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Understanding Change in Healthcare: Theories, Models, and Strategies

Theories and Models of Change in Healthcare

On completion of this lesson, the student will be able to:
• Understand some of the theories and models to explain “change” as a concept
• Outline some of the stages of change
• Identify some strategies to assist individuals to change
• Discuss the concepts of organizational culture and organizational climate

Change is the very essence of health care today. Lesson 1.2 talked about amalgamations that have and are occurring in health care sectors across Canada – moving from several health districts for the administration and organization of care, to a single “Super Board” as Alberta has done and which Nova Scotia has moved to implement. With the scarcity of certain types of health personnel (nurses and doctors), newly created roles are emerging to fill the perceived “gaps” and to re-distribute workloads and enhance or expand roles. Nurse Practitioners, Unregulated Health Care Workers, Physician Assistants are just a few of the “new” careers being created. An essential role of nurse leaders is to be able to understand the vision of change and provide that vision and direction to their staff and other stakeholders. Additionally, nurse leaders and managers must have the skills to be able to translate that vision and necessity for change into implementable steps. However, a natural response to the reality or even perception of change is to resist any change to what is perceived as the “status quo” (even though change is ongoing and never ‘stops’ per se).

It is not only the nurse leader’s responsibility to guide the change from vision to evaluation, but also all nurses who will be affected. They too must be committed to the change. However, the culture of the organization may be an impeding rather than a supporting factor in any change process. As the authors state: “Organizational climate is the perceptions employees have about aspects of their workplace, and these perspectives influence outcomes such as employee’s affect,

Unfreezing – there is dissatisfaction with the current state of affairs, perhaps a practice or policy. It is the most important stage where we prepare ourselves for change
- Transition or movement – a time of uncertainty where there is instability, no one is particularly sure of what processes or practices should be happening as “new” ideas are trialed. It is a very difficult and threatening time
- Freezing - Refreezing) - occurs when the new way of doing things becomes accepted and routine (a habit). Stability is reaffirmed.

Stages of Change

However, in today’s world of constant change, there is no such concept of “stability” wherein people can become acclimated to the “new way of doing things”. There is no time to settle into comfortable routines as the next change or adjustment may only be days or weeks away. Instead, the concept of greater flexibility to adapt more rapidly to “change” (whatever it is) is today’s norm.Since Lewin’s ground-breaking work several theories and models of change have been postulated and tested. Let’s look at five of them.

1. Establishing a Sense of Urgency – helping others to see the need for change; identifying the crisis or opportunity
2. Creating the Guiding Coalition – assembling a group with enough power to lead the change effort and encourage them to work as a team
3. Developing a Change Vision – creating a vision to help direct the change effort and develop strategies to achieve that vision
4. Communicating the Vision for Buy-in – make sure that as many people as possible understand and accept the vision using every means possible to achieve that buy-in 5. Empowering Broad-based Action – removing obstacles to change or those systems or
structures that could undermine the proposed change
6. Generating Short-term Wins – plan for easy, visible wins that can be recognized and acknowledged, with employee rewards
7. Never Letting Up – use increased credibility to change systems, structures and policies that do not fit the vision; hire, promote, and develop those employees who can be positive role models; reinvigorate the project with new projects, themes and change
8. Incorporating Changes into the Culture – make the connections between the new behaviors and organizational success and develop ways to ensure leadership development and succession (Kotter International, 2012).

This theory was developed by E.M. Rogers in 1962 and is one of the oldest social science theories As its name describes, the theory is that a new product, idea, or behavior must gain momentum over time, eventually spreading (diffusing) to people (as part of a social system) who adopt the idea, product, or behavior. The process is said to “diffuse” and be “adopted”. The key to adoption is that the person(s) must see the idea, behaviour, or product as new or innovative.

When promoting an innovation, it is important to understand the dynamics of the target audience, as some individuals will help the innovations introduction while others will hinder its acceptance. Additionally, there will be individuals who adopt the idea ‘soonest” while others will drag their feet. Rogers identified five adopter categories, with the majority of individuals falling into the middle category:
? Innovators – first to want to try the new idea, behaviour or product
? Early Adopters – people who are called opinion leaders as they enjoy leadership roles and embrace change opportunities
? Early Majority – rarely the leaders but who like to adopt new ideas before the average person
? Late Majority – these people are the skeptics and will only adopt a change after it has been tried by the majority
? Laggards – bound by tradition and very conservative – the hardest people to bring on board with the innovation (Boston University School of Public Health, 2013) Roger also describes five features of an innovation that denotes how long it will take for the majority of people to sign on for the change. The features include: relative advantage, compatibility, complexity, trialability, and observability.

No matter how small or large the proposed change, whether in a multi-facility organization or in a community walk-in clinic, change will cause disruption to the perceived “stability” of the work environment. The predictable responses may range from an enthusiastic “yes” to those who will refuse to embrace the proposed change. It is therefore important to determine the possible reasons for this resistance, so that you can anticipate and assist employees through the change. Resistance to change in the workplace can include:
? Fear of failure to perform well
? Belief that they may not be able to do the things now required
? Sense of loss about how tings used to be done
? Perception that this change means previous practices are no good
? Not understanding or knowing how to do things differently
? Not understanding the need for the change.

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