Change Theories and Relevance in Health Care

 One of the top challenges for complex healthcare organizations is how to effectively deal with change. Rising healthcare costs, declining reimbursement, work force shortages, new technology, and the growing elderly population are many of the critical factors driving the force for change, whether this be in a clinical or hospital setting. “Contemporary healthcare agencies then must continually institute change to upgrade their structure, promote greater quality, and keep their workers” (Marquis & Huston, 2017). Healthcare organizations must continually make changes aimed at organizational restructuring, patient satisfaction, and employee satisfaction leading to retention. However, it is important to realize that not every organizational change program is a success. “There are many variables that influence the results of change such as the content of change; the process of change; the context of the organization and the people within the organization that are involved with the change” (Walker, Armenakis, & Bernerth, 2007).

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 The purpose of this paper is to provide knowledge and background on change theories that are used to implement change in organizational structures such as the healthcare setting. By examining and implementing the use of change theories such as Kurt Lewin’s models of change, Burrowes and Need’s Contemporary Adaption of Lewin’s model, complexity science and adaptive systems, and Edward Lorenz’s Chaos Theory, healthcare organizations can implement effective change to meet the demands of the ever-changing healthcare system. This paper will also discuss important factors in implementing change, such as the change agent. Lastly, how these theories can be used in healthcare situations to help promote efficient change will be covered. Since healthcare is constantly changing, it is very important to understand different theories of change, factors influencing change, and understanding when change is necessary to increase patient satisfaction, increase employee satisfaction, and to maintain a successful thriving organization.

Types of Change

 Planned changed and change by drift are two types of change that can be observed with organizations and even throughout a person’s life. Prior to the mid-1900s, people often questioned whether they should intervene in a situation or simply let nature run its course (Tiffany & Johnson-Lutjens, 1998). The thinking prior to this time went more in line with the change by drift method of change, in which there is no control over change or effort put into change. It is considered accidental change, where planned change is intentional or purposeful.

  During planned change, skills and knowledge of the leader are used to influence and implement change within the organization (Marquis & Huston, 2017). By the 1950s, there was a shift in the way people thought about change and how it should be handled. Instead of contemplating whether intervening was necessary to make change, people begin to question how and when to plan for change. “Progress took on a meaning that mandated the use of science in the service of humans and said that experts should meet peoples’ needs according to the ways the experts interpreted those needs” (Tiffany & Johnson-Lutjens, 1998). During this time, healthcare organizations were growing, technology was advancing, and the needs of the patient population were growing and changing. It was essential for these organizations to not only recognize the need for change, but correctly plan interventions to implement and maintain change.

Change Agent

 A change agent is a person who is skilled in the theory and implementation of planned change and the ability of this person can play a major role in whether change is successful or unsuccessful (Marquis & Huston, 2017). The change agent helps to provide balance among all aspects of the organization that will be affected by the change. The person acting as the change agent is often the manager, or internal source, but external sources are used in some situations. Behaviors of a positive change agent include role modeling, guidance, and facilitation to inspire change amongst peers and leaders (Davis, 2017). The change agent should remain throughout the entire process of change. They will continue to provide support to peers affected by change and feedback based on the outcomes of change. Change is never easy and often brings about feelings of achievement and pride, as well as loss and stress in the people or organization that is affected. To deal with these feelings, the change agent must then use developmental, political, and relational expertise. This will ensure that the change is not sabotaged by those that are resisting (Marquis & Huston, 2017). Successful change agents must be able to build relationships, have great communication skills, be able to plan and evaluate, and take responsibility during the implementation of change. It is important to note that having a skilled change agent alone is not enough to make change effective (Marquis & Huston, 2017).

Eight Step Model for Effective Change

 Dr. John Kotter, a professor in organizational science, is best known for his eight-step change model and its use to direct change within organizations. In 1995, he shared the 8-step process, in which he perceived to be essential for successful change in organizations (Educational Business Article, 2017). Many efforts can be made to encourage change, but by using Kotter’s model, organizations are likely to provide an environment that will increase the success of change. First, once an event has occurred necessitating change, Kotter says it is important to act with urgency. After a problem has been identified, the next step is to build a team including a change agent to facilitate and implement change. “In relation with organizational change, previous research always mention about the importance of leader and leadership style in organizational change can be achieved successfully (Balogun & Hailey, 2008). This team will develop a vision which is the third step in the model. The team will then communicate the vision to all who will be affected by the change. The fifth step involves empowering action, where leaders encourage risk-taking and non-traditional ideas and efforts (Wheeler & Holmes, 2017). Next, the change agent, team leaders, and other members of the team generate short-term wins. These short-term wins are noticeable and encourage the forward movement of change. By generating these wins, the team can continue to step seven in which they are reminded to not give up. It is very important to highlight positive outcomes throughout the course of change to gain momentum. The last step in the model is to make the change stick. The change agent and team will remain involved to ensure the changes are maintained and continue to provide benefits (Wheeler & Holmes, 2017). Organizations can utilize this eight-step method to successfully help implement change.

Kurt Lewin’s Model of Change Theory of Nursing

 Kurt Lewin was a German-American psychologist and considered the founder of modern social psychology having done research in group dynamics, experimental learning, and action research. Lewin’s three phase model of change from the 1950s still directs how planned change is implemented now. This model helps explain the striving forces to maintain status quo and push for change (Lewin, 1947). Unfreezing, movement, and refreezing are the three phases that Lewin outlined in this model for change.

Unfreezing

 According to Lewin and his research, for an organization to implement successful change, it must be planned, and this requires unfreezing of the system (Hussain, T.H., Lei, Akram, Haider, Hussain, S.H., & Ali, 2016). The process of unfreezing occurs when the change agent emphasizes the need for change and convinces group members that change is necessary. This phase is often referred to as discontent because the change agent elicits such a response in others allowing them to see that change is necessary. This discontent needed to promote change can be either internal or external. To make this effort of change successful, it is crucial for the change agent to be able to clear away competing priorities and emphasize the need for change to occur (Marquis & Huston, 2017). The change agent must also be able to prevent resistance from those who are afraid of change. People resisting change often experience increased stress and require comforting, which puts more strain on the change agent. When this occurs motivation declines (Rockwell, 2015). Rockwell suggests that instead of comforting such peoples, the change leader should ask “What would you like to do about that?”

Movement

 The next phase of Lewin’s theory is the movement phase. The change agent identifies, plans, and implements appropriate strategies. They also ensure that the driving forces outweigh the restraining ones. Since change is a complex process, it requires detailed planning, appropriate timing, and must be implemented gradually if possible (Marquis & Huston, 2017). During this phase, the importance of the change agent’s leadership skills becomes evident when addressing and appropriately responding to the increased stress felt by all who are affected by the change. While in the movement phase, the change agent is responsible for giving inspiration, goal setting, building trust, and making change a priority (Zenger & Folkman, 2015).

Refreezing

 The final phase of Lewin’s theory is refreezing. The goal of this phase is for the change to be integrated into the status quo, so the change agent must assist in stabilizing the system (Marquis & Huston, 2017). If this phase is incomplete, change will be ineffective and pre-change behaviors will resume. During this time, the change agent must be very supportive and reinforce the adaptive efforts occurring in all organizational members that are affected. “Many researchers showed that the important variable in terms of the success of change is people, as without the supports of people, whatever good the change program was developed, the change cannot be achieved successfully (Mangundjaya, Utoyo, & Wulandari, 2015).

 Kurt Lewin’s model for change can be used for many scenarios of implementation of change in the healthcare setting. Whether it be to make a change in a surgical technique to decrease the risk of post operation infection or helping a patient make a lifestyle change to lose weight, Lewin’s Theory of Change can be utilized. Since the 1950s, this model has helped drive change in the health care setting.

Lewin’s Theory of Driving & Restraining Forces

 Kurt Lewin extended his theory by including “force field analysis.” He theorized that people maintain the status quo based on driving and restraining forces. The driving forces are considered facilitators, where as the restraining forces are considered the barriers (Marquis & Huston, 2017). Based on this portion of Lewin’s theory, human behavior is caused by forces, which may include beliefs, values, expectations, cultural norms, and experiences that occur throughout life. Pressure from a supervisor, offering incentives, and competitive and social demands can all be potential positive or driving factors. On the other hand, restraining factors often affect the ability to move forward with change. This could be due to the fear of change, too high of a cost, or lack of time or energy (Kaminski, 2011). Forces that drive some people may be a restraining force in others, so the change agent must consider several factors when considering driving and restraining forces.

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 This theory also has many applications in the health care setting. When providing patient care and setting goals for treatment, the health care team and patient should recognize both the driving and restraining forces that will affect their outcome. If a patient requires continued monitoring for a condition but has too many restraining forces such as no transportation, no insurance, or inability to miss work, it is unlikely for the change to occur that may be necessary for their condition. On the other hand, if the clinic or hospital helped arrange transportation and offered payments based on income, this patient may seek help and make the necessary change.

Contemporary Adaptation of Lewin’s Model

 In 2009, Nina Burrowes and Adrian Needs shared a more contemporary of adaptation to Lewin’s model. Their discussion was broken down into a five-step stages of change model (SCM). They believed that by breaking down the process of change into steps, it would be easier to assess the readiness for change (Burrowes & Needs, 2009). Precontemplation or Stage 1 occurs when there is not intention to change behavior. It is followed by contemplation, the stage in which the individual or organization consider making a change. At this point, the change agent may consider techniques to further motivate. Stage 3 is considered preparation, in which the individual intends to make a change. Action occurs in stage 4 and the individual actively modifies his or her behavior. This is followed by the fifth and final stage of maintenance. The change agent ensures that the change is maintained in the final stage and relapse is avoided. By illustrating the stages of change in a cycle, Burrowes and Needs imply that individuals following this model of change may spiral around several times before successful change has occurred (Prochaska & DiClemente, 1982).

 This SCM model is often used in the rehabilitation setting of healthcare. For rehabilitation programs to be successful, increasing the understanding of readiness to change that is initiated by the patient. “This could lead to improved selection processes for rehabilitation programs, reduced drop out from programs, more efficient use of resources, and development of interventions to improve readiness to change (Burrowes & Needs, 2009).

Bennis, Benne, & Chinn’s Theory for Effective Change

 In 1969, Bennis, Benne, & Chinn identified three strategies for effective change as it relates to behavioral strategies. The change agent must not only be familiar with the steps of change, but also recognize the use of behavioral strategies to encourage change (Marquis & Huston, 2017). By being aware of the person or group affected by change, the change agent can select the most appropriate strategy and increase the rate of success.

The first group of behavioral strategies is rational-empirical, in which the change agent understands resistance is due to other’s lack of knowledge. By recognizing this, the change agent can provide factual information that details the need for change (Marquis & Huston, 2017). An application of this strategy could be used in helping a patient with weight reduction by providing information on the health problems associated with being overweight and resources to help with dieting.

Peer pressure is used to implement change in the normative-reeducative strategies. This strategy differs from the power-coercive strategy in the sense of power. The change agent has no legitimate power over others in the normative-reeducative strategy. During this phase, the patient’s spouse and family members’ support is encouraged by the change agent. In the power-coercive strategy, the change agent forces power by having authority (Marquis & Huston, 2017). In the power-coercive approach, the change agent may provide every meal for the patient trying to lose weight by having control over their menu choices and giving them no other choice but to eat healthy foods.

Complexity and Complex Adaptive Systems Change Theory

 With ever changing technology and the discovery of the subatomic world and quantum physics, complexity science has emerged. This theory suggest that the world is as complex as the humans that live in it (Marquis & Huston, 2017). Complexity science theory looks at the behaviors of individuals and body systems, practices used in healthcare, and thinking, all of which must be considered when caring for a patient (Cornforth, 2013). These factors are not only dynamic and complex, but individualized to the patient, allowing for a more holistic approach to medical care (Cornforth, 2013).

 The Complex Adaptive Systems (CAS) theory stems from complexity science and states that internal components of the system are unstable, and adaptations occur due to this instability. Instead of trying to predict change through stages of development, CAS allows for the adaptation of uncertainty during change. These adaptations are considered nonlinear, which means they are unpredictable and uncontrollable (Cornforth, 2013). When applying this to organizational change of healthcare, the focus should be on a microlevel rather than macrolevel. With this change, it is important for the change agent to be able to focus on the relationships of each element (Marquis & Huston, 2017).

 Both the complexity science and complex adaptive systems change theory can be very useful in healthcare because treatments and goals are based on many factors, which are individualized, and outcomes of patients are not always predictable. In relation to a patient with several chronic illnesses, it can be hard for healthcare professionals to predict what will occur with different treatment, but by examining the specific symptoms of that patient and looking at the whole picture, a better outcome should be achieved. It would not be beneficial to treat each diagnosis of that patient separately.

Chaos Theory

 Edward Lorenz, a meteorologist in the 1960s, set out to improve weather forecasting techniques, which later became the basis for the chaos theory. What he concluded was that even tiny changes in situations can have very dramatic affects. Along with that, he noted that these changes often appear chaotic and uncontrolled, but they are not. The chaos theory is aimed at finding the underlying order in what seems to be random data (Marquis & Huston, 2017). Chaos theory is more congruent with how change occurs across a person’s lifespan. There are cycles of unpredictability and chaos, but stability can also be at time (Bussolari & Goodell, 2009). Chaos theory is often very useful in the emergency department setting. It often seems disorganized and chaotic, but if you have one person, such a change agent step in, stabilization can occur (Marquis & Huston, 2017). Although the emergency department seems like complete chaos, there is order that occurs.

Conclusion

 The healthcare system is continually going through changes to meet the needs of patients to provide better outcomes, provide better services at a cheaper cost, and increase retention of employees working in the healthcare system. For effective change to occur, individuals and/or organizations must consider many factors, such as culture, knowledge of the population, whether there is a true need for change, is the timing appropriate, and what change theory should be used to provide the most beneficial outcome. The skills, knowledge, and leadership of the change agent will also hugely affect the outcome of implementing change. Lewin’s Models of Change Theory in Nursing and Theory of Driving and Restraining Forces laid the foundation for change theories, which gave direction for Bennis, Benne, & Chinn’s Contemporary Adaptation, Complexity Science, CAS, and the Chaos Theory. It is important for healthcare professionals to understand the importance of change, the theories used to implement change, the role of the change agent, and why this is necessary in the healthcare setting.

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