Health care changes constantly: new evidence, new technology (electronic health records, smart pumps, virtual nursing), new regulations, mergers, and staffing redesign. Change management is the deliberate process of moving people and systems from a current state to a desired state while limiting disruption.

Qualities of an effective change agent: credibility and trust, clear vision, strong communication and listening, flexibility, persistence, knowledge of the system and the evidence, and the ability to involve others. Trusting relationships with the people affected matter more than formal authority.

Lewin's three-stage model (the most tested)

Force-field analysis: change occurs when driving forces are stronger than restraining forces. Reducing restraining forces (for example, providing training or equipment) is usually more effective than simply adding pressure, which can increase resistance.

Other change models

Change strategies (Chin and Benne, published in Bennis, Benne, and Chin's The Planning of Change)

• Empirical-rational — people are rational and will change when shown evidence of benefit (data, research). Works for minor, clearly beneficial changes.
• Normative-reeducative — people change when their values, norms, and relationships support it; uses participation, education, and group influence. Most effective for most nursing practice changes.
• Power-coercive — change imposed by authority, law, policy, or sanctions. Fast and sometimes necessary (new regulation), but produces more resistance.

Common sources of resistance: fear of the unknown or of failure, threat to job security or status, habit and comfort with the old way, lack of information or skill, loss of control, poor timing, distrust of leaders, and disagreement with the purpose.

Ways to manage resistance: communicate the "why" early and honestly; involve those affected in planning (participation builds ownership); provide education, time, and support; pilot and share early successes; negotiate where appropriate; use informal leaders and early adopters as champions; and listen to objections, which may reveal real flaws.

Steps for planned change on a unit (evidence-based practice example)

1. Identify the problem and gather baseline data (for example, catheter-associated urinary tract infection rates).
2. Review the evidence and choose the practice change (a nurse-driven catheter removal protocol).
3. Assess the unit: readiness, driving and restraining forces, resources, informal leaders.
4. Involve stakeholders: staff nurses, providers, infection prevention, educators.
5. Plan: goals, timeline, education, equipment, documentation changes, measures.
6. Pilot on one unit or shift; collect feedback; adjust.
7. Implement widely with champions (super-users) available on every shift.
8. Refreeze: update policy, orientation, and electronic order sets; audit compliance; share outcome data and celebrate wins.
9. Evaluate: compare outcomes with baseline; sustain or revise.

Using adopter categories: recruit early adopters (respected opinion leaders) as champions; give the late majority evidence of success and peer support; do not let laggards set the pace, but understand their concerns.

Technology change (for example, a new documentation system): involve end users in design and testing, provide super-users at go-live, plan for downtime procedures, and monitor for workarounds, which can signal a design problem and create safety risks.

Organizational change (mergers, restructuring, layoffs): uncertainty is high — communicate often, even when information is incomplete; be honest about what is not yet known; support staff through grief for the old way.

• Staff nurse: act as a change agent by identifying practice problems, bringing evidence, joining councils and pilot projects, and giving honest feedback. Resisting a change by ignoring a new policy is not acceptable; concerns are raised through proper channels.
• Charge nurse and champions: model the new practice, coach peers, and report barriers.
• Nurse manager: diagnose readiness; lead unfreezing with data; secure resources; protect time for training; recognize staff; monitor results; hold staff accountable for the adopted standard.
• Nurse executive: set the vision, align change with organizational strategy, and sustain it through structures (policies, budgets, performance measures).

• Standard of care changes with evidence and policy. Once a new policy is adopted, nurses are held to it; following an outdated practice after the change is not a defense.
• Regulation as a driver: changes required by law or accreditation (for example, CMS Conditions of Participation or The Joint Commission's requirements) are power-coercive changes that must be implemented; managers still use education and participation to gain acceptance.
• Safety during transition: transitions (new equipment, new systems) are high-risk periods; competency must be validated before independent use, and downtime and backup procedures must exist.
• Labor considerations: where nurses are represented by a union, changes to wages, hours, and working conditions (for example, a new shift pattern) are generally subjects of collective bargaining (see Topic 17).
• Ethics: honesty and transparency with staff, respect for their input, and keeping client welfare as the purpose of change (ANA Code of Ethics, 2025 revision).

Case 1 — Identify the stage. A manager presents fall data to the staff and asks them why falls are rising before introducing hourly rounding. Stage: unfreezing. Six months later, rounding is written into the policy, included in orientation, and audited monthly. Stage: refreezing.

Case 2 — Best first response to resistance. An experienced nurse says, "The old pain assessment was fine; this new tool is a waste of time." Best response: explore the concern and explain the evidence and purpose, and involve the nurse in testing the tool. Poor responses: ignoring the comment, or threatening discipline as a first step.

Case 3 — Choosing a strategy. A state law requires a new workplace violence reporting process by a deadline. Strategy: the requirement itself is power-coercive, but the manager adds normative-reeducative methods (discussion, training, staff involvement in workflow design) to improve adoption.

Case 4 — Force-field analysis. Nurses want to use a new early-warning score, but the electronic record requires double documentation. Best action: reduce the restraining force (work with informatics to remove the duplicate entry) rather than just increasing reminders.

• Mixing up the order of Lewin's stages or thinking implementation happens during unfreezing.
• Treating resistance as purely negative — it is expected and often informative.
• Thinking power-coercive strategies produce lasting change on their own; they tend to create compliance without commitment.
• Skipping refreezing — without reinforcement, staff drift back to the old practice.
• Starting with the most resistant staff; start with early adopters and opinion leaders.
• Assuming a change agent must be a manager — any nurse can be a change agent.
• Implementing a change hospital-wide without a pilot or baseline data, which makes evaluation impossible.

• Planned change = deliberate and systematic, led by a change agent.
• Lewin: unfreeze (awareness, reduce resistance) → move (implement) → refreeze (stabilize, reinforce).
• Force-field analysis: strengthen drivers and, more effectively, weaken restrainers.
• Rogers: knowledge → persuasion → decision → implementation → confirmation; use early adopters as champions.
• Kotter begins with urgency and ends by anchoring change in the culture.
• Lippitt (seven phases) and Havelock (six stages) expand Lewin's model.
• Strategies: empirical-rational (evidence), normative-reeducative (values, participation — most effective in nursing), power-coercive (authority, law).
• Best way to reduce resistance: communicate the reason and involve staff early.
• Workarounds after a change are a safety signal.
• Once adopted, the new policy becomes the standard nurses are held to.