Change Theory: Nursing Examples and Explanations

Whether it’s a new protocol for catheter insertion or a hospital leadership reorganization at the highest level, change is constant in nursing. But even though change is unpredictable by nature, understanding patterns and systems of change will make adjusting to it easier. This is the core of change theory: Nursing is ever-shifting, yet constant in its goal of caring for patients.

As a clinician, you have to adapt to new evidence-based practices, technologies, and care delivery systems. The development of artificial intelligence, new professional tracks, and shifts in staffing mean that modern nurses have to be quick on their feet. But if these changes sound intimidating, consider some of the other majors transitions that nurses have had to adapt to:

• Shifting from tradition-based medicine to evidence-based practices (EBP).
• Transitioning from paper charting to electronic medical record (EMR) charting.
• Introduction of patient safety initiatives, such as time-outs in the OR and falls risk protocols.
• Going from drip-counting IV rates to programmable infusion pumps.

If you’re intimidated or frustrated with adopting a new policy, remember that each of the above shifts was challenging to adopt in their time. Understanding how change theory applies to nursing will help you make sense of changes and encounter them with more confidence. And if you lead change at your facility, understanding these models will help you promote innovation with confidence.

What Is Change Theory in Nursing?

Nursing theories are frameworks that guide the practice, research, and education of nursing. Change theory is a middle range nursing theory that guides how healthcare professionals approach, manage, and implement changes in organizations. These theories create a structure for understanding the dynamics of change — how to plan for it, implement it, and ensure that it’s successful.

Change can be met with resistance, even when it’s positive or beneficial. Adopting new practices takes effort and intention, and people may not want to abandon their old ways. Change theories take this into account, creating structures that support change and incentivize progress.

Change Theories for Nursing: 4 Theorists to Know

Here are four main change theories in nursing to know in your practice.

1. Lewin’s Change Theory

The most well-known is Lewin’s change theory. Nursing professional change, according to social psychologist Kurt Lewin, has three stages:

1. Unfreezing: finding an alternative method, which allows people to see that they can let go of old patterns that must be improved
2. Change stage: the process of altering behavior, feelings, and thoughts
3. Refreezing: solidifying changes after they’ve been implemented, making what was new into a habit

Within the process of change, Lewin described forces working in opposing directions. These are:

• Driving forces for change: incentives to complete a task in a new way, or EBP that shows nurses why a new process is better for patients
• Restraining forces for change: cultural resistance, or outdated systems that make it more difficult to implement change
• Equilibrium: when driving and restraining forces are in balance, and no change is needed

Let’s tie in some real-world scenarios for Lewin’s change theory. Nursing examples include:

Example 1

Maria has just learned about a new protocol for capping central lines. As her unit makes this switch, they are in the change phase of Lewin’s theory. Driving forces include new evidence that supports this practice, and the fact that the unit has stopped supplying the old line caps. A restraining force is that nurses are used to the old way of capping lines, and many have their own stocks of the old line caps. But within a month, the unit has adopted the new protocol, and refreezing has occurred.

Example 2

After a medication error, an ICU quality-improvement team finds a communication gap in handoff processes. As the team investigates and finds solutions, they are in the unfreezing process. A driving force in change is that an error has occurred. A restraining force is that the nurses all have copies of the old handoff sheet, and it will take a few weeks to get everyone the new protocol.

2. Lippitt’s Change Theory

Expanding on Lewin’s model is Lippitt’s change theory. Nursing innovation is driven by change agents, who have the power to inspire, facilitate, and coordinate change at any point in the unfreeze, change, and refreeze processes. Change agents can come from one of two places:

• Internal: nurse managers and team members who can lead change because they understand the history, procedures, and personnel involved
• External: consultants and external trainers, who are not bound by institutional culture or traditions

Within Lewin’s model, Lippitt outlined additional stages of change. These are:

1. Diagnose the problem: Identify and understand the situation that requires change.
2. Evaluate the team’s motivation and capacity for change: Evaluate whether the people involved want to change and have the necessary resources and skills.
3. Assess the change agent’s motivation and resources: Determine the change agent’s (leader’s) readiness, resources, and ability to facilitate the change.
4. Set change goals: Setclear objectives that are manageable and measurable.
5. Communicate the change agent’s role and team expectations: Decide how actively the change agent will be involved, whether as a leader, facilitator, or supporter.
6. Maintain change: Ensure the change is sustained over time, preventing a return to old practices.
7. Phase out the change agent’s role: Gradually reduce the involvement of the change agent, allowing the organization or group to maintain the change independently.

Example

To illustrate how this process might work in the real world, here’s an example of Lippitt’s model in practice:

A nursing home wants to implement a new patient skin care protocol to improve infection control. Cathy, the facility’s director of nursing, is developing a plan following Lippitt’s model. She lays out the steps in her plan below.

1. Diagnose the problem: Cathy has noticed that rates of skin infections are higher in her facility than in others. This is a significant concern that warrants action.
2. Assess motivation and capacity for change: Cathy assesses her staff’s willingness to adopt new practices and evaluates their training needs, ensuring they have the skills and resources to implement the new protocol.
3. Assess the change agent’s motivation and resources: Cathy chooses two of the clinical supervisors from her team to act as change agents, and asks them if they feel equipped for this role. They agree and feel confident they can improve bathing rates.
4. Set change objectives: Cathy sets clear, incremental goals for implementing new soap and bathing regimens. She implements regular staff training and creates a system for tracking baths shift-to-shift.
5. Choose the role of the change agent: Cathy communicates the clinical supervisor’s roles, and offers staff additional support as changes are made.
6. Maintain change: Cathy puts systems in place to monitor adherence to the new protocol, including regular audits and feedback sessions.
7. Terminate the helping relationship: Once the new protocol is integrated into daily practices and infection rates improve, the clinical supervisors gradually step back from their change agent roles, allowing the nursing home staff to independently manage and sustain the change.

3. Rogers’ Change Theory

Another popular model is Rogers’ change theory. Nursing innovation happens over time, through communication between members in a social system. Rogers highlights five steps that potential adopters go through. As nursing professionals go through these stages, they can either progress toward change or reject it. The stages are:

1. Knowledge: becoming aware of the change, and beginning to understand its function
2. Persuasion: people form an opinion about the change, which is often influenced by peers, evidence, and the perceived advantages
3. Decision: choosing to adopt or reject the innovation based on the information they have
4. Implementation: putting the change into practice
5. Confirmation: looking for confirmation that their decision is correct, seeking more evidence that it is the right choice

Rogers’ change theory of nursing also highlights five types of potential adopters when the change process is occurring. Depending on the specific change, and how quickly a person moves through the stages above, every person involved in a change process will fall into one of these categories. These are:

• Innovators: people who drive change themselves; they are risk-takers, willing to try new things
• Early adopters: people who are quick to make a change once they’ve seen others do it, and can endorse the change for others
• Early majority: people who implement changes once they’ve had feedback and modeling from early adopters
• Late majority: a more cautious group that adopts new behaviors once they have been adopted by the majority of the team
• Laggards: the last to adopt an innovation; people who may require penalties in order to change

Trying to get a better understanding of Rogers’ change theory? Nursing examples include:

Example 1

A hospital is introducing a new medication administration record (MAR). Jennifer hears about this change during a staff meeting (knowledge phase). Based on the information she gathers, she is skeptical (persuasion).

During training, she tries the new system, and initially finds it hard to work with, but knows she needs to learn it before the old system is phased out (decision). She adopts the system in the late majority(implementation), after she has seen others use it. Once she is comfortable with the new system, she finds that it is easier to work with than the old one, and she is glad the hospital made the change (confirmation).

Example 2

Liam learns about a new evidence-based pain assessment tool in a workshop (knowledge phase). He is curious about how it can help him address a patient’s pain more thoroughly (persuasion) and wants to try it on his next shift (decision). He introduces a patient to the scale (implementation) as an early adopter. He later hosts a training for other nurses to help them use the new scale in their practice (confirmation).

4. Kotter’s Change Theory

If you’re in a nurse leadership position and you need a framework for leading change, check out Kotter’s change theory. Nursing change, according to change management theorist Dr. John Kotter, happens via an eight-stage process. These stages are:

1. Developing urgency: Inspire team members to act.
2. Building a guiding team: Select a group of team members to guide change.
3. Creating a vision: Communicate the ways that change will be good for everyone.
4. Enlisting: Rally team members around the vision.
5. Enabling action: Take out roadblocks that slow or stop progress.
6. Creating short-term wins: Recognize and reward small amounts of progress.
7. Sustain acceleration: Continue to push for change after the first successes.
8. Solidify change: Communicate the connection between new behaviors and the success of the organization to solidify change.

Example

Kotter’s change theory doesn’t just describe change as it happens, it also gives managers and nursing leaders a framework for encouraging change. Here’s an example of Kotter’s theory in action:

Mark is a PMHNP who leads a community mental health clinic, and his team is trying to implement a telehealth program to meet the needs of rural patients. He follows Kotter’s steps to promote the adoption of this change:

1. 1. Urgency: Mark hosts a meeting to share evidence that patients in their area need more remote care solutions. He has acquired county funding for this initiative, and he sets a deadline for when this new solution must launch.
   2. Guiding Team: Mark selects two other NPs and their clinic’s IT manager to help him coordinate this change.
   3. Vision: Mark develops specific goals for this program, outlining how remote psychiatric care will increase access, reduce costs, and decrease acute psychiatric needs.
   4. Communication: Mark hosts a webinar to explain the vision, attaching a detailed infographic for how this plan will be implemented.
   5. Enlisting: Staff are trained in using the telehealth system, and are given handouts that they can disseminate to their patients.
   6. Short-term wins: Mark tracks how many patients enroll in the program, and sends staff congratulatory emails when 20 patients have signed up.
   7. Sustain: Based on early enrollment, Mark takes feedback and makes it easier for residents to schedule appointments and fill prescriptions from their telehealth app.
   8. Solidify: Over time, the community learns to lean on telehealth psychiatric support for their mental health needs, and Mark’s clinic integrates remote care training into their onboarding process.

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