Change is inevitable : Nursing Management

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Department: Leadership Q&A

Change is inevitable

Drake, Kirsten DNP, RN, OCN, NEA-BC

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Nursing Management (Springhouse) 51(7):p 56, July 2020. | DOI: 10.1097/01.NUMA.0000669092.10582.06
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Q How can I make effective changes on my unit?

The most well-known change management model is Lewin's three-step process from the 1940s: unfreeze-change-refreeze. However, over the decades change management has progressed and now there are several models from which to choose. Consider the change you want to make before selecting a model to use. We'll discuss three models here.

Introduced in the 1950s, the Deming cycle developed into what's now known as Plan-Do-Study-Act (PDSA), or Plan-Do-Check-Act, which is a staple in quality improvement projects. It starts with recognizing the need for a change and then planning for it. The next step is conducting a pilot of the proposed changes, followed by studying (checking) if the pilot was successful and looking at the opportunities during the process. Based on what was experienced, the change can then be made on a larger scale. Often, it takes more than one cycle to find success.1,2 An example using the PDSA model is changing the process of obtaining consent for surgery.

Kotter's eight steps to accelerate change was developed in 1996 and enhanced in 2014.3,4 The steps in this change model are:

  • Create a sense of urgency to communicate the importance of the need for change.
  • Build a guiding coalition from all levels of the organization to lead the change.
  • Form a strategic vision and initiatives to clarify how the future will be different.
  • Enlist volunteers.
  • Enable action by removing barriers and encouraging work across teams.
  • Generate short-term wins to provide feedback for the change.
  • Sustain acceleration once a win is realized to press harder for the change.
  • Institute the change.

An example using this model is a change in organizational structure, such as changing from a 12 hours per week supervisor to a 40 hours per week model.

The Prosci ADKAR model is a goal-oriented framework to motivate and guide change in others, based on research starting in 1998.5 Think of a time on your unit when you initiated a change and it failed. Did it fail because it was a bad idea or because there was no support for the change? This model assists with addressing the people side of change. The acronym ADKAR stands for:

  • Awareness of the need for change
  • Desire to participate in and support the change
  • Knowledge on how to change
  • Ability to implement required skills and behaviors
  • Reinforcement to sustain the change.

Let's apply the ADKAR model to a unit changing from on-unit ghost monitors to implementation of a new central monitoring room. First, staff members need to know why the change is being made; start by communicating the reasons. If employees are unaware, they may be hesitant to change. Next, assess their desire to participate in the change. They may have a low desire to change if they perceive they'll be losing their ability to interpret telemetry if they aren't seeing the monitors constantly. Once these two steps are established, staff members need to know how to effectively work in the new state. The lack of knowledge about how things will work can be a barrier with technology changes. Allow staff members to provide feedback about the change and support them during the implementation. Lastly, reinforce the change, which may take time. During reinforcement, celebrate wins, look for resistance to the change, and coach for corrections.

I hope one of these models will help you make changes on your unit. Please visit the references noted for further information.


1. The W. Edwards Deming Institute. PDSA cycle.
2. ASQ. What is the Plan-Do-Check-Act (PDCA) cycle?
3. Kotter, Inc. 8 steps to accelerate change in your organization. 2018.
4. Kotter, Inc. 8-step process.
5. Prosci. The Prosci ADKAR model.
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