Nurses Leading Change

Change is nothing new. In fact, it is often said that change is the only constant. Change, particularly in the health-care environment, is complex and is occurring at an unprecedented rate. Change is driven by many factors: the increasing cost of health-care delivery, the nursing shortage, the rapid advancements in technology and information management, and new expectations by the public to have a more active role in health-care decisions. Meeting the health-care needs of the world requires that the nurse be proactive and creative in guiding change. The ability to create and manage meaningful change is an essential skill for nurses in the 21st century. Change fosters growth and innovation; progress cannot occur without change. If nurses are to be leaders of change, it is imperative that they understand the changes occurring in the health-care arena, use political clout to have a hand in the changes, and master the change process. This chapter will introduce readers to the principles of planned change, barriers commonly encountered when introducing change, strategies for overcoming barriers, and the role of the nurse as the change agent.

Elements of Change

Change is an integral part of any organization, and the process can be uncomfortable and disturbing to those who are affected. An awareness of the elements common to the change process is important.


Change means to be different, to cause to be different, or to alter. Change may be personal or organizational and can occur suddenly or incrementally. Change may be planned or unplanned. Unplanned change, or reactive change, usually occurs suddenly and in response to some event or set of circumstances. For example, an unanticipated rise in patient census may precipitate the need for a change in patient assignments. Decisions are made—and change follows—as a reaction to an event. Planned change, however, entails planning and application of strategic actions designed to promote movement toward a desired goal. Planned change is deliberate and proactive. For example, changing staffing patterns from extensive use of unlicensed assistive personnel to an all-professional staff requires time and planning. Specific strategies need to be developed and implemented before such a sweeping change is adopted. Generally, planned change is more likely to occur incrementally, over time. Planned change responds to anticipated events in the environment or community.

Change may be initiated in response to internal or external forces. Internal forces stem from within the organization. Internal forces include organizational values and beliefs, culture, and past experiences with change. External forces come from outside the organization. These can be social influences, economic factors, or legislation. For example, a 1996 legislative mandate put the federal Health Insurance Portability and Accountability Act (HIPAA) in place (Public Law 104-191). This piece of legislation forced all health-care agencies, schools of nursing, and their governing bodies to plan and implement major system-wide changes in the way personal information is collected, handled, and stored.

Another factor essential to change is the presence of a change agent. A change agent is one who generates ideas, introduces the innovation, and works to bring about the desired change. In fact, the one who assumes the leadership role of change agent in today’s health-care environment is the nurse. Members of an organization assume different roles in a change, depending on the nature of the change and their role in the organization. A leader often assumes the role of change agent and initiates change; an effective follower actively participates in the change effort and is essential to the successful implementation of change. Registered nurses are frequently in a position of leadership within health care organizations and, as such, are well positioned to be the leaders of change.


When initiating change, the following assumptions are important to consider. Assumption 1 Change of any kind represents loss. Even if the change is positive, there is a loss of stability. This loss of the familiar may produce anxiety and even grief in many individuals. The leader of change must be sensitive to the loss experienced by others.

Assumption 2

The more consistent the change goal is with the individual’s personal values and beliefs, the more likely the change is to be accepted. Likewise, the more different the goal is from the individual’s personal values, the more likely it is to be rejected. The change agent needs to know and respect the values and beliefs of those most affected by the change.

Assumption 3

Those who actively participate in the change feel accountable for the outcome. The more people who are involved in the process, the more the group will feel responsible for the outcome.

Assumption 4

With each successive change in a series of changes, individuals’ psychological adjustment to the change occurs more slowly. It is for this reason that the leader of change must avoid initiating too many changes at once. Timing is important.

Assumption 5

Power is important to the change process. Organizations with many layers of hierarchy between the initiator of change and the ultimate decision makers may have difficulty with implementing change. The shorter the distance the change proposal must travel from the initiator to the decision maker, the greater the likelihood that the change will be accepted. Conversely, the greater the distance, the more likely resistance will occur.


Assessing readiness for change is generally the first step in any change project. Until participants are ready for change, little can be done to bring about change. According to Terry (1993), readiness for change is assessed by answering the following questions:

1. What is the ultimate purpose of the action/ change?

2. Why might I lead or be involved in this change?

3. What is at stake if I lead or participate in this change action?

4. What structures are in place either to foster success or hinder the change?

5. Are the necessary resources available to achieve this change action?

6. What is the stakeholders’ level of commitment to the change?

Practice to Strive

Strategies for Leading Planned Change

Those wishing to bring about change must develop strategies to foster change. Bennis, Benne, and Chin (1969), in their classic text, The Planning of Change, identified three strategies to promote change: rational-empirical, normative-re-educative, and power-coercive. Decisions about which strategies to employ depend, to a great extent, on three factors: the type of change planned, the power of the change agent, and the amount of resistance expected. These strategies may be used independently or together. More often than not, some combination of strategies is indicated: the larger the change and the more resistance expected, the more strategies the change agent must employ.


This strategy assumes that people are rational beings and will adopt a change if it is justified and in their self-interest. When using this strategy, the change agent’s role includes communicating the merit of the change to the group. If the change is understood by the group to be justified and in the best interest of the organization, it is likely to be accepted. This strategy emphasizes reason and knowledge. It presents those affected by the change with the knowledge and rationale they need to accept and implement the change. This strategy is most useful when little resistance to a change is expected. The power of the change agent is typically not a factor in changes amenable to this strategy. This strategy assumes that once given the knowledge and the rationales, people will internalize the need for the change and value the result.


A second strategy takes into account social and cultural implications of change and is based on the assumption that group norms are used to socialize individuals. This strategy requires “winning over” those affected by the change. Success is often relationship-based; relationship, not information, is the key to this strategy. The success of this approach often requires a change in attitude, values, and/or relationships. Sufficient time is essential to the successful use of the normative-re-educative strategy. This strategy is most frequently used when the change is based in the culture and relationships within the organization. The power of the change agent, both positional and informal, becomes integral to the change process. For example, one of the most powerful changes in recent history occurred when the norm changed regarding when to wear surgical gloves for preventing the spread of infection. More than knowledge (rational-empirical) and administrative directives were needed to bring about this change: it took a change in cultural values that redefined the practice norms.


This strategy is based on power, authority, and control. Political or economic power is often used to bring about desired change. The change agent “orders” change, and those with less power comply. This strategy requires that the change agent have the positional power to mandate the change. Change effected by this strategy is often based either on the followers’ desire to please the leader or fear of the consequences for not complying with the change. This strategy is very effective for legislated changes, but other changes accomplished using this strategy are usually short-lived if people have not embraced the need for the change through some other mechanism (Table 11-1).

Barriers to Change and Strategies to Overcome Them

All changes have the potential for both gain and loss. It is important to identify all the potential barriers to change, to  examine them contextually with those affected by the proposed change, and to  develop strategies collectively to reduce or remove the barriers. Barriers most common to change within the health-care environment are discussed below, along with some strategies to overcome them. Additional barriers appear in Table 11-2.

Change requires movement, which, as physics indicates, is a kinetic activity that requires energy to overcome resistance. Also, as in physics, an object at rest (and that includes an organization) prefers to remain at rest. Movement over barriers requires an


Change Strategies

Common Barriers to Change and Strategies to Overcome Them

Common Barriers to Change and Strategies to Overcome Them (continued)

even greater expenditure of energy. The very energy requirement to change ay be too much of a drain on an already overtaxed organization, and the energy required to be a leader of change in a resistant group can be overwhelming. For this reason, timing is a critical element of the change process. Correctly determining when people are most receptive to the initiation of change can be the determining factor in the success or failure of the change process. When people are dissatisfied with the status quo and yet not too overwhelmed with merely trying to keep up, the time for change is ripe. People become comfortable with what “is.” The functional parameters are clear as are expectations and rewards. Change, by its very nature, moves people away from their comfort zones. By providing realistic planning of and adequate information about how the impending change will affect each of those areas, some—probably not all—of this resistance can be minimized.

Although legendary heroes and heroines led massive societal changes, within an organization change rarely occurs without the assistance of others. Frequently, individuals have great ideas that would truly improve the function of the organization, but because the idea cannot be implemented by one person, it becomes lost to the organization. The support of both formal and informal leaders can be a critical element to successful change. Both types of leaders have their own audiences and their own abilities to sway groups and influence the “buy-in.” That buyin and ownership of the change will become a shared vision for the organization that will draw in other supporters. Because the formal and informal leaders have, in essence, “blessed” the change, a number of trust issues for subordinates will also have been overcome.

Change Theories

A number of theories exist to explain the change process. These theories provide a framework within which to guide change efforts. They are useful for planning both personal change and organizational change. Tiffany et al. (1994) surveyed 176 nurseauthored journal articles dealing with planned change. This study identified the type and frequency of planned change theories found in the nursing literature. Lewin’s Change Theory was most commonly used as a framework for change. Several other change theories were also frequently referenced. A brief description of Lewin’s theory, along with Lippitt’s Phases of Change, Havelock’s Six Step Change Model, and Rogers’ Diffusion of Innovations Theory, follows. These models of change are a mere sampling of change models. They provide a strong basis for understanding change theory. Before exploring the change theories, consider this brief discussion of change agents, an element in any change theory.


A change agent is the individual or group that seeks to lead change. The change agent may be from inside or outside the organization. Change agents may have formal lines of authority or may be informal leaders. In either case, the change agent is responsible for moving those affected by the change through the process and implementing the change. Effective change agents are masters of change. They do three things correctly: they sense the right moment to initiate the plan, they find supporters for their ideas, and they have vision (Bruning, 1993).

The successful change agent earns the respect and trust of the target system (individuals, groups, or organizations) by communicating openly and honestly, offering assistance, and demonstrating ability. A change agent’s success depends on communication and consultation style, interpersonal skills, and expert power. Ongoing communication is integral to the role of the change agent (Box 11-1).

Becoming a Change Agent: A Practical Guide

Change is an inevitable part of life; learning to lead change effectively is a skill that can be cultivated

and mastered with practice. If you have been given the responsibility of leading an organizational change, there are several practical steps you can take to increase your chance for success.

1. Begin by articulating the change vision clearly and concisely.

2. Select the change project team carefully.

3. Identify the formal and informal leaders who can help you implement the change successfully.

4. Stay alert to political forces, both for and against the change.

5. Develop communication skills. Keep communication lines open.

6. Practice problem-solving skills.

7. Develop conflict resolution skills.

8. Learn to trust yourself and your project team. Functioning effectively as a change agent requires the nurse to have an understanding of the theoretical frameworks of change. A discussion of several classic, as well as emerging, theories of change follows.


Lewin’s Force Field Analysis is probably one of the best known and frequently used change theories (Tiffany et al., 1994). This theory conceptualizes change as movement across time. Lewin views behavior as a dynamic balance of forces working in opposite direction within a field (individual or organization). According to Lewin, change occurs in response to disequilibrium within a system (Lewin, 1951). Therefore, in order to effect change, there must be an imbalance between the forces that push for change (driving forces) and those forces that oppose change (restraining forces) staving to maintain the status quo. Basically, strategies for change are aimed at increasing driving forces and decreasing restraining forces. Lewin identified three phases of change: unfreezing, moving, and refreezing.


Unfreezing the existing equilibrium involves motivating others for change. The change agent must loosen, or “unfreeze,” the forces that are maintaining the status quo. This involves increasing the perceived need for change and creating discontent with the system as it exists. If individuals do not see a need for change, they are not likely to be motivated or ready for change and may even hinder change. Assessment of readiness for change is critical in this phase.


During the moving phase, the change agent identifies, plans, and implements strategies to bring about the change. The change agent must do all that is possible to reduce restraining forces and strengthen driving forces. It is critical that the change agent continue to work to build trust and enlist as many others as possible. The more ownership there is in the change, the more likely the change will be adopted. Timing is also important during this phase. People need time to assimilate change; therefore, the change agent must allow enough time for people to redefine how they view this change cognitively.


During the  refreezing phase, the change agent reinforces new patterns of behavior brought about by the change. Institutionalizing the change by creating new policies and procedures helps to refreeze the system at a new level of equilibrium. Refreezing has occurred when the new way of doing things becomes the new status quo.


Lippitt’s Phases of Change Theory (1958) is built on the Lewin model. He extended the model to include seven steps in the change process. Lippitt’s model focuses more on the role of the change agent than on the evolution of the change process. Communication skills, team building, and problem solving are central to this theory. The participation of key personnel, those most affected by the change, and those most critical in promoting the change is essential to the success of the change effort (Noone, 1987). The seven steps of Lippitt’s phases of change are:

Step 1: Diagnosis of the Problem

The person or organization must believe there is a problem that requires change. The change agent helps others see the need for change and involves key people in data collecting and problem solving. The ideal situation exists when both the organization and the change agent recognize and accept the need for change.

Step 2: Assessment of the Motivation and Capacity for Change

Determine if people are ready for change. Assess the financial and human resources. Are they sufficient for change? Analyze the structure and function of the organization. Will it support the change, or does there need to be organizational redesign? This process is essentially defining the restraining and driving forces for change within the organization.

Step 3: Assessment of the Change Agent’s Motivation and Resources

This step is crucial to achieving change. The change agent (either an individual or a team) must count the personal cost of change. The change agent must be willing to make the commitment necessary to bring about the planned change. He or she must have the energy, time, and necessary power base to be successful. The change agent may take on the role of leader, expert consultant, facilitator, or cheerleader, but whatever role is assumed, the change agent must be willing to see the change through.

Step 4: Selection of Progressive Change Objectives

The change is clearly defined in this step. Establish the change objectives. Develop a plan of action; include specific strategies for meeting the objectives. Decide how to evaluate the change plan and final result.

Step 5: Implement the Plan

It is critical to remain flexible during implementation. If resistance is higher than anticipated, slow down. Give others a chance to catch up. On the other hand, if all is going well and the momentum is good, keep the plan moving ahead.

Step 6: Maintenance of the Change

During this phase the change is integrated into the organization. It is becoming the new norm. In this phase, the role of the change agent is to provide support, positive feedback and, if necessary, make modifications to the change.

Step 7: Termination of the Helping Relationship

The change agent gradually withdraws from the role and resumes the role of member of the organization (Lippitt, Watson, & Wesley, 1958).


Havelock’s Six Step Change Model (1973) is another variation of Lewin’s change theory. The emphasis of this model is on the planning stage of change. Havelock’s model asserts that with sufficient, careful, and thorough planning, change agents can overcome resistance to change. Using this model, essential to the success of change is inclusion. It is imperative that the change agent encourage participation at all levels. This follows the assumption that the more people are part of the plan, the more they feel responsible for the outcome, and the more likely they will work to make the plan succeed.

The planning stage of Havelock’s model includes: (1) building a relationship; (2) diagnosing the problem; and (3) acquiring resources. This planning stage is followed by the moving stage, which includes choosing the solution and gaining acceptance. The last stage is stabilization and renewal (Havelock, 1973).


Everett Rogers (1983) developed a diffusion theory, as opposed to a planned change theory. It is included with change theories because it describes how an individual or organization passes from “first knowledge of an innovation” to confirmation of the decision to adopt or reject an innovation or change. Rogers defined diffusion as “the process by which innovation is communicated through certain channels over time among the members of a social system” (as cited in Hagerman and Tiffany, 1994, p. 58). Rogers’ framework emphasizes the reversible nature of change. Initial rejection of change does not mean the change will never occur. Likewise, the adoption of change does not ensure its continuation. Rogers’ five-step innovation/decision-making process is:

Step 1: Knowledge

The decision-making unit (individual, team, or organization) is introduced to the innovation (change) and begins to understand it.

Step 2: Persuasion

The change agent works to develop a favorable attitude toward the innovation (change).

Step 3: Decision

A decision is made to adopt or reject the innovation.

Step 4: Implementation/Trial

The innovation is put in place. Reinvention or alterations may occur.

Step 5: Confirmation

The individual or decision-making unit seeks reinforcement that the decision made was correct. It is at this point that a decision previously made may be reversed.


The classic models of change are linear. While they have been used successfully in many situations, they may not be as useful as they once were in the complex, ever-changing health-care arena. Because health care is changing so rapidly, health-care organizations must be able to organize and implement change quickly. The linear models of the past may not be sufficient to meet this challenge. Two models

of change that are quickly becoming recognized in leadership circles are the Learning Organizations and Chaos theories.

Learning Organizations Theory

The Learning Organizations Theory is based on systems theory. It is a framework for seeing the interrelatedness of relationships; the whole is not just the sum of its parts, because each separate part affects the whole. Indeed, each part is essential in defining the whole. Peter Senge (1990) described learning organizations as organizations where people at all levels are collectively and continuously working together to improve what they do. Learning organizations celebrate differences and recognize that every member of the organization has something to contribute to organizational growth.

Over time, a learning organization embraces change as a means of creating the organizational environment it desires. A learning organization develops the capacity to recreate itself in response to change. Senge describes five disciplines that must be mastered if an organization is to achieve the status of a learning organization. Learning organizations model the change process (Table 11-3).

Discipline 1: Personal Mastery

First, the members of a learning organization must develop personal mastery. Personal mastery involves clarifying and deepening a personal vision. There must be personal vision before there can be shared vision. People with a high level of personal mastery are continually expanding their ability to create the results they want in life. Two important characteristics of personal mastery are a clear vision of what one wants and the ability to see current

Senge’s Five Disciplines of Learning Organizations

reality accurately. Creative tension exists whenь there is a gap between the vision and the current reality. In order to shorten the gap, change must occur.

Discipline 2: Mental Models

A mental model is an internal picture of how one views the world. Mental models are deeply held thoughts or beliefs about how the world works. They are the filters for everything one sees or hears. Often, mental models are so deeply engrained that individuals are not consciously aware of them.Mental models shape action. Learning to recognize and question mental models is crucial to becoming part of a learning organization. Change will require the development of new mental models.

Discipline 3: Building Shared Vision

Shared vision is translating a personal vision into a collective vision, created together. Shared vision derives its power from a common caring about something the organization truly wants. Individuals do not have to give up their personal beliefs or passions, but instead continue to learn and grow together. Shared vision is essential if members of an organization are going to work well together. Shared vision takes time and ongoing conversation to create. When building shared vision, the goal is to create the most inclusive environment possible. It is a process that requires commitment, not just compliance. Shared vision does not require knowing how to get where you want to go; it does require knowing where you want to go.

Discipline 4: Team Learning

Team learning is the process of aligning and developing the capacity of organizational members to achieve the vision. This requires much communication. It involves examining all ideas. It requires listening to others’ ideas and suspending judgment for a time. When people suspend judgment and think together, new ideas arise. The objective is to go beyond personal understanding and gain new insight into the issue. When this process is used, people become observers of their own thinking, and that leads to greater insight. Learning teams, as the name implies, are highly participatory in decision making. One person is not the teacher or leader; rather, all members have something to teach and a responsibility to lead. Team learning accepts both individualism and collectivism.

Discipline 5: Systems Thinking

Systems thinking is the cornerstone for learning organizations. This fifth discipline weaves the other four disciplines together into a cohesive body of theory and practice. It is a shift from seeing “parts” to seeing “wholes.” When problems are identified in the organization, they are examined through the lens of a system. The question asked is, “What is wrong with the system?” Systems thinking is about finding solutions to problems, not placing blame. Learning organizations are distinctive because of their ability to learn and not simply be content with what they are doing (Senge, 1990). The capacity to reflect and to see patterns of interdependency is critical. Senge states “Systems thinking is the discipline for seeing wholes. It is a framework for seeing interrelationships rather than things, for seeing patterns of change rather than static snapshots” (p. 68). The art of systems thinking lies in being able to recognize increasingly complex and subtle structures amid the wealth of details, pressures, and cross-currents that exist in real management settings. The essence of mastering systems thinking as a management discipline lies in seeing the patterns where others see only singular events. Senge lists some of the laws of the fifth discipline:

1. Today’s problems come from yesterday’s “solutions.”

2. The harder you push, the harder the system pushes back.

3. Behavior grows better before it grows worse.

4. The easy way out usually leads back in.

5. The cure can be worse than the disease.

6. Faster is slower.

7. Cause and effect are not closely related in time and space.

8. Small changes can produce big results—but the areas of highest leverage are often the least obvious.

9. You can have your cake and eat it too, but not at once.

10. Dividing an elephant in half does not produce two small elephants.

11. There is no blame.

Chaos Theory (1995)

Chaos Theory has its genesis in quantum physics. The universe does not run rigidly in accordance with the laws of classic physics. Hawking (1987) noted that this uncertainty was likely the result of tiny fluctuations that interacted within systems and resulted in large-scale effects. The result stems from multiple interrelated changes within the universe. Chaos Theory hypothesizes that chaos actually has an order. Changes that seem to occur at random are, in reality, the result of a complex order.

Complex systems give rise to complex and interrelated behaviors. The paradox that disorder can be a source of order is particularly encouraging to nursing and to health care in general. Health care is in chaos. Instability is caused by many interrelated variables, including managed care, shifting demographics, age, gender, and ethnicity. According to Valadez and Sportsman (1999), three principles can be drawn from quantum/chaos theory to help leaders in nursing manage the environment: “a) the world is unpredictable, b) the world is not independent of the observer; rather, the intent of the observer influences what is seen; and c) the relationships among things are what counts, not the things themselves” (p. 210). While strategic planning remains important to the life of an organization, the plan cannot remain static; it must change, take into account new data, examine the relationships inherent in the system, and allow for the exploration of differences of multiple perspectives of stakeholders in the organization. Pascale (2002) states that innovation increases near the edge of chaos. In the face of threat or opportunity, organizations move into mutation and experimentation. The challenge is to disturb the system in a manner that will push the system in the direction of a desired outcome. Just as the path of the universe cannot be changed with complete accuracy, neither can the path of health care be directed. But it can be nudged in the right direction.

Example of Chaos Theory in Action

Consider this example of Chaos Theory in action at Medical Surgical Services of Utopia Medical Center:

Mission Statement

It is the mission of our collaborative, interdisciplinary health-care team to provide holistic care for the patients on our units and their families. We will support each other in the accomplishment of our responsibilities through open communication and by striving for flexibility through which to manage the multiple priorities of our service.

Members of the Medical Surgical Services Team Nurses

Physical therapists

Respiratory therapists

Radiology technicians


Unlicensed assistive personnel

Registered dietitians


The nurses have approached their manager about the problems associated with nursing care that are caused by professionals from other disciplines who appear on the unit and commandeer the patients. These situations have been long-standing, are interrupting patient care, are causing delays in administration of medication, and have resulted in the inability of the nurses to conduct patient education sessions on much needed topics, such as diabetes care.

Problem Solving

The Director of Medical Surgical Services has called a team meeting to discuss potential solutions to these problems. Each discipline voices understanding of the problem, but there seems to be no solution to which everyone can agree immediately. This is an example that the world is not independent of the observer and that the intent of the observer influences what is seen. Each discipline agrees there is a problem but views it primarily from its own frame of reference. The director asks one of the charge nurses for ideas about how to solve the dilemma. The charge nurse suggests that the group focus on the mission statement for the area. As the team discusses the implications of the mission statement, it is reminded that holistic patient care is the ultimate goal, and the members recognize that fragmented care is not holistic care. They also recognize that their environment is complex and rapidly changing. Their worldview recognizes unpredictability. They recall their commitment to supporting each other through open communication and a flexible approach. They decide that, together, they can make a general schedule for when certain activities will occur and that through communication about exceptions or crisis situations they can arrange to provide patient care in a more organized, synchronized fashion. The relationships among things is what counts, not the things themselves. In this situation, the mission statement served as the “strange attractor” that brought the team together to meet a common goal

All Good Things...

It is important to remember that change is a journey, not a destination; it is a process, not an outcome. It is less important to know how many steps are in the change process than it is to understand the process of change. With this in mind, recognize that change theories, regardless of the number of steps involved, have several common elements. All change theories begin with diagnosing a problem, identifying what requires change. They provide a thoughtful plan for an innovation—the change idea. Change theories develop strategies to bring about the change. These strategies include a plan for implementation, and contingency plans for overcoming obstacles to change. Finally, they should provide a means for evaluation of the change. Pascale (2002) wrote that “ships can’t steer if they are not moving, and living systems—such as organizations—can’t survive without change, challenge, variety, and surprise” (p. 17). Learn to lead change, rather than let change lead you.

NCLEX Questions

1. Which activity would be considered expected behavior during the refreezing phase of planned change?

A. Developing policies and procedures

B. Working to develop trust

C. Identifying restraining forces

D. Allowing time for people to assimilate the change

2. The change agent can increase the likelihood of the success of planned change by:

A. Implementing the change rapidly to prevent development of the objections

B. Including only formal leaders in planning the change to ensure management support

C. Instituting the change process during a period of low staffing so fewer people will be affected

D. Being sensitive to the internal and external environment of the organization to ensure the change will be culturally acceptable

3. Which change strategy is represented by changing the location of unit patient information boards so the information cannot be seen except by those who need the information in order to provide patient care?

A. Rational-empirical

B. Normative-re-educative

C. Notional-intuitive

D. Power-coercive

4. Gaining trust is a fundamental element in planned change. Which process or behavior would hinder the development of trust?

A. Providing all necessary information

B. Providing only information deemed necessary by formal leaders

C. Achieving buy-in from formal and informal leaders

D. Including all interested parties in the planning of the change

5. An organization that celebrates differences and embraces change is known as:

A. An externally sensitive organization

B. An internally sensitive organization

C. A learning organization

D. A collective vision organization

6. Chaos Theory embraces which of the following principles?

A. It is important that the observer not influence what is being observed

B. Certain parts of the world interact predictably with certain other parts

C. Relationships between objects are more important than objects themselves

D. Change occurs following certain sequential steps

7. Achieving a shared vision requires which of the following?

A. That individuals sublimate their individual goals and desires

B. That one individual champion a personal vision

C. The exclusion of some individuals from the collective

D. Commitment rather than compliance

8. Which of the following is best described as change that applies strategic actions to promote movement toward a specific goal?

A. Reactive change

B. Planned change

C. Internal force change

D. External force change

9. Which of the following is an important assumption to make about change?

A. A positive change represents a gain for everyone affected by the change

B. The fewer the people involved in the process, the more likely the change will be accepted

C. The shorter the gap between change initiator and decision maker, the more likely the change will be implemented

D. When a series of changes is desired, it is more efficient to implement them all at once 10. The change agent must do which of the following?

A. Have a formal line of authority

B. Have a disregard for organizational politics

C. Be a member of the organization

D. Possess conflict resolution skills


List of educational literature:

A. Main:

1. Kelly, P. (2008). Nursing Leadership and Management. (2nd ed.). Clifton Park, NY: Delmar Learning

2. Huber, D. (2000), Leadership and Nursing Care Management, (2nd ed.), Philadelphia: W.B. Saunders.

3. Nagelkerk, J. (2000), Study Guide for Huber Leadership and Nursing Care Management, (2nd ed.), Philadelphia: W.B. Saunders.

4. Sullivan, E. J. (2004). Becoming influential: A guide for nurses. Upper Saddle River, NJ: Pearson.

B. Additional:

1. See required Websites:

2. Course Website – Log in @


Prepared by Volkova N.M.

Adopted by Department of Medical Bioethics and Deontology sitting

11 June 2012, Minute № 2