally responsible for moving people into this level of resistance when giving them information they do not like or were not prepared for.
There is no point in trying to deal with this simply by presenting facts and figures and with logical argument. You need to listen to them; discuss their fears, listen to their concerns with an open mind and explore options; try to understand how they feel and why.
Reassure them or try to find some common ground to work. A simple formula is to ask them the following questions: What’s in it for me? What’s in it for you? What’s in it for us? (Maurer, 2010).
Level 3 - people have trust and confidence in you or they do not
This often has little to do with the immediate situation and can be deeply entrenched, stemming from relationships, culture, previous experiences or events.
These people may actually love your idea but may not like or trust you or who or what you represent. No idea will be judged on its own merits but will be influenced by previous experiences, personal or traditional antagonism, or the culture of the workplace.
Rumours and assumptions are the enemy in this situation so do all you can to quash them. Building bridges and repairing relationships are essential elements in any strategy for dealing with this level of resistance. Do not be too defensive or apologetic; listen to what is being said and respond honestly. Start small by identifying common ground where all sides can see a benefit and begin working on this in order to build a foundation of trust.
Working with this level of resistance is difficult and you will need to persevere. However there may be some resistance that proves impossible to overcome. The trick is to recognise and isolate it before it can do any damage or you become disillusioned.
Once you have dealt with resistors and hopefully turned resistance into commitment, you can move forward with your plans. The final article in this series will look at implementing and reviewing the change.
- Careful planning is a key part of managing change
- Developing a plan shows your commitment and enables others to see how you intend to manage the change
- You need active involvement in your project and clear objectives for people to follow
- Objectives need to be specific, measurable, achievable, realistic and timely (SMART)
- It is important to identify and deal with resistance
Ambler G (2006) Setting SMART Objectives.
Anderson A (2010) A Guide to Managing Change.
Lewin K (1951) Field Theory in Social Science. London: Harper Row.
Maurer R (2010) Beyond the Walls of Resistance. Austin, TX: Bard Press.
National Leadership Council (2011) NHS Leadership Framework.
NHS Institute for Innovation and Improvement (2008) Improvement Leaders’ Guides.